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Vol. 50. Issue 9.
Pages 407-409 (September 2014)
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Vol. 50. Issue 9.
Pages 407-409 (September 2014)
Clinical Report
DOI: 10.1016/j.arbr.2014.08.001
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Effective Management of Hemoptysis Via Endobronchial Application of Ankaferd Hemostat
Tratamiento efectivo de la hemoptisis mediante aplicación endobronquial del hemostásico Ankaferd
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Oguz Uzuna,
Corresponding author
oguzuzun67@yahoo.com.tr

Corresponding author.
, Levent Erkana, Ibrahim C. Haznedaroglub
a Department of Pulmonary Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turquía
b Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turquía
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Table 1. Clinical characteristics of patients who received endobronchial ABS in the treatment of hemoptysis.
Abstract

Hemoptysis is symptomatic of potentially serious and life-threatening chest disease and requires urgent evaluation and treatment. The aim of this study was to evaluate the hemostatic efficacy of endobronchial application of Ankaferd Blood Stopper® (ABS) solution in patients with hemoptysis.

This retrospective study included 20patients with hemoptysis in whom endobronchial ABS was applied in 25bronchoscopic procedures.

Endobronchial application of ABS was successful in 23 of the 25 bronchoscopic procedures. ABS application was repeated due to recurrent bleeding in 4patients.

This is the first case series demonstrating the endobronchial application of ABS, a novel hemostatic agent, effective in the management of bleeding, especially in local endobronchial malignant lesions. Bronchoscopic ABS application may be an alternative supportive therapeutic method in cases of uncontrolled hemoptysis.

Keywords:
Hemoptysis
Endobronchial application
Liquid hemostatic agent
Ankaferd hemostat
Resumen

La hemoptisis es una manifestación sintomática de una enfermedad torácica que puede ser grave y poner en peligro la vida, y requiere una evaluación y tratamiento urgentes. El objetivo del presente estudio fue evaluar la eficacia hemostásica de la aplicación endobronquial de la solución Ankaferd Blood Stopper® (ABS) en pacientes con hemoptisis.

Este estudio retrospectivo se realizó en 20 pacientes con hemoptisis en los que se aplicó ABS endobronquial mediante 25broncoscopias.

La aplicación endobronquial de ABS tuvo éxito en 23 de las 25broncoscopias. Se repitió la aplicación de ABS a causa de una recidiva hemorrágica en 4pacientes.

Esta es la primera serie de casos que describe el uso de la aplicación endobronquial de ABS, un nuevo agente hemostásico que constituye un método eficaz para el tratamiento de la hemorragia, sobre todo en lesiones malignas endobronquiales locales. Pensamos que la aplicación broncoscópica de ABS puede ser un método terapéutico alternativo y de apoyo en casos de hemoptisis no controlada.

Palabras clave:
Hemoptisis
Aplicación endobronquial
Hemostático líquido
Hemostásico Ankaferd
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Introduction

Ankaferd hemostat (Ankaferd Blood Stopper® [ABS]) is an extract of popular medicinal plants that has been used as a hemostatic agent in traditional Turkish medicine. It consists of a standard mixture of plants, all of which have antithrombin, antiplatelet, antioxidant, antiatherosclerotic and antitumor activity. The basic mechanism of action of ABS is the formation of an encapsulated protein network that provides a focus for vital erythroid aggregation.1 The paradoxical antithrombotic action of an antihemorrhagic product can be explained by its effects on gamma fibrinogen seen in functional proteomic analysis.2 ABS was recently registered for the treatment of clinical bleeds when conventional control methods are ineffective. The aim of this study was to evaluate retrospectively the efficacy of the endobronchial application of ABS hemostat in the treatment of hemoptysis.

Patients and methods

ABS was used in 20 patients (18 men and 2 women) who underwent 25 local bronchoscopies with flexible fiberoptic bronchoscope (Olympus® BF XT20, BF-1T160 and Pentax® 18P). Informed consent was obtained from all patients before performing the bronchoscopy. The main indication for the use of ABS was the control of bleeding originating in the bronchial tree that persisted despite lavage of the affected segment with saline cooled in ice and/or adrenaline instillation in the bleed site. In 7 cases, bleeding began after an endobronchial or transbronchial biopsy, and in the other 13 there was diffuse or local endobronchial bleeding. If the bleeding lesion was visible, ABS was applied directly onto the bleed site via the bronchoscopic probe. If there was diffuse bleeding in a lung segment, ABS was applied from the main carina with a bronchoalveolar lavage catheter. The 2ml dose was repeated if response was insufficient. Depending on the amount of daily bleeding (hemoptysis severity), patients were assigned to 4 groups as follows,3 mild: only hematic streaks in sputum; moderate: 30-100cm3; severe: 100-600cm3; massive: > 600cm3. Successful control of bleeding after ABS application was defined as cessation of bleeding during the bronchoscopic intervention and no hemorrhagic relapse over a 24-hour period.

Results

The mean age of patients was 58 years (range, 25-81 years). Hemoptysis was the presenting symptom in 13 patients and in 7 it was bleeding after bronchoscopic biopsy. Bleeding could be controlled with ABS a few seconds after instillation in the hemorrhagic focus in 23 interventions, but it was ineffective in 2 cases. ABS was reapplied due to relapsed bleeding in 4 patients in whom hemoptysis recurred within 24hours after the first intervention. Clinical characteristics of patients are listed in Table 1.

Table 1.

Clinical characteristics of patients who received endobronchial ABS in the treatment of hemoptysis.

Patient number  Age/Sex  Hemoptysis grade before intervention  Endobronchial lesion (Yes/No)  ABS application route (Directa/catheterb)/Dose:  Intervention outcome  Diagnosis  Relapse (Yes/No)  Last evaluation of patient status 
Patients with lung cancer
69/M  Mild  Yes  Direct/2 ml  Effective  Microcytic  No  Death due to disease progression 4 months after intervention 
79/M  Mild  No  Direct/2 ml  Ineffective  Microcytic (mucosal erosion due to radiotherapy)  No  Remission 
68/M  Mild  Yes  Direct (after biopsy)/2 ml  Effective  Microcytic  No  Death due to disease progression 3 months after intervention 
74/M  No  Yes  Direct (after biopsy)/2 ml  Effective  Neuroendocrine tumor  No  Death due to disease progression 3 months after intervention 
68/M  No  Yes  Direct (after biopsy)/2 ml  Effective  Neuroendocrine tumor  No  Death due to disease progression 3 months after intervention 
73/M  Mild  Mucosal infiltration  Direct (before and after biopsy)/2 ml  Effective  Epidermoid carcinoma  Yes  Remission 
7c  75/M  No  Yes  Direct (after tumor debulking with electrocautery)/2 ml  Effective  Sarcomatoid carcinoma  No  Death due to disease progression 5 months after intervention 
64/M  Massive  Yes  Direct/2 ml  Effective  Epidermoid carcinoma  No  Remission 
58/M  No  Yes  Direct(after biopsy)/2 ml  Effective  Epidermoid carcinoma  No  Lost to follow-up 
10  59/M  No  No  Direct (after transtracheal aspiration procedure)/2 mL  Effective  Microcytic + superior vena cava syndrome de + thrombocytopenia  No  Death 2 weeks after intervention 
11d  60/M  Moderate  Yese  Direct/2 ml  First intervention effective/second ineffective  Epidermoid carcinoma /Mucosal erosion due to radiotherapy  No  Remission 
Patients without lung cancer
12  75/F  Moderate  No  Direct/2 ml  Effective  Cavitary pulmonary disease    In follow-up 
13f  25/M  Massiveg  No  Direct/2 ml  Effective  Welder's lung  Yes  Cure 
14h  55/M  Massiveg  No  Direct/2 ml  Effective  Leukocytoclastic vasculitis  Yes  Cure 
15  53/M  Massive  No  Direct/2 ml  Effective  Wegener's granulomatosis + aspergilloma  Yes  Remission 
16  53/M  Moderate  No  Direct/2 ml  Effective  Drug-induced (acetylsalicylic acid and clopidogrel)  No  Cure 
17  35/M  Massive  No  Catheter/4 ml  Effective  Behçet's disease  No  Remission 
18  40/M  Moderate  No  Direct/4 ml  Effective  Acute myeloblastic leukemia  No  In follow-up 
19  81/M  Moderate  Yes  Direct/2 ml  Effective  Pulmonary metastatic prostate carcinoma  Yes  Death due to metastatic disease 6 months after intervention 
20  45/F  No  No  Direct (after biopsy)/2 ml  Effective  Rheumatoid arthritis + Bronchiolitis  No  In follow-up 

ABS: Ankaferd Blood Stopper®; F: female; M: male.

a

ABS applied directly via the bronchoscopic probe.

b

Catheter: ABS applied via a catheter.

c

ABS applied in 3 different bronchoscopic tumor debulking sessions.

d

Bronchoscopy repeated after radiotherapy session due to recurrent hemoptysis.

e

No endobronchial lesion observed in second intervention.

f

ABS application repeated 1 day after the first application when bleeding recurred.

g

The second bleeding episode was also massive in these patients.

h

ABS application was repeated 2 days after the first application due to recurrent bleeding.

Eight patients had hemorrhagic endobronchial lesions due to lung cancer, with tumor infiltration of the mucosa in one. Bleeding began after transbronchial biopsy in one patient and after a transtracheal aspiration procedure in another.

In 9 of the patients, hemoptysis was due to non-malignant causes (Table 1). Six patients had massive bleeding (5 in the non-malignant group and one in the malignant group). Vasculitis was the most common cause of massive bleeds.

Discussion

The aim of this study is to describe an alternative therapeutic option in emergency settings using the endobronchial application of ABS. Endobronchial application of a dose of 2-4ml ABS was found to be effective in most situations. Due to the fast action of ABS, hemorrhage can be controlled in a few seconds after application. This drug was particularly effective in local hemorrhagic lesions. Only one case of endobronchial application of ABS for the control of a malignant endobronchial lesion has been described.4 However, the topical administration of ABS has been successfully tested in many other bleeding situations, such as gastrointestinal hemorrhage, epistaxis, hemorrhages in hemophiliacs, dental bleeds and post-tonsillectomy bleeding.5 Lung cancer was the underlying cause of the majority of cases in this series (11 patients) and in 7 cases, bleeding began after biopsy. The endobronchial application of ABS stopped bleeding in all cases, thus preventing unnecessary diagnostic and curative delays in patient management. In this study, there were 5 cases of massive hemoptysis in patient groups without cancer. In all these patients, ABS was effective in the treatment of pulmonary bleeding. Moreover, immunosuppressive treatment in vasculitis and supportive treatment in hemoptysis due to welding fumes improved clinical and radiological results.

To conclude, this is the first case series describing the use of endobronchial application of ABS, a new hemostatic treatment representing an effective method for the treatment of bleeding, particularly in local endobronchial malignant lesions. Consequently, bronchoscopic application of ABS may be an alternative supportive treatment in cases of uncontrolled hemoptysis. More controlled, prospective clinical studies will be necessary to fully identify the safety, dosage regimen and efficacy of the topical use of ABS in patients with hemoptysis.

References
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B.Z. Haznedaroglu, Y. Beyazit, S.L. Walker, I.C. Haznedaroglu.
Pleiotropic cellular, hemostatic, and biological actions of Ankaferd hemostat.
Crit Rev Oncol Hematol, 83 (2012), pp. 21-34
[2]
D. Ozel-Demiralp, N. Igci, B. Ayhan, Y. Egin, I.C. Haznedaroglu, N. Akar.
Prohemostatic antithrombin activities of Ankaferd hemostat are linked to fibrinogen gamma chain and prothrombin by functional proteomic analyses.
Clin Appl Thromb Hemost, 18 (2012), pp. 604-610
[3]
O. Uzun, Y. Atasoy, S. Findik, A. Atici, L. Erkan.
A prospective evaluation of hemoptysis cases in a tertiary referral hospital.
Clin Respir J, 4 (2010), pp. 131-138
[4]
S. Arslan, I.C. Haznedaroglu, B. Oz, H. Goker.
Endobronchial application of Ankaferd blood stopper to control profuse bleeding leading to hypoxemia and hemodynamic instability.
Res Med CME, 2 (2009), pp. 144-146
[5]
H. Goker, I.C. Haznedaroglu, S. Ercetin, S. Kirazlı, U. Akman, Y. Ozturk, et al.
Haemostatic actions of the folkloric medicinal plant extract Ankaferd blood stopper.
J Int Med Res, 36 (2008), pp. 163-170

Please cite this article as: Uzun O, Erkan L, Haznedaroglu IC. Tratamiento efectivo de la hemoptisis mediante aplicación endobronquial del hemostásico Ankaferd. Arch Bronconeumol. 2014;50:407–409.

Copyright © 2014. SEPAR
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Archivos de Bronconeumología (English Edition)

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