Endobmnchial Balloon Tamponade of Hemoptysis in Patients with Cystic Fibrosis Robert B. Swersky, M.D., John B. Chang, M.D.,
B. George Wisoff, M.D., and Jack Gorvoy, M.D. ABSTRACT The flexible bronchoscope with Fogarty balloon and irrigating catheters is used effectively to manage and treat hemoptysis in a series of patients with cystic fibrosis. This procedure is well suited to such patients, who are prone to recurrent hemoptysis, and may also be indicated in any inoperable patient with poor cardiopulmonary reserve.
The management of the patient with hemoptysis has undergone many advances over the past several decades. The primary objective is prevention of asphyxiation and exsanguination while preserving lung tissue. This is accomplished best by establishing the cause of the bleeding by localizing the source of the bleeding and obtaining hemostasis or limited resection of lung parenchyma. Traditionally, endobronchial control of hemoptysis has been obtained with the rigid bronchoscope and pledgets soaked in vasoconstrictive drugs. Double-lumen Carlens tubes or single-lumen tubes wedged into the main bronchus have been recommended for isolating the bleeding site [l, 51. Recently, arteriographic evaluation and control of hemoptysis have been described [2, 9, 141. The flexible fiberoptic bronchoscope gives the surgeon the ability to reach the segmental and subsegmental bronchi. By using this instrument in combination with the Fogarty balloon catheter and Fogarty irrigating catheter, the patient can be managed through the short-term and long-term phases of hemoptysis.
Technique Flexible fiberoptic bronchoscopy is performed under general anesthesia with a nasotracheal or From the Departments of Cardio-Thoracic Surgery and Pediatrics, Long Island Jewish-Hillside Medical Center, New Hyde Park, NY. Accepted for publication Apr 27, 1978. Address reprint requests to Dr. Swersky, 212 Middle Neck Rd, Great Neck, NY 11021.
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endotracheal tube, or under topical anesthesia pernasally. Lavage and identification of the bleeding segment or subsegment is then carried out. The distal injector cap on the No. 4 Fogarty catheter is then cut away, and the catheter is advanced with its wire stylet in place down the bronchoscope channel into the segment involved. The catheter is stabilized with the bronchoscopic forceps by grasping the end of the wire stylet (Fig 1A). The bronchoscope is carefully withdrawn from the patient over the forceps, and correct catheter position is checked by reintroducing the bronchoscope. The wire stylet is removed, and a No. 22 needle and three-way stopcock are attached (Fig 18).The balloon is inflated with 0.5 ml of hypaque solution to occlude the bronchus. Finally, the Fogarty irrigating catheter is positioned alongside the balloon catheter in a similar manner. The tracheobronchial tree is lavaged thoroughly and is reevaluated for bleeding or residual clots. If the patient was intubated, the physician carefully removes the endotracheal or nasotracheal tube over the two catheters. It may be necessary to kink the balloon catheter and put a Luer-Lok cap on the No. 22 needle in order that the endotracheal tube can slide over the catheters (Fig 1C). The Fogarty balloon and irrigating catheters are anchored to the nose with benzoin and tape, and a roentgenogram is made to demonstrate the hypaque-filled balloon in the occluded bronchus (Fig 2). Serial roentgenograms are made to assure correct balloon inflation and position. The balloon is kept inflated for 48 hours and then deflated. For the next 24 to 48 hours the irrigating Fogarty catheter is used to instill 2 ml of 1:100,000 solution of epinephrine every 4 hours. If hemoptysis has not recurred, both catheters are removed. The patient is monitored carefully and maintained on a regimen of antitussive and antibiotic agents for an additional ten to fourteen days.
0003-4975/79/030262-03$01.25@ 1978 by Robert B. Swersky
263
How to Do It: Swersky et al: Endobronchial Balloon Tamponade of Hemoptysis
PROTRUDING WIRE STYLET IN N 0 . 4 FOGARTY
BRONCHOSCOPIC BIOPSY FORCEPS
A SWAY STOPCOCK AND 3cc
22 GAUGE NEEDLE
Fig 2. Close-up of the hypaque-filled balloon in the tarnponade position.
B LUER-LOK CAP TO MAINTAIN BALLOON INFLATION
(
Allows Endotracheal Tube Removal 1
C
Fig I. (A) Bronchoscopic forceps stabilizes the Fogarty catheter with its wire stylet, while the bronchoscope is withdrawn. ( B ) A 22-gauge needle and a stopcock are attached to the catheter for balloon inflation. (Q Luer-Lok cap is put on the needle.
Results This technique has been used for 7 episodes of hemoptysis in 4 patients with cystic fibrosis who ranged from 18 to 25 years old. One patient was a woman, and 3 were men. Three of the episodes were acute, and there was massive bleeding of 200 ml in less than 1hour. The other 4 episodes were protracted with 600 ml of bleeding in 48 hours. The bleeding was halted successfully in all episodes. Time in the operating room ranged from 30 to 90 minutes. No complications resulted from the catheter placements. One patient did have severe bronchospasm at the time of extubation, with an associated bradycardia and cerebral hypoxia. The prenasal catheter position was well tolerated, and the patients were eating and walking one day after catheter placement. Two of the patients had episodes of bleeding, 1 at six months and 1 at eight months after operation. Catheter tamponade was again performed successfully for hemostasis in both instances.
264 The Annals of Thoracic Surgery Vol 27 No 3 March 1979
Comment The life expectancy of the patient with cystic fibrosis has increased as better management of pulmonary and gastrointestinal problems has evolved. Those patients living to adolescence and older are seen with end-stage lung disease, secondary to long-term or recurrent pulmonary infections. In the patient with cystic fibrosis and hemoptysis exact isolation and control of the bleeding are essential. Measures to control the recurrent hemoptysis should be designed to preserve whatever lung substance is functional, and to avoid or minimize resection. If massive hemoptysis continues despite antitussive agents, wide-spectrum antibiotics, fluids given intravenously, and mild sedation, then endobronchial tamponade is indicated. The balloon tamponade technique for hemoptysis has been described previously by Hiebert [61, but only as a temporary method before lung resection. The patient with severely compromised cardiopulmonary reserve, be it from primary cardiac disease, long-term obstructive pulmonary disease, interstitial lung disease, or cystic fibrosis, cannot tolerate one or more lung resections [8, 91. For this patient, balloon tamponade is effective treatment for the acute and recurrent episode. The addition of irrigation with vasoactive substances aids in constricting the eroded bronchial vessels and allows for liquefaction and removal of the clots and mucous in the blocked segment of bronchial tree. Further studies to evaluate the histological effects of sustained tamponade on the bronchial tree and lung parenchyma distal to the occluded bronchus are being evaluated in our laboratories.
References 1. Crocco JA, Rooney JJ, Fankushen DS, et al: Massive hemoptysis. Arch Intern Med 121:495, 1968 2. Fellows KE, Stigot L, Shuster S, et al: Selective bronchial arteriography in patients with cystic fibrosis and massive hemoptysis. Radio1 Diagn (Berl) 114:551, 1975 3. Fogarty T: A method of extraction of arterial emboli and thrombi. Surg Gynecol Obstet 116: 241, 1963 4. Gottlieb LS, Hillberg R: Endobronchial 'tamponade for intractable hemoptysis. Chest 67:482, 1975 5. Gourin A, Garzon AA: Control of hemorrhage in emergency pulmonary resection for massive hemoptysis. Chest 68:120, 1975 6. Hiebert CA: Balloon catheter control of lifethreatening hemoptysis. Chest 66:308, 1974 7. Holsclaw DS, Grand RJ, Schwachman H: Massive hemoptysis in cystic fibrosis. J Pediatr 76:829, 1970 8. Meams MB, Hodson CJ, Jackson ADM: Pulmonary resection in cystic fibrosis. Arch Dis Child 47:499, 1972 9. Ores CN, Baker DC Jr: Localization of hemoptysis in patients with cystic fibrosis. Am Rev Respir Dis 99:790, 1969 10. Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 122:33, 1977 11. Sau EC, Gottlieb LS, Yokoyama T, et al: Flexible fiberoptic bronchoscopy and endobronchial tamponade in the management of massive hemoptysis. Chest 70:589, 1976 12. Schuster SR, Shwachman H, Harris GB: Pulmonary surgery for cystic fibrosis. Thorac Cardiovasc Surg 48:750, 1964 13. Smiddy JF, Elliot RC: The evaluation of hemoptysis with fiberoptic bronchoscopy. Chest 64:158, 1973 14. Wholey MH, Chamorro HA, Rao G, et al: Bronchial artery embolization for massive hemoptysis. JAMA 2369501, 1976
B. George Wisoff, M.D., and Jack Gorvoy, M.D. ABSTRACT The flexible bronchoscope with Fogarty balloon and irrigating catheters is used effectively to manage and treat hemoptysis in a series of patients with cystic fibrosis. This procedure is well suited to such patients, who are prone to recurrent hemoptysis, and may also be indicated in any inoperable patient with poor cardiopulmonary reserve.
The management of the patient with hemoptysis has undergone many advances over the past several decades. The primary objective is prevention of asphyxiation and exsanguination while preserving lung tissue. This is accomplished best by establishing the cause of the bleeding by localizing the source of the bleeding and obtaining hemostasis or limited resection of lung parenchyma. Traditionally, endobronchial control of hemoptysis has been obtained with the rigid bronchoscope and pledgets soaked in vasoconstrictive drugs. Double-lumen Carlens tubes or single-lumen tubes wedged into the main bronchus have been recommended for isolating the bleeding site [l, 51. Recently, arteriographic evaluation and control of hemoptysis have been described [2, 9, 141. The flexible fiberoptic bronchoscope gives the surgeon the ability to reach the segmental and subsegmental bronchi. By using this instrument in combination with the Fogarty balloon catheter and Fogarty irrigating catheter, the patient can be managed through the short-term and long-term phases of hemoptysis.
Technique Flexible fiberoptic bronchoscopy is performed under general anesthesia with a nasotracheal or From the Departments of Cardio-Thoracic Surgery and Pediatrics, Long Island Jewish-Hillside Medical Center, New Hyde Park, NY. Accepted for publication Apr 27, 1978. Address reprint requests to Dr. Swersky, 212 Middle Neck Rd, Great Neck, NY 11021.
262
endotracheal tube, or under topical anesthesia pernasally. Lavage and identification of the bleeding segment or subsegment is then carried out. The distal injector cap on the No. 4 Fogarty catheter is then cut away, and the catheter is advanced with its wire stylet in place down the bronchoscope channel into the segment involved. The catheter is stabilized with the bronchoscopic forceps by grasping the end of the wire stylet (Fig 1A). The bronchoscope is carefully withdrawn from the patient over the forceps, and correct catheter position is checked by reintroducing the bronchoscope. The wire stylet is removed, and a No. 22 needle and three-way stopcock are attached (Fig 18).The balloon is inflated with 0.5 ml of hypaque solution to occlude the bronchus. Finally, the Fogarty irrigating catheter is positioned alongside the balloon catheter in a similar manner. The tracheobronchial tree is lavaged thoroughly and is reevaluated for bleeding or residual clots. If the patient was intubated, the physician carefully removes the endotracheal or nasotracheal tube over the two catheters. It may be necessary to kink the balloon catheter and put a Luer-Lok cap on the No. 22 needle in order that the endotracheal tube can slide over the catheters (Fig 1C). The Fogarty balloon and irrigating catheters are anchored to the nose with benzoin and tape, and a roentgenogram is made to demonstrate the hypaque-filled balloon in the occluded bronchus (Fig 2). Serial roentgenograms are made to assure correct balloon inflation and position. The balloon is kept inflated for 48 hours and then deflated. For the next 24 to 48 hours the irrigating Fogarty catheter is used to instill 2 ml of 1:100,000 solution of epinephrine every 4 hours. If hemoptysis has not recurred, both catheters are removed. The patient is monitored carefully and maintained on a regimen of antitussive and antibiotic agents for an additional ten to fourteen days.
0003-4975/79/030262-03$01.25@ 1978 by Robert B. Swersky
263
How to Do It: Swersky et al: Endobronchial Balloon Tamponade of Hemoptysis
PROTRUDING WIRE STYLET IN N 0 . 4 FOGARTY
BRONCHOSCOPIC BIOPSY FORCEPS
A SWAY STOPCOCK AND 3cc
22 GAUGE NEEDLE
Fig 2. Close-up of the hypaque-filled balloon in the tarnponade position.
B LUER-LOK CAP TO MAINTAIN BALLOON INFLATION
(
Allows Endotracheal Tube Removal 1
C
Fig I. (A) Bronchoscopic forceps stabilizes the Fogarty catheter with its wire stylet, while the bronchoscope is withdrawn. ( B ) A 22-gauge needle and a stopcock are attached to the catheter for balloon inflation. (Q Luer-Lok cap is put on the needle.
Results This technique has been used for 7 episodes of hemoptysis in 4 patients with cystic fibrosis who ranged from 18 to 25 years old. One patient was a woman, and 3 were men. Three of the episodes were acute, and there was massive bleeding of 200 ml in less than 1hour. The other 4 episodes were protracted with 600 ml of bleeding in 48 hours. The bleeding was halted successfully in all episodes. Time in the operating room ranged from 30 to 90 minutes. No complications resulted from the catheter placements. One patient did have severe bronchospasm at the time of extubation, with an associated bradycardia and cerebral hypoxia. The prenasal catheter position was well tolerated, and the patients were eating and walking one day after catheter placement. Two of the patients had episodes of bleeding, 1 at six months and 1 at eight months after operation. Catheter tamponade was again performed successfully for hemostasis in both instances.
264 The Annals of Thoracic Surgery Vol 27 No 3 March 1979
Comment The life expectancy of the patient with cystic fibrosis has increased as better management of pulmonary and gastrointestinal problems has evolved. Those patients living to adolescence and older are seen with end-stage lung disease, secondary to long-term or recurrent pulmonary infections. In the patient with cystic fibrosis and hemoptysis exact isolation and control of the bleeding are essential. Measures to control the recurrent hemoptysis should be designed to preserve whatever lung substance is functional, and to avoid or minimize resection. If massive hemoptysis continues despite antitussive agents, wide-spectrum antibiotics, fluids given intravenously, and mild sedation, then endobronchial tamponade is indicated. The balloon tamponade technique for hemoptysis has been described previously by Hiebert [61, but only as a temporary method before lung resection. The patient with severely compromised cardiopulmonary reserve, be it from primary cardiac disease, long-term obstructive pulmonary disease, interstitial lung disease, or cystic fibrosis, cannot tolerate one or more lung resections [8, 91. For this patient, balloon tamponade is effective treatment for the acute and recurrent episode. The addition of irrigation with vasoactive substances aids in constricting the eroded bronchial vessels and allows for liquefaction and removal of the clots and mucous in the blocked segment of bronchial tree. Further studies to evaluate the histological effects of sustained tamponade on the bronchial tree and lung parenchyma distal to the occluded bronchus are being evaluated in our laboratories.
References 1. Crocco JA, Rooney JJ, Fankushen DS, et al: Massive hemoptysis. Arch Intern Med 121:495, 1968 2. Fellows KE, Stigot L, Shuster S, et al: Selective bronchial arteriography in patients with cystic fibrosis and massive hemoptysis. Radio1 Diagn (Berl) 114:551, 1975 3. Fogarty T: A method of extraction of arterial emboli and thrombi. Surg Gynecol Obstet 116: 241, 1963 4. Gottlieb LS, Hillberg R: Endobronchial 'tamponade for intractable hemoptysis. Chest 67:482, 1975 5. Gourin A, Garzon AA: Control of hemorrhage in emergency pulmonary resection for massive hemoptysis. Chest 68:120, 1975 6. Hiebert CA: Balloon catheter control of lifethreatening hemoptysis. Chest 66:308, 1974 7. Holsclaw DS, Grand RJ, Schwachman H: Massive hemoptysis in cystic fibrosis. J Pediatr 76:829, 1970 8. Meams MB, Hodson CJ, Jackson ADM: Pulmonary resection in cystic fibrosis. Arch Dis Child 47:499, 1972 9. Ores CN, Baker DC Jr: Localization of hemoptysis in patients with cystic fibrosis. Am Rev Respir Dis 99:790, 1969 10. Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 122:33, 1977 11. Sau EC, Gottlieb LS, Yokoyama T, et al: Flexible fiberoptic bronchoscopy and endobronchial tamponade in the management of massive hemoptysis. Chest 70:589, 1976 12. Schuster SR, Shwachman H, Harris GB: Pulmonary surgery for cystic fibrosis. Thorac Cardiovasc Surg 48:750, 1964 13. Smiddy JF, Elliot RC: The evaluation of hemoptysis with fiberoptic bronchoscopy. Chest 64:158, 1973 14. Wholey MH, Chamorro HA, Rao G, et al: Bronchial artery embolization for massive hemoptysis. JAMA 2369501, 1976
