Impact of multidetector CT-angiography on the emergency management of severe hemoptysis

doi:10.1016/j.ejrad.2013.07.009

European Journal of Radiology

Volume 82, Issue 11, November 2013, Pages e742-e747

https://doi.org/10.1016/j.ejrad.2013.07.009 Get rights and content

Abstract

Background

Multidetector CT-angiography (MDCTA) is commonly used in patients with severe haemoptysis requiring admission to intensive care unit. However, the impact of MDCTA on the management of severe haemoptysis in emergency setting is poorly evaluated.

Methods

We prospectively compared data provided by clinical bedside evaluation (clinical examination, chest-X-ray and fiberoptic bronchoscopy) to MDCTA data in terms of lateralization, location of the bleeding site, etiology as well as impact on the treatment choice.

Results

Over a 13-month period, 87 patients (men n = 58, median age = 61 years, median haemoptysis expectorated volume = 180 mL) were included. Etiology was mainly (67%) bronchiectasis, tuberculosis sequelae and tumor. MDCTA and clinical bedside evaluation were equally effective in determining lateralization (87.4% and 93.1%, respectively, p = 0.23) and location (85% and 82.7%, respectively, p = 0.82) of the bleeding site. MDCTA was significantly more accurate than the clinical bedside strategy in determining the haemoptysis cause (86% and 70%, respectively, p = 0.007). Moreover, MDCTA suggested the involvement of systemic arteries as bleeding mechanism in 92% of cases, leading to the modification of the treatment initially considered after bedside evaluation in 21.8% of patients.

Conclusion

MDCTA provides useful information for the management of patients with severe haemoptysis, especially in the treatment choice. Thus, in the absence of emergency fiberoptic bronchoscopy (FOB) requirement for airways management, MDCTA should be the first-line procedure performed in emergency clinical setting.

Introduction

Severe haemoptysis is a life-threatening condition inducing mortality in more than 50% of untreated patients [1], [2]. It requires prompt management including localization of the bleeding site, determination of its cause and treatment initiation [2], [3], [4], [5]. As nowadays, bronchial artery embolization (BAE) is recommended as the first-line treatment, identification of the bleeding location and mechanism may avoid embolization of the uninvolved bronchial artery or nonbronchial artery in case of pulmonary involvement [6], [7]. When surgery is considered, location of the bleeding site is crucial. The role of conventional CT-scan in determining the bleeding site location and the cause of haemoptysis has been well demonstrated [8], [9], [10]. However, its impact on the management of severe haemoptysis has only been evaluated in one retrospective study, which suggested that this procedure might influence the treatment choice [11]. Recently, owing to technological advances, multidetector CT-angiography (MDCTA) has been successful in providing a detailed mapping of the thoracic vasculature and the mechanism(s) of haemoptysis, which should be helpful for the management of this disease in emergency setting [12], [13]. However, the impact of this procedure on the management of patients has not been assessed prospectively.

We prospectively evaluated the impact of MDCTA on the management of patients admitted in intensive care unit (ICU) for severe haemoptysis, on identifying lateralization and location of the bleeding site, etiology of the bleeding, and initial (emergency) treatment choice.

Section snippets

Patients and methods

From December 2005 to December 2006, we studied all the patients admitted for severe haemoptysis to the ICU of the haemoptysis referral center of a tertiary hospital (Paris, France). Over the last 15 years, the criteria used to define severe haemoptysis requiring admission in our center were usually: (i) an expectorated amount >100 mL; (ii) a respiratory failure requiring oxygen or mechanical ventilation; (iii) hemodynamic instability (iv) presence of severe comorbidities (e.g. lung cancer,

Population characteristics

During the study period, 100 patients with severe haemoptysis were admitted, of whom 13 were secondarily excluded (bleeding originating from gastrointestinal tract n = 2; MDCTA out of order n = 2; FOB not performed because of poor respiratory state n = 9). Therefore, 87 patients (58 men, 29 women) with a median age of 61 years (47–74 years) were analyzed. Forty-two patients (48.3%) had a prior respiratory condition [tuberculosis n = 17 (20%); bronchiectasis n = 16 (18%); lung cancer n = 5 (6%); mycetoma n =

Discussion

Our prospective evaluation of MDCTA suggests that it is an essential procedure in the emergency management of patients with severe haemoptysis. While MDCTA identifies the bleeding site location with the same accuracy as a bedside evaluation including FOB, it is more effective in identifying the cause and the mechanism of haemoptysis, and therefore modifies the first-line treatment considered after bedside evaluation in a significant proportion of patients. Therefore, the use of MDCTA could

Conclusion

In patients with severe haemoptysis requiring no FOB for airways management, MDCTA should be considered as the first-line procedure considering its sensitivity in identifying the bleeding site and the cause of haemoptysis. Moreover, MDCTA significantly influences treatment choice.

Author's contribution

The study was conceptualised and designed by Ludivine Chalumeau-Lemoine, Antoine Khalil, Marie-France Carette, Muriel Fartoukh and Antoine Parrot. The data were acquired by Ludivine Chalumeau-Lemoine and Hélène Prigent. The data were analysed by Ludivine Chalumeau-Lemoine, Antoine Khalil and Antoine Parrot and interpreted by Ludivine Chalumeau-Lemoine, Antoine Khalil, Marie-France Carette, Muriel Fartoukh and Antoine Parrot. The manuscript was written by Ludivine Chalumeau-Lemoine, Antoine

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Cited by (29)

Severe hemoptysis in the onco-hematology patient
2024, Revue des Maladies Respiratoires
En France, l’hémoptysie sévère sur cancer est devenue la première cause d’hémoptysie alors qu'elle est exceptionnelle en cas d’hémopathie. En l’absence d’un traitement adéquate, la mortalité hospitalière dépasse 60 % et atteint 100 % à 6 mois. La prise en charge, discutée avec l’oncologue, comprend l’angioscanner volumique incontournable, en dehors de la situation d’hémoptysie menaçante où la fibroscopie bronchique peut être réalisée de première intention. L’angioscanner volumique permet de localiser le saignement, d’en déterminer la cause et le mécanisme vasculaire. Dans plus de 90 % des cas, l’hémoptysie est liée à l’hypervascularisation systémique bronchique ou non bronchique, dans moins de 5 % des cas elle est en rapport avec une atteinte de la circulation pulmonaire et exceptionnellement avec une lésion de la barrière alvéolocapillaire. Les patients les plus graves doivent être pris en charge en réanimation dans des centres disposant d’une radiologie interventionnelle, d’une chirurgie thoracique et idéalement d’une bronchoscopie interventionnelle. La radiologie interventionnelle est le traitement symptomatique de première intention. L’artériographie bronchique avec embolisation permet un contrôle immédiat dans plus de 80 % des cas. La chirurgie en urgence doit être évitée, car elle est associée à une mortalité significative. Cette prise en charge adéquate réduit la mortalité hospitalière à 30 % et permet aux patients de bénéficier des traitements les plus récents qui améliorent leur survie.
In France, even though it occurs only exceptionally in cases of hemopathy, severe hemoptysis in cancer is the leading cause of hemoptysis. Without adequate treatment, in-hospital mortality exceeds 60%, even reaching 100% at 6 months. The management of severe hemoptysis should be discussed with the oncologist. Aside from situations of threatening hemoptysis, in which bronchoscopy should be performed immediately, CT angiography is an essential means of localizing the bleeding and determining the causes and the vascular mechanisms involved. In more than 90% of cases, hemoptysis is linked to systemic bronchial or non-bronchial hypervascularization, whereas in fewer than 5%, it is associated with pulmonary arterial origin or, exceptionally, with damage to the alveolar-capillary barrier. The most severely ill patients must be treated in intensive care in centers equipped with interventional radiology, thoracic surgery and, ideally, with interventional bronchoscopy. Interventional radiology is the first-line symptomatic treatment. In over 80% of cases, bronchial arteriography with embolization allows immediate control. Emergency surgery should be avoided, as it is associated with significant mortality. Appropriate and adequate care reduces hospital mortality to 30%, enabling patients to benefit from the most recent, survival-prolonging treatments.
Haemoptyis in lung transplant recipients: What is the right question?
2022, Respiratory Medicine and Research
Management of massive hemoptysis secondary to pulmonary hydatidosis: Special features
2020, Revue des Maladies Respiratoires
L’hémoptysie massive (HM) représente une circonstance de découverte rare du kyste hydatique pulmonaire. Les études portant sur l'HM d’origine hydatique sont limitées à des cas sporadiques.
À travers une étude rétrospective menée entre janvier 2000 et décembre 2015, tous les dossiers des patients pris en charge dans notre département de chirurgie thoracique pour une HM d’origine hydatique confirmée ont été étudiés.
Parmi 270 patients opérés pour hydatidose pulmonaire, 13 (4,8 %) avaient une HM. La moyenne d’âge était de 24 ± 12 ans (13–60 ans) et le sexe-ratio était à 0,85. Une embolisation préopératoire a été tentée chez 5 patients, avec échec dans tous les cas. Tous les patients avec HM ont été opérés en urgence. L’origine du saignement a été déterminée et contrôlée dans tous les cas (branche de veine ou de l’artère pulmonaire). La ré-expansion pulmonaire était satisfaisante après capitonnage de la cavité résiduelle, permettant d’éviter une résection réglée pour tous les patients. Les suites opératoires ont été simples chez 11 patients. Un bullage prolongé au-delà de 7 jours a été noté chez deux patients, avec des suites ultérieures simples. La durée moyenne du suivi postopératoire a été de 32 mois (8–63 mois). Un seul patient (vomique hydatique avec HM) a présenté une récidive hydatique controlatérale opérée avec succès. Aucune récidive d’hémoptysie n’a été notée durant la période du suivi.
L’HM secondaire à l’hydatidose pulmonaire peut mettre en jeu le pronostic vital. La chirurgie des kystes, associée à une suture directe des vaisseaux érodés, permettrait à elle-seule de contrôler l’hémoptysie et d’éviter ainsi une résection réglée.
Massive hemoptysis is a rare but serious presentation of pulmonary hydatid cysts. The literature reporting this clinical phenomenon is limited to sporadic cases.
We undertook a retrospective study considering patients who had undergone lung surgery because of hydatid cyst from January 2000 o December 2015 and examined features associated with massive hemoptysis.
Among 270 patients operated on for lung hydatidosis, 13 (4.8%) had experienced massive hemoptysis. This sub group had an average age of 24 ± 12 years (13–60 years) and a sex ratio of 0.85. Preoperative embolization was attempted in 5 patients but failed in all cases. All patients with massive hemoptysis were operated on emergency. The origin of bleeding was determined and controlled in all cases (from a vein or an artery from the pulmonary circulation). Pulmonary re-expansion was satisfactory after obliteration of the residual cavity and no pulmonary resection was necessary. The postoperative course was uneventful in 11 patients. Prolonged air-leak beyond 7 days was noted in two patients but settled subsequently with simple follow-up. Average postoperative follow-up was 32 months (8–63 months). One patient (who had hydatid vomit with massive hemoptysis) developed controlateral hydatid recurrence that was also successfully operated on. No recurrence of hemoptysis was noted during the follow-up period for all patients.
Massive haemoptysis secondary to pulmonary hydatidosis may be life-threatening. Surgery of hydatid cysts associated with direct vascular control of eroded vessels is sufficient to control hemoptysis.
Value of CT-Angiography in the Emergency Management of Severe Hemoptysis
2019, Chinese Medical Sciences Journal
To depict imaging anatomy of bronchial artery (BA) using multidetector CT-angiography (MDCTA) and evaluate the value of MDCTA for management of hemoptysis patients requiring admission to emergency room.
We retrospectively studied the clinical and radiological data of patients with severe hemoptysis (≥ 100 ml of expectorated blood in a 24-hour period) requiring admission to emergency room from Jan 1, 2013 to Dec 31, 2015. Patients' images of MDCTA, treatment modalities, and outcome were discussed.
A total of 108 patients underwent MDCTA scans. Etiology of hemoptysis was mainly bronchiectasis (44%), tuberculosis sequelae (26%) and tumor (18%). MDCTA visualized 197 traceable BAs and also suggested the involvement of 35 nonbronchial systemic arteries. The mean diameter of BAs, measured at the level of the bronchial bifurcation in the mediastinum, was 2.8±1.2 mm. The mean diameter of BAs, for 52 patients who only received conservative treatment, was 2.9±1.1 mm, and was not significantly larger than that of BAs for 56 patients who underwent bronchial artery embolization (BAE) for continued bleeding which did not resolve after conservative treatment (2.7±1.1 mm, P = 0.94). The technical success rate of embolization was 95% (53/56). Clinical success rate during follow-up was achieved in 50 (94%) of 53 patients who had undergone embolization.
MDCTA provides useful information for identifying the anatomical characteristics of bleeding-related BAs and nonbronchial systemic arteries for the management of patients with severe hemoptysis. However, MDCTA could not determine the individuals who need BAE through measuring diameter of BAs.
Diagnosis and Treatment of Hemoptysis
2016, Archivos de Bronconeumologia
La hemoptisis es la expectoración de sangre proveniente del árbol traqueobronquial. Las enfermedades que más frecuentemente la originan son las bronquiectasias, la bronquitis crónica y el carcinoma broncogénico. Las arterias bronquiales son el origen de la mayoría de las hemoptisis. Ante un paciente con sospecha de hemoptisis se debe confirmar su existencia, establecer su gravedad, localizar el origen y determinar su causa. La radiografía de tórax posteroanterior y lateral es la primera prueba de imagen que debe realizarse, aunque la existencia de una radiografía de tórax normal no excluye la posibilidad de malignidad u otra patología de base. Debe realizarse TC multidetector (TCMD) de tórax en todos los pacientes con hemoptisis franca, en los que presentan esputo hemoptoico y sospecha de bronquiectasias o factores de riesgo de carcinoma broncogénico, y en los que tienen radiografía de tórax patológica. La angio-TCMD ha sustituido a la arteriografía como método diagnóstico de las arterias que son fuente de sangrado en las hemoptisis. La angio-TCMD es una técnica de imagen no invasiva que identifica correctamente la presencia, el origen, el número y el trayecto de las arterias sistémicas torácicas, bronquiales y no bronquiales, y de las arterias pulmonares que pueden ser fuente del sangrado. El tratamiento más seguro y eficaz para detener el sangrado en la mayoría de los casos de hemoptisis masiva o recurrente es la embolización endovascular. La embolización está indicada en todos los pacientes con hemoptisis amenazante o recurrente en los que se detectan arterias patológicas en la angio-TCMD. La broncoscopia flexible juega un papel primordial en el diagnóstico de la hemoptisis, tanto de la expectoración hemoptoica como de la hemoptisis franca. Puede ser realizada rápidamente en la cama del paciente (UCI) y, además de su utilidad en el control inmediato de la hemorragia, tiene una alta rentabilidad en la localización del sangrado. La broncoscopia flexible es el procedimiento inicial de elección en pacientes con hemoptisis amenazante e inestabilidad hemodinámica, donde el control de la hemorragia es vital. La cirugía en estos casos tiene una tasa de mortalidad muy alta, por lo que la indicación actual de cirugía en la hemoptisis amenazante está reservada para aquellas situaciones en las que la causa de la misma sea tributaria de tratamiento quirúrgico y haya una localización concreta y fiable del origen de la hemorragia.
Hemoptysis is the expectoration of blood from the tracheobronchial tree. It is commonly caused by bronchiectasis, chronic bronchitis, and lung cancer. The expectorated blood usually originates from the bronchial arteries. When hemoptysis is suspected, it must be confirmed and classified according to severity, and the origin and cause of the bleeding determined. Lateral and AP chest X-ray is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology. Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray. MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding. MDCT angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding. Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis. The procedure can be performed rapidly at the bedside (intensive care unit); it can be used for immediate control of bleeding, and is also effective in locating the source of the hemorrhage. Flexible bronchoscopy is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis, in whom control of bleeding is of vital importance. In these cases, surgery is associated with an extremely high mortality rate, and is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located.
Severe hemoptysis: From diagnosis to embolization
2015, Diagnostic and Interventional Imaging
Citation Excerpt :
In terms of severity, the volume of hemoptysis and respiratory consequences can clinically identify the majority of SH [6]. If the clinical enquiry however is unreliable, MDCTA may again offer assistance [7]. We have shown that the extent of parenchymal involvement on CT correlates with the magnitude of the bleed and with clinical severity.
Severe hemoptysis is life-threatening to patients because of the asphyxia it causes. The diagnosis and treatment are therefore urgent and chest imaging is essential. Multidetector CT-angiography provides an exhaustive non-invasive assessment which includes localization, mechanisms, causes and severity of the hemoptysis. It is an invaluable step in preparation for endovascular treatment which is the first line invasive therapy, particularly with bronchial arteriography embolization in the majority of cases (over 90%) and erosion or rupture of the pulmonary artery in less than 10% of cases. Hemoptysis control is achieved in 65 to 92% of cases depending on the cause.

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Impact of multidetector CT-angiography on the emergency management of severe hemoptysis

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Population characteristics

Discussion

Conclusion

Author's contribution

British Journal of Anaesthesia

Revue de Pneumologie Clinique

Chest

Annals of Thoracic Surgery

Chest

Chest

Clinical assessment and management of massive hemoptysis

Critical Care Medicine

An integrated approach to diagnosis and management of severe haemoptysis in patients admitted to the intensive care unit: a case series from a referral centre

Respiratory Research

The pulmonary physician in critical care * Illustrative case 7: assessment and management of massive haemoptysis

Thorax

Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization

Cardiovascular and Interventional Radiology

ACR appropriateness criteria hemoptysis

Journal of Thoracic Imaging

A prospective analysis of 184 hemoptysis cases: diagnostic impact of chest X-ray, computed tomography, bronchoscopy

Respiration

Value of thoracic CT in the management of severe hemoptysis

Journal de Radiologie