Operative Treatment of Massive Hemoptysis

Transcription

1 Operative Treatment of Massive Hemoptysis Anatole Gourin, M.D., and Antonio A. Garzon, M.D. ABSTRACT Fifty-five pulmonary resections have been performed at our institution for hemoptysis of 600 ml. or more in 24 hours. The overall mortality was 18% as compared with more than 75% in patients who bled 600 ml. or more in 16 hours and 54% in patients who bled 600 ml. or more in 48 hours, all of whom were managed conservatively. Mortality correlated with the rate of bleeding irrespective of the extent of resection. Nineteen patients were bleeding massively at the time of pulmonary resection and required single lung ventilation; of these, 7 (37%) died. Of the 36 patients in whom active bleeding had ceased at the time of pulmonary resection, 3 (8%) died. In 2 patients with extensive bilateral disease, cavernostomy and packing of bleeding cavities was employed. The most common cause of death was respiratory insufficiency. Our experience indicates that operative treatment of massive hemoptysis offers a reduced mortality as compared with conservative management. C onservative management of patients with hemoptysis of 600 ml. or more in 48 hours has been associated with a mortality of 54y0 in our institution and was primarily related to the rate of bleeding. In patients who bled 600 ml. or more in 16 hours the mortality exceeded 757, [3]. These dismal results prompted us to operate on all patients with measured hemoptysis of 600 ml. or more in 24 hours if they were considered able to tolerate thoracotomy and provided the source of bleeding had been demonstrated bronchoscopically. In the past eight years 57 patients have undergone operative treatment for massive hemoptysis; they form the basis of this report. A preliminary communication on our first 35 pulmonary resections for massive hemoptysis has been published previously [5]. Material and Methods Sixty-two patients with hemoptysis of 600 ml. or more in 24 hours were hospitalized at our institution during the years 1964 through There were 47 men and 15 women in the series. Their ages ranged from 18 to 74 years with an average of 42 years. Forty-five patients bled from cavitary tuberculosis, and 16 of them had acid-fast bacilli cultured in the sputum or the resected specimen. Bronchiectasis was the cause of bleeding in 7 patients, From the Department of Surgery, State University of New York Downstate Medical Center, Brooklyn, N.Y. Presented at the Tenth Anniversary Meeting of The Society of Thoracic Surgeons, Los Angeles, Calif., Jan , Address reprint requests to Dr. Gourin, Department of Surgery, State University of New York Downstate Medical Center, 450 Clarkson Ave., Brooklyn, N.Y THE ANNALS OF THORACIC SURGERY

2 TABLE 1. UNDERLYING PULMONARY DISEASE IN 62 PATIENTS HAVING OPERATIVE TREATMENT OF MASSIVE HEMOPTYSIS Disease No. of Patients Pulmonary tuberculosis Inactive 29 Active 16 Bronchiectasis 7 Lung abscess 4 Bronchogenic carcinoma 2 Actinomycosis 1 Goodpasture s syndrome 1 No causative disease found 2 Total 62 lung abscess in 4, bronchogenic carcinoma in 2, actinomycosis in 1, and Goodpasture s syndrome in 1. No inflammatory or neoplastic process could be found in the resected specimens of 2 patients, and the source of bleeding was thought to be a pulmonary vascular abnormality (Table 1). The decision on a patient s ability to tolerate thoracotomy was based on the clinical impression of the general condition and chest roentgenograms, with the addition of ventilatory studies in patients able to cooperate. The site of bleeding was frequently suggested by chest roentgenogram and was confirmed in each case by preoperative bronchoscopy under topical anesthesia. Our criteria for inoperability included: bilateral far-advanced pulmonary disease, unresectable bronchogenic carcinoma with distant metastases, impairment of pulmonary function with vital capacity less than 40y0 of the predicted value, or forced expiratory volume of less than 40y0 in 1 second. Only 5 patients were considered inoperable and treated conservatively. Fifty-five patients were candidates for pulmonary resection. Cavernostomy and packing of large bleeding cavities was employed in 2 patients. Ventilatory studies could not be carried out in 28 patients because of continuous bleeding throughout the preoperative period which made them unable to cooperate. In 34 patients in whom the determinations were performed, the average value for the forced vital capacity was 66y0 of the predicted level. In 15 of these patients it was also possible to obtain the maximum voluntary ventilation, which averaged 78y0 of the predicted value. Nineteen patients who were bleeding massively at the time of pulmonary resection were operated upon using single lung ventilation or a double-lumen endotracheal tube to protect the nonbleeding lung from massive aspiration of blood and asphyxiation. Early in our experience we used Carlens double-lumen tubes for this purpose. These tubes did not work well in our hands because their relatively small lumina made it difficult to suction large amounts of blood. The following method of single lung VOL. 18, NO. 1, JULY,

3 GOURIN AND GARZON TABLE 2. MORTALITY IN 57 PATIENTS UNDERGOING OPERATIVE TREATMENT OF MASSIVE HEMOPTYSIS' No. of Treatment Patients Mortality All pulmonary resections (18%) Lobectomy 43 6 (14%) Pneumonec tomy 12 4 (33%j Cavernostomy 2 1 (50%) "Five additional patients were considered inoperable; 4 (80%) died. ventilation has proved more effective for us in controlling contralateral aspiration during operation. Right-Sided Bleeding. A single-lumen cuffed tube was advanced into the left main bronchus and the cuff was inflated. The patient was placed in a Trendelenburg position to allow blood to run out of the trachea around the cuffed tube. The left lung alone was ventilated until the bronchus of the bleeding lobe was dissected and cross-clamped, at which time the cuffed tube was momentarily deflated and withdrawn into the trachea. All residual blood was aspirated from the tracheobronchial tree and the operation completed with bilateral ventilation. Left-Sided Bleeding. A Fogarty occlusion catheter," size S/ 14F, 80 cm. long and equipped with a 10 ml. balloon was used as a blocker. The catheter was lengthened by interposing a 40 cm. segment of plastic tubing between the proximal end of the hub and the Luer-Lok fitting. The catheter was inserted through a bronchoscope into the left main bronchus, and the balloon was inflated to block the bronchial lumen and prevent contralateral aspiration of blood. The extra length of the catheter allowed the bronchoscope to be removed without displacing the inflated balloon from its position in the left main bronchus, Immediately after removal of the bronchoscope, a cuffed endotracheal tube was inserted and the cuff inflated. The inflated cuff held the Fogarty catheter against the tracheal wall and prevented dislodgement. The patient was positioned for left lateral thoracotomy. The right lung alone was ventilated until the bronchus of the bleeding lobe was dissected and cross-clamped, at which time the balloon catheter was deflated and removed by the anesthesiologist. All residual blood was aspirated from the tracheobronchial tree, and the operation was completed with bilateral ventilation. R esu I ts The overall mortality in the 55 patients who had pulmonary resection was 18% (10 patients) (Table 2). There were 43 lobectomies with 6 deaths (14%) and 12 pneumonectomies with 4 deaths (33%). Four of the 5 patients considered inoperable died in the hospital from recurrent episodes of massive 'Edwards Laboratories, Santa Ana, Calif. 54 THE ANNALS OF THORACIC SURGERY

4 Operative Treatment of Massiue Hemoptysis A Chest roentgenogram (A) and cavernostomy viewed posteriorly (B) in a 39-year-old woman with bilateral far-advanced pulmonary tuberculosis who was bleeding from a large cavity in the posterior segment of the left upper lobe. Latex rubber tubing I inch in diameter was incorporated into the packing gauze to prevent premature closure of the wound. B hemoptysis. Two patients with bilateral far-advanced pulmonary tuberculosis and bleeding from large cavities were considered unable to tolerate pulmonary resection. Cavernostomy and packing effectively controlled hemoptysis. One of these 2 patients died in respiratory failure two days after the operation; the survivor required a tailoring thoracoplasty four months later in order to collapse the cavity. In both patients treated by cavernostomy the bleeding cavities were located in the posterior segments of the upper lobes and were approached through vertical incisions, as shown in the Figure. The rate of bleeding in the 12 hours preceding pulmonary resection correlated with the mortality, averaging 400 ml. in the 45 survivors and 800 ml. in the 10 patients who died. As mentioned before, 19 patients were bleeding massively at the time of pulmonary resection and required single lung ventilation to prevent massive contralateral aspiration of blood. The mortality in these 19 patients was double (37y0, 7 patients) the overall mortality for all pulmonary resections (18y0) and more than four times the mortality in the 36 patients with minimal bleeding at the time of pulmonary 3 patients) who were ventilated with a single-lumen endotracheal tube (Table 3). None of the 8 minimally bleeding patients who underwent pneumonectomy died, whereas all 4 patients who were bleeding massively at the time of pneumonectomy died. Mortality following lobectomy in massively bleeding patients was double (20yo, 3 of 15 patients) that in the patients bleeding minimally at the time of operation (llyo, 3 of 28 patients). Carlens double-lumen tubes were used in 7 patients with 4 deaths directly attributable to intraoperative aspiration VOL. 18, NO. 1, JULY,

5 GOURIN AND GARZON TABLE 3. MOKTAI.ITY.ICCORI)ISL 'ro RATE OF BLEEIIISC; DUKISG l'l'l\losaky KESECTIOS IOR IIASSIVE HEMOPTYSIS Death by Operation No. of Patients Mortality Aspiration of Blood Massive bleeding (one lung ventilation) Lobectomy 15 Pneumonectomy 4 All resections 19 7 (37%) Minimal bleeding (two lung ventilation) Lobec tomy 28 3 (11%) Pneumonectomy 8 All resections 36 3 (8%) of blood. There were no deaths from aspiration in 6 patients bleeding from the right lung who were managed with left bronchial intubation nor in 6 patients with left-sided bleeding in whom balloon catheters were used to block the left main bronchus. In 1 patient the magnitude of bleeding was underestimated and a regular endotracheal tube was used, resulting in massive intraoperative aspiration of blood and death from respiratory failure three weeks postoperatively. As can be seen in Table 4, the most common cause of death following pulmonary resection was respiratory failure. In 5 patients, massive aspiration of blood was the cause of respiratory failure and death. Two patients died in respiratory failure without significant aspiration. One patient with active tuberculosis died on the thirty-eighth postoperative day of bronchopleural fistula and empyema. One patient developed fatal delirium tremens and liver failure three weeks after operation, and 1 patient exsanguinated from a stress ulcer on the eighth postoperative day. Postoperative complications developed in 25 of the 46 survivors (54%) (Table 5). Fifteen tracheostomies were done, 9 of them for aspiration of blood. Persistent apical spaces were noted in 6 patients after lobectomy. Seven thoracoplasties were done, 6 for bronchopleural fistula in patients with active tuberculosis and 1 to collapse a cavity after cavernostomy. TABLE 4. CAUSE OF DEATH IN 55 PULMONARY RESECTIONS FOR MASSIVE HEMOPTYSIS Cause of Death Respiratory failure With massive aspiration of blood Without aspiration of blood Bronchopleural fistula and empyema Delirium tremens & liver failure Bleeding stress ulcer Total No. of Patients 56 THE ANNALS OF THORACIC SURGERY

6 Operative Treatment of Massive Hernoptysis TABLE 5. POSTOPERATIVE COhlPLICATlONS IS SI!R\ I\ OKS FOLLOWISC OPERATIVE TREATMENT OF MASSIVE HEMOI TYSIS Patient Data No. of survivors No. of survivors with complications Aspiration Tracheostomy required Bronchopleural fistula Apical space Thoracoplasty required Wound infection Lobectomy Pneumonectomy (51%) 5 (62%) Cavernostomy Total Comment The etiology of hemoptysis was pulmonary tuberculosis in almost threefourths of our patients. This is similar to other reports in the literature. Apparently, 15% of patients with tuberculosis develop hemoptysis and 20/, bleed profusely [2, 8,9]. There is no uniform agreement, however, as to what constitutes life-threatening pulmonary hemorrhage requiring aggressive surgical treatment [l, 2, 10, 11, 181. Yeoh and associates [13] reported a 25% mortality in patients bleeding 200 ml. in 24 hours who were treated conservatively. In our institution, hemoptysis of 600 ml. in 48 hours was associated with a mortality of 540/, with conservative treatment; this figure rose to over 75y0 in patients who expectorated the initial 600 ml. in 16 hours [3]. The amount of expectorated blood does not represent the total amount of pulmonary hemorrhage, because blood can also be swallowed or aspirated; but it has been a valid guide, in our experience, to the degree a patient s life is endangered and as an indication for an aggressive surgical approach. In the last eight years we have performed pulmonary resections on all operable patients who bled a minimum of 600 ml. in 24 hours or less, even if hemoptysis had stopped, to avert further hemorrhage. Rate of bleeding was found to be the one constant factor in the mortality rates of both inoperable patients and operable patients who did not undergo resection [3]. The results of pulmonary resection were not influenced by patients age, sex, nature of the underlying pulmonary disease, or activity of tuberculosis. In a preliminary communication based on our first 85 pulmonary resections, we concluded that mortality correlated with the magnitude of resection [5]. It is important to note, however, that all 4 patients who died following pneumonectomy were operated upon during a massive bleeding episode. Since the publication of that preliminary report, 8 pneumonectomies have been performed without mortality in patients who were bleeding minimally at the time of operation. Our total experience indicates that the only constant factor affecting mortality is the rate of bleeding, irrespective of the VOL. 18, NO. I, JULY,

7 GOURIN AND GARZON magnitude of resection. The incidence of postoperative complications in surviving patients was lower in those who had had lobectomy (51y0, 19 of 37 patients) than in patients who underwent pneumonectomy (62%, 5 of 8 patients). Localization of the site of bleeding by bronchoscopy is an essential prerequisite to surgical intervention, and failure to do so is one of the criteria of inoperability. Preoperative bronchoscopy in hemoptysis is considered too dangerous by some [2], while others report no ill effects [I]. Bronchoscopy did not aggravate bleeding in our experience. It was always done under topical anesthesia at the earliest possible time and with the operating room ready for immediate thoracotomy if necessary. The validity of ventilatory studies in patients with blood in the tracheobronchial tree is questionable. Results probably underrepresent the pulmonary reserve. Values obtained in 35 patients able to cooperate were above the limits set for inoperability. In patients bleeding massively at the time of pulmonary resection, control of aspiration of blood and protection of the contralateral lung were achieved more successfully in our hands with endobronchial intubation or the use of a blocker with selective unilateral ventilation than with Carlens double-lumen tubes. We used Carlens tubes with satisfactory results for control of purulent secretions. In the presence of massive intrabronchial hemorrhage, however, their relatively small lumina made it difficult to suction blood rapidly enough; similar difficulties have been reported by others [I]. Selective unilateral ventilation has been shown to be physiologically advantageous in terms of blood gas values and physiological shunt determinations [12]. Among the reported methods for controlling pulmonary hemorrhage in patients in whom pulmonary resection is not feasible are bronchial ligation [4], plombage thoracoplasty [6], and ligation of the pulmonary artery [7]. We were able to control hemorrhage by cavernostomy and packing of large bleeding tuberculous cavities in 2 patients who were not candidates for pulmonary resection because of bilateral far-advanced disease. The peripheral location of the cavities with pleural adhesions allowed one-stage cavernostomy under local anesthesia in these critically ill patients. Only 5 patients in our series were found unsuitable for surgical treatment, and 4 of them died from asphyxiation by aspirated blood in recurrent episodes of massive hemoptysis. References 1. Amirano, M., Frater, R., Tirschwell, P., Tanis, M., Bloomberg, A., and State, D. An aggressive surgical approach to significant hemoptysis in patients with pulmonary tuberculosis. Am. Rev. Re$. Dis. 97: 187, Bahabozorshi, S., Jallah, E. A., and Cook, W. A. Tuberculous pulmonary hemorrhage. N.Y. State J. Med. 73:659, THE ANNALS OF THORACIC SURGERY

8 O$erntive Treatment of Massive Hemoptysis 3. Crocco,,J. A., Rooney, J..J., Fankushen, D. S., DiBenedetto, R. J., and Lyons, H. A. Massive hemoptysis. Arch. In.tern. Med. 121:495, Epstein, T. V. Surgical methods in treating tuberculous patients with pulmonary hemorrhage and recurrent hemoptysis. Grudn. Khir. 5:60, Garzon, A. A., Cerruti, M., Gourin, A., and Karlson, K. E. Pulmonary resection for massive hemoptysis. Surgery 67:633, Laforet, E. G., and Strieder, 1. W. Subcostal extraperiosteal plombage for massive tuberculous hemoptysis. Am. Rev. Resp. Dis. 81 :397, Randolph, H. Hemorrhage in pulmonary tuberculosis as a surgical emergency. Dis. Chest 28:416, Ross, C. A. Emergency pulmonary resection for massive hemoptysis in tuberculosis. J. Thorac. Surg. 26:435, Ryan, T. C., and Lineberry, W. T. Pneumonectomy for pulmonary hemorrhage in tuberculosis. Am. Rev. Tuberc. 61:426, Rzepecki, W., and Badmajew, P. Hemorrhage in tuberculosis as an urgent indication for resection of pulmonary tissue. Dis. Chest 41:372, Thorns, N. W., Wilson, R. F., Puro, H. E., and Arbulu, A. Life-threatening hemoptysis in primary lung abscess. Ann. Thorac. Surg. 14:347, Wood, R. E., Campbell, D., Razzuk, M. A., Paulson, D. L., and Urschel, H. C. Surgical advantages of selective unilateral ventilation. Ann. Thorac. Surg. 14: 173, Yeoh, E. B., Hubaytar, R. T., Ford, J. M., and Wylie, R. H. Treatment of massive hemorrhage in pulmonary tuberculosis. J. Thorac. Cardicruasc. Surg. 54:503, Discussion DR. WILLIAM A. COOK (Bronx, N.Y.): I am pleased to discuss this paper because thoracic surgeons in all metropolitan areas must know how to deal swiftly and correctly with this emergency. Among 21 consecutive patients with tuberculous pulmonary hemorrhage who came to operation at the Albert Einstein College of Medicine, 8 had positive sputum and 13 were addicted to alcohol, heroin, or both; of concern to us also were 6 young people with previously undiagnosed tuberculosis. All came to operation bleeding, with roentgenographic evidence of aspiration. Two patients had cardiac arrest before they reached the operating room, a third during preoperative bronchoscopy, and a fourth postoperatively when he aspirated blood retained above the endotracheal tube cuff. These cardiac arrests led to deaths in all 4 patients. One additional patient died of ventilatory failure, an overall mortality of 23.8y0. Of 19 patients well enough to undergo resection, right pneumonectomy was performed in 5, left pneumonectomy in 5, right upper lobectomy in 4, left upper lobectomy in 4, and right bilobectomy in 1. The operative mortality was 11.1% for lobectomies (1 patient) and 20% for pneumonectomies (2 patients). These results compare favorably with the authors mortality rate for their 19 bleeding patients. We think roentgenographic evidence of aspiration of blood rather than the amount of external bleeding is the indication for operation. This avoids many unnecessary resections but also alerts the surgeon to the patient who bleeds internally but expectorates little blood. Two patients emphasize these points. One young woman admitted in the sixth month of pregnancy with massive hemoptysis had no aspiration on roentgenogram and was treated by bed rest and two new antituberculosis drugs. During the next 72 hours she coughed UP more than 3,000 ml. of blood. Roentgenograms taken every 6 hours showed no additional aspiration, operation was avoided, and delivery was uneventful. A second young woman with new disease and 125 ml. of hemorrhage bled in small amounts for five days and stopped. For three days she had no hemoptysis VOT.. 18, NO. 1, JULY,

9 GOURIN AND GARZON and then suddenly had a cardiac arrest and died of aspiration. This tragedy impressed on us the absolute necessity of watching for roentgenographic evidence of aspiration even when external hemorrhage is slight. Seven of our patients with aspiration necessitating resection expectorated less than 200 ml. of blood. DR. ACUSTIN ARBULU (Detroit, Mich.): I congratulate the authors for their timely presentation. My associate, Dr. Norman W. Thoms, has been interested for a long time in the problem of hemoptysis, particularly in lung abscess. He called the problem life-threatening hemoptysis rather than massive hemoptysis, because we learned in one of our initial cases that the association of hemoptysis in a lung abscess with significant roentgenographic changes carries tremendous importance. The significant roentgenographic changes in patients with lung abscess and hemoptysis are: (1) fluid level changes within the cavity, (2) a movable mass within the abscess cavity, (5) a cavity that fills, or, fills and empties, and (4) the presence of a persistent density. In hemoptysis associated with lung abscess, what happens essentially is that the abscess cavity is poorly drained and the roentgenographic changes are indicative of a blocked abscess that carries the prognosis of imminent lifethreatening hemoptysis. Recently we have seen 2 more patients with serial chest roentgenograms showing a persistent density. One had hemoptysis and the other did not. Timely lobectomy saved the life of 1 of these patients. The other died with his first episode of hemoptysis. This last case has taught us that a patient who has a lung abscess that remains blocked, as evidenced by serial chest roentgenograms, should undergo resection. DR. GOURIN: I wish to thank the discussants for their remarks and to emphasize in conclusion that in pulmonary hemorrhage the blood can exit in three different directions: it can be expectorated, it can be swallowed, or it can be aspirated. Our experience has convinced us that the measured amount of expectorated blood is a valid guide to the degree that the patient s life is endangered and is therefore an indication for an aggressive surgical approach. 60 THE ANNALS OF THORACIC SURGERY