ABSTRACT

Three cases from a single institution are presented demonstrating a novel technique of endobronchial blocker insertion under fluoroscopic guidance in patients with massive hemoptysis. This article discusses advantages and limitations compared with bronchoscopic and blind insertion techniques. In all three cases, fluoroscopic guidance demonstrated successful insertion with technically appropriate positioning, allowing for hemodynamic stabilization and more definitive interventional treatment. In one case, endobronchial blocker tamponade, itself, was definitive treatment, without recurrence of hemoptysis during the patient's hospital course. All patients had resolution of their hemoptysis and were eventually discharged from the hospital. Fluoroscopy-guided endobronchial blocker insertion was demonstrated to be both technically feasible and effective in these cases of massive hemoptysis. Moving forward, this can be a valuable tool when emergent endobronchial control of hemoptysis is required in certain instances.

INTRODUCTION

The overall incidence of hemoptysis is approximately 0.1% in the ambulatory setting and 0.2% in the inpatient setting.[1] Although there is some debate regarding the precise volume, massive hemoptysis has been defined as any amount of bleeding that compromises a patient's respiratory status.[2] A rapid, multispecialty approach is necessary to effectively treat hemoptysis. Endobronchial blockers (EBs) are important temporizing tools that have been used in two main capacities for patients with hemoptysis. First, EBs allow for continued ventilation of the contralateral lung by preventing aspiration of blood contralaterally. Second, EBs allow for temporary stabilization, thus allowing time for definitive treatment (often arterial embolization) after the patient is transported to the interventional radiology (IR) department.[3,4] EBs are commonly placed under bronchoscopic guidance; however, techniques for blind placement of an EB have also been described.[5] This article describes three cases in which EBs were placed under fluoroscopic guidance for patients with hemoptysis. In these cases, bronchoscopy was not immediately available, or bronchoscopy was performed and the EB subsequently was displaced. In all cases, adequate stabilization of the patient was achieved, allowing for definitive treatment and clinical improvement.

For this type of study formal consent is not required. This study used publicly available information and was considered IRB exempt.

CASE 1

A 58-year-old woman with a history of ischemic cardiomyopathy who had previously undergone five-vessel coronary artery bypass grafting was scheduled to undergo placement of a CardioMEMS device (Abbott Inc., Atlanta, GA, USA). During the procedure, pulmonary artery angiography was performed, at which time the patient developed hemoptysis. The IR department was urgently consulted.

The patient was first seen by the IR staff in the cardiac catheterization laboratory. Bronchoscopy was not immediately available, and given the substantial amount of hemoptysis, the decision was made to immediately intubate the patient and place an EB in an attempt to control the bleeding and stabilize the patient for transfer to the IR department. Under fluoroscopic guidance, a guide wire was advanced through the endotracheal tube into the left main stem bronchus, and a 7-French EB (Cook Critical Care, USA) was advanced over the guide wire. Once proper positioning of the EB was confirmed with fluoroscopy, the EB balloon was inflated to control the bleeding.

In the IR angiography suite, pulmonary artery angiography was performed. An angled pigtail catheter was placed into the left pulmonary artery, and the pressure was noted to be 49/17 mm Hg with a mean of 20 mm Hg. No extravasation was noted, however cone beam computed tomography (CT) showed alveolar hemorrhage in the lateral basal artery territory, which prompted further investigation. Angiography was performed in the anterior-posterior, left, and right anterior oblique projections. No source of bleeding was identified, and it was presumed tamponade effect from the endobronchial blocker may have led to hemostasis.

The patient was transferred to a hospital room and monitored. She recovered without further complications and was discharged after 8 days.

CASE 2

A 56-year-old man with a history of squamous cell carcinoma of the left lower lobe who had previously undergone radiation and chemotherapy presented, as a transfer from an outside hospital, with hemoptysis estimated at 1 L. The patient was stable when he arrived and bronchoscopy was performed; however, no intervention was required. Later, the patient experienced a second episode of hemoptysis estimated at 1.5 L, during which the patient lost consciousness and went into cardiac arrest. Cardiopulmonary resuscitation was performed, and there was return of spontaneous circulation. An intensivist attempted to perform a right main stem intubation but was unsuccessful and asked for assistance from the IR department. At bedside, IR staff placed a 7-French EB into the left main stem bronchus over a guide wire under C-arm fluoroscopic guidance. The patient was transported to the IR department, where pulmonary angiography demonstrated a large pseudoaneurysm protruding into the necrotic left lower lobe tumor cavity; this pseudoaneurysm was subsequently embolized (Figure 1). The EB was deflated 24 hours after placement, with no immediate bleeding occurring after deflation.

Figure 1

Images from digital subtraction angiography (A) and cone beam computed tomography (B) performed in the interventional radiology suite after an endobronchial blocker was placed at bedside under mobile fluoroscopic system guidance.

Figure 1

Images from digital subtraction angiography (A) and cone beam computed tomography (B) performed in the interventional radiology suite after an endobronchial blocker was placed at bedside under mobile fluoroscopic system guidance.

Eight days later, the patient underwent CT angiography of the chest, which showed evidence of a liquefied left lower lobe necrotic mass and increased bilateral pleural effusion. There was concern for bleed from the left pulmonary artery, so additional angiography and embolization were performed. Angiography revealed a left lower pulmonary artery pseudoaneurysm, which ruptured during catheter manipulation. The patient became transiently hypoxic and hypotensive. A 7-French EB was replaced under fluoroscopic guidance (Figure 2), and the patient responded to suctioning and administration of vasopressors. Coil embolization was then performed in the left lower pulmonary artery, resulting in hemostasis. The EB was removed 48 hours after this second embolization, with no bleeding occurring after removal. Extubation was performed, and the patient was ultimately discharged.

Figure 2

Angiogram demonstrating (A) pulmonary artery rupture. (B) Placement of an endobronchial blocker, which achieved hemostasis and allowed the embolization to be completed.

Figure 2

Angiogram demonstrating (A) pulmonary artery rupture. (B) Placement of an endobronchial blocker, which achieved hemostasis and allowed the embolization to be completed.

CASE 3

A 29-year-old woman with a history of chronic thromboembolic pulmonary hypertension and recurrent endocarditis who had previously undergone transcatheter aortic valve replacement three times presented with bacteremia, respiratory distress, and hypotension. The patient was placed on veno-venous extracorporeal membrane oxygenation (ECMO); this treatment was complicated by right hemothorax and inadvertent chest tube placement in the lung parenchyma. CT of the chest demonstrated right middle and lower lung parenchymal hemorrhage with contrast pooling. Bronchoscopy revealed the airway was filled with blood clots. The right airway was cleared, and an EB was placed in the right main bronchus. The IR department was consulted, and IR staff performed angiography, which revealed a pseudoaneurysm arising from the distal segmental branch of the lateral basal artery in the right lower lobe. This pseudoaneurysm was embolized. During this procedure, the patient demonstrated elevated airway pressure. Cone beam CT demonstrated that the EB was misplaced; therefore, the EB was deflated and repositioned in the right main stem bronchus under fluoroscopic guidance (Figure 3). The left main stem bronchus was then suctioned to remove the clotted blood. Peak airway pressure was reduced from 40 cm H2O to 22 cm H2O.

Figure 3

Cone beam computed tomography images obtained before (A) and after (B) a dislodged endobronchial blocker was repositioned from the trachea to the right main stem bronchus.

Figure 3

Cone beam computed tomography images obtained before (A) and after (B) a dislodged endobronchial blocker was repositioned from the trachea to the right main stem bronchus.

The next morning, increased blood volume was seen in the right chest tube. Bronchoscopy demonstrated a large amount of bleeding in the trachea, limiting accurate EB placement under bronchoscopic guidance. IR staff decided to attempt fluoroscopic EB placement, with the goal of placing an EB in the trachea to tamponade the blood in the airway and allow it to clot while the patient was on ECMO with planned clot evacuation at a later time. A 9-French EB was placed in the trachea, with a 7-French EB left in the right main stem bronchus (Figure 4). The procedure continued with intercostal angiography demonstrating active extravasation from the T7 and T8 intercostal arteries surrounding the right-sided chest tube, which were embolized with gelfoam slurry and coils. Next, bilateral bronchial artery angiography revealed a massive shunt to the pulmonary vein, therefore coil occlusion was performed at the origin of the bilateral bronchial arteries. The next day, the chest tube output was minimal, and the patient had clinically improved. Extracorporeal membrane oxygenation was stopped 6 days later, and the patient was discharged from the hospital 4 weeks after the IR intervention.

Figure 4

Cone beam computed tomography images of endobronchial blockers placed in the trachea and right main stem bronchus under fluoroscopic guidance.

Figure 4

Cone beam computed tomography images of endobronchial blockers placed in the trachea and right main stem bronchus under fluoroscopic guidance.

DISCUSSION

These three cases demonstrate unique instances of successful EB placement under fluoroscopic guidance. Techniques for blind insertion of EBs have been previously described, including insertion with a gum elastic bougie, and with a bougie combined with cricoid displacing. When these techniques were assessed, one of 26 EBs inserted using the bougie and two of 26 EBs inserted using the bougie combined with cricoid displacing were found to be malpositioned. Five of 26 EBs inserted using the bougie and three of 26 EBs inserted using the bougie combined with cricoid displacing had to be repositioned due to poor lung isolation.[5] Fluoroscopic EB placement may be an effective alternative to these techniques. With fluoroscopic placement, the EB can be visualized in the absence of fiberoptic bronchoscopy; this may be of particular value when the hemoptysis is massive and the bronchoscopic view is obscured by blood products. Fluoroscopic guidance has previously been shown to be technically successful in the pediatric population, with 18 of 18 patients undergoing successful fluoroscopic EB placement.[6]

EBs are compliant balloons and therefore no max or burst pressures are reported. The 7-French balloons inflated with 4 to 6 mL in each of the described cases until the balloon conformed to the bronchus wall, as observed fluoroscopically. No complications arose from fluoroscopically placed EB in the described cases. Risks of fluoroscopically placed EBs are likely similar to EBs placed bronchoscopically, such as pressure necrosis, structuring, and bronchial injury as a result of EB overinflation. Additional risks of radiation and underdistention of the balloon due to lack of direct visualization are possible, and additional experience is needed to fully characterize these risks.[7,8]

Placing EBs at bedside or in the IR suite offers many advantages, including the ability to control pulmonary hemorrhage without delay when bronchoscopy is not immediately available and the ability to place an EB when bronchoscopic visualization is obscured by high-volume bleeding.[9] Maintenance of proper EB positioning also can be difficult after successful placement with standard techniques,[10] but fluoroscopy allows for intraprocedural confirmation of position and for repositioning of the EB when necessary.

Limitations of fluoroscopic EB placement include the inability to know the relative location of the EB to the bleeding and the lack of immediate visual confirmation of hemorrhage cessation without the use of angiography. Another limitation is the current availability of EBs in the IR department and unfamiliarity of IR physicians with the technical deployment and use. Last, there may be institutional pushback based on regulations and certification processes.

CONCLUSION

This case series shows that EBs can be placed successfully under fluoroscopic guidance, allowing for definitive treatment of hemoptysis and positive clinical outcomes. The role of IR in the management of hemoptysis can therefore extend beyond embolization, to placement of EBs in the IR suite, as well as at bedside. The addition of fluoroscopic EB placement to the IR armamentarium can allow greater control and versatility in the acute management of hemoptysis.

ACKNOWLEDGMENT

We thank Megan Griffiths for her help with manuscript editing and preparation.

References

References
1.
Ittrich
H,
Bockhorn
M,
Klose
H,
Simon
M.
The diagnosis and treatment of hemoptysis
.
Dtsch Arztebl Int
.
2017
;
114
:
371
381
.
2.
Rali
P,
Gandhi
V,
Tariq
C.
Massive hemoptysis
.
Crit Care Nurs Q
.
2016
;
39
:
139
147
.
3.
Radchenko
C,
Alraiyes
AH,
Shojaee
S.
A systematic approach to the management of massive hemoptysis
.
J Thorac Dis
.
2017
;
9
(suppl 10)
:
S1069
S1086
.
4.
Reisz
G.
Topical hemostatic tamponade: another tool in the treatment of massive hemoptysis
.
Chest
.
2005
;
127
:
1888
1889
.
5.
Liang
P,
Ni
J,
Zhou
C,
Yu
H,
Liu
B.
Efficacy of a new blind insertion technique of Arndt endobronchial blocker for lung isolation: comparison with conventional bronchoscope-guided insertion technique—a pilot study
.
Medicine (Baltimore)
.
2016
;
95
:
e3687
.
6.
Marciniak
B,
Fayoux
P,
Hebrard
A,
Engelhardt
T,
Weinachter
C,
Horber
RK.
Fluoroscopic guidance of Arndt endobronchial blocker placement for single-lung ventilation in small children
.
Acta Anaesthesiol Scand
.
2008
;
52
:
1003
1005
.
7.
Grant
T.
Do current methods for endotracheal tube cuff inflation create pressures above the recommended range? A review of the evidence
.
J Perioper Pract
.
2013
;
23
:
198
201
.
8.
Roscoe
A,
Kanellakos
GW,
McRae
K,
Slinger
P.
Pressures exerted by endobronchial devices
.
Anesth Analg
.
2007
;
104
:
655
658
.
9.
Dalia
AA,
Streckenbach
S,
Andrawes
M,
Channick
R,
Wright
C,
Fitzsimons
M.
Management of pulmonary hemorrhage complicating pulmonary thromboendarterectomy
.
Front Med (Lausanne)
.
2018
;
5
:
326
.
10.
Heir
JS,
Sekhon
AK,
Thakar
DR,
Jackson
TA,
Lasala
JD,
Purugganan
RV.
External tracheal manipulation maneuver (ETMM) to facilitate endobronchial blocker placement
.
J Cardiothorac Vasc Anesth
.
2016
;
30
:
1061
1063
.

Competing Interests

Source of Support: None. Conflict of Interest: None.