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Ann Thorac Surg 1999;67:1288-1291
© 1999 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, The University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
b Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
Accepted for publication September 26, 1998.
Address reprint requests to Dr Smythe, Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 109, Houston, TX 77030
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Abstract |
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Methods. The cases of 3 patients with different sources of exsanguinating hemoptysis during cardiopulmonary bypass managed initially with rigid bronchoscopy were reviewed.
Results. In all patients, airway control was rapidly established and weaning from cardiopulmonary bypass CPB was accomplished. Two patients survived the operative procedure. The other patient died in the operating room of unremitting bilateral pulmonary hemorrhage.
Conclusions. Major hemoptysis during cardiopulmonary bypass is best dealt with initially by rapid airway control and cessation of bypass in an expeditious manner. An algorithm for suggested management is provided. The rigid bronchoscope is the optimal tool for initial management and it should always be available. Definitive treatment is determined by the cause and the persistence of hemorrhage once these maneuvers have been performed.
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Introduction |
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Reports of hemoptysis during CPB have been infrequent. Most have involved minimal hemoptysis and have not offered an acceptable plan for airway management and successful CPB termination [3–5]. The cases of 3 patients with exsanguinating hemoptysis during CPB (all with a different cause) are presented here, and management of this problem, with emphasis on the use of rigid bronchoscopic airway control, is discussed.
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Material and methods |
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Patient 1
An 80-year-old woman had a history of congestive heart failure. The workup revealed critical aortic stenosis and coronary artery disease. The patient underwent elective aortic valve replacement and coronary artery bypass grafting. Weaning from CPB was initiated, but a large amount of bright-red blood began to appear in the endotracheal tube. The hemorrhage became so massive (approximately 500 mL over 5 minutes) that the airway could not be cleared with suction through the endotracheal tube, and the arterial oxygen saturation dropped to 45%.
The patient was precipitously weaned from bypass, and protamine sulfate was administered. The endotracheal tube was removed, an 8-mm rigid bronchoscope was inserted into the airway, and ventilation was reestablished through a side port connection. The hemorrhage was localized to a right lower lobe segmental bronchus. Adequate ventilation and oxygenation (arterial oxygen saturation, then 97% to 100%) were maintained by both suction and intermittent isolation of the right-sided airway by placement of the bronchoscope into the left mainstem bronchus. With reversal of coagulopathy, the hemorrhage ceased, and an endotracheal tube was reinserted by use of a tube-changing cannula placed through the rigid bronchoscope.
Postoperative chest roentgenograms demonstrated a new right lower lobe opacification consistent with an area of possible infarction secondary to Swan-Ganz catheter trauma. The patient experienced one additional episode of minimal hemoptysis on the fourth postoperative day. She eventually recovered completely and was discharged home in good condition.
Patient 2
A 64-year-old woman underwent an elective right hemicolectomy for cecal carcinoma and was found to have an isolated left hepatic lobe metastasis, which was not removed. Postoperatively she was placed on both a regimen of subcutaneous heparin sodium and pneumatic compression stockings. On the evening of the second postoperative day, she was found in electromechanical dissociation. She was resuscitated with external cardiac compression and required several intravenous boluses of epinephrine to maintain a mean blood pressure of 50 mm Hg. The electrocardiogram demonstrated diffuse ST segment elevations, and the transthoracic echocardiogram revealed a dilated right ventricle, 4+ tricuspid regurgitation, and an underfilled left ventricle.
The patient was taken emergently to the operating room where a transesophageal echocardiogram confirmed the diagnosis of a large pulmonary saddle embolus. The main pulmonary artery was opened, and a large portion of the thromboembolus was removed from both main branch pulmonary arteries. At discontinuation of CPB, a large amount of blood began to appear in the endotracheal tube, and ventilation and adequate oxygenation (arterial oxygen saturation, 50%) were not possible. Because the endotracheal tube became obstructed with clot, it was removed; attempts at replacement were unsuccessful. Full CPB was rapidly reinstituted. A rigid bronchoscope was inserted and after suction, ventilation was reestablished through a side port connection. Massive hemorrhage (greater than 200 mL/min) from both mainstem bronchi was noted. Protamine and blood products were administered, and a large endotracheal tube was inserted into the airway through a tube-changing cannula placed through the rigid bronchoscope as weaning from CPB was undertaken. The patient died shortly after cessation of bypass of uncontrolled bilateral pulmonary hemorrhage and right ventricular failure.
Patient 3
A 4-year-old girl weighing 15 kg had Shone’s complex and had had repair of aortic coarctation as an infant. The development of mitral stenosis and regurgitation with congestive heart failure necessitated mitral valve replacement. A prosthetic valve was used. Postoperatively she sustained refractory cardiac arrest without an obvious precipitating factor and was placed on extracorporeal membrane oxygenation by way of chest cannulation. Global biventricular dysfunction was noted on repeated transesophageal echocardiograms, and she was listed for heart transplantation. After 24 days of extracorporeal membrane oxygenation and ventilatory support, a donor heart became available.
The extracorporeal membrane oxygenation circuit was converted to conventional bypass. The heart and supraannular valve were removed, and the donor heart was anastomosed using a standard biatrial approach. The donor heart functioned well, and weaning from CPB was started along with intravenous administration of isoproterenol hydrochloride and dopamine hydrochloride. As bypass was terminated, a large amount of bright-red blood was noted in the endotracheal tube, and the arterial oxygen saturation dropped precipitously to 60%. Suctioning did not clear the hemorrhage (more than 250 mL), and right ventricular function worsened, necessitating a return to CPB.
Once bypass was resumed, the endotracheal tube was removed, and a 4.0-mm pediatric rigid bronchoscope was inserted into the proximal airway. Suctioning alone did not clear the airway sufficiently to determine the site of bleeding; therefore epinephrine solution was repeatedly instilled into the airway. The hemorrhage was then noted to originate from deep posterolateral proximal tracheal erosion, and a cuffed endotracheal tube was placed with the cuff directly over the area for tamponade; there was immediate cessation of bleeding. Although the arterial oxygen saturation returned to normal and intravascular volume was repleted, the patient could not be weaned from CPB because of residual ventricular dysfunction. Extracorporeal membrane oxygenation was reinstituted through thoracic cannulas. Although no further airway bleeding was noted, the patient died several days later of fungal sepsis and aortic hemorrhage.
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Comment |
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The pathophysiology of hemoptysis during CPB is potentially diverse. Any aggressive manipulation of the airway (suctioning, difficult endotracheal tube placement) can lead to hemorrhage in an anticoagulated patient. In addition, elevated left atrial or pulmonary artery pressures can be present secondary to underlying cardiopulmonary pathologic conditions.
Reports of hemoptysis of any degree during CPB have been rare and have all dealt with basically the same cause: pulmonary artery catheter complications. McDaniel and associates [3] reported three cases of pulmonary artery catheter–induced hemoptysis during CPB. However, in their report, 2 of the patients experienced only minimal hemoptysis, and no patient required any specific intervention save heparin reversal with protamine. The authors discussed a proposed treatment protocol that called for "immediate surgical intervention" if hemoptysis were massive and unabated by protamine administration. No discussion of airway management or control with termination of CPB was offered.
Barash and coauthors [4] described six cases of catheter-induced pulmonary artery perforation. In 1 of the patients, hemoptysis developed during weaning from CPB, and a double-lumen endotracheal tube was inserted in an effort to isolate the bleeding lung. This attempt was unsuccessful. No mention of attempted bronchoscopy was made. The involved pulmonary hilum was surgically clamped, and although the hemoptysis improved, the patient subsequently died in the operating room of a combination of bleeding and hypoxia. Fleischer and co-workers [5] treated a patient who had pulmonary artery perforation and hemoptysis during CPB with encirclement of the involved main pulmonary artery and flexible bronchoscopic placement of an inflatable balloon catheter into the bleeding bronchial orifice. Protamine was administered, weaning from CPB was accomplished, and a lobectomy was performed. The patient died several hours later of a cardiac arrest.
A number of creative short-term solutions to hemoptysis (without CPB) have been offered. They include insertion of various types of endotracheal tube devices with the capability of isolating one lung or a portion of a lung, insertion of inflatable-balloon catheters into the bleeding mainstem, lobar, or segmental airway by way of a flexible bronchoscope, and use of emergent transcatheter embolization of the bronchial arteries [6–8]. Although these methods may be successful, they all require a relatively well controlled airway. In our 3 patients, the endotracheal tube became ineffectual because it could not be cleared sufficiently for oxygenation or ventilation. The patients were literally "drowning" in blood, and only after removal of the endotracheal tube and placement of a rigid bronchoscope was control established.
In the original series of patients with exsanguinating hemoptysis [2], the rigid bronchoscope was the instrument of choice for initial airway control. Rigid bronchoscopy has been described as a potentially lost art among thoracic surgeons [9]. However, the rigid bronchoscope is the ideal tool for initial management of major hemoptysis for three main reasons: its large lumen, which can accommodate larger and more vigorous suction devices, its use as a conduit for ventilation and oxygenation, and its ability to localize and isolate nonbleeding areas emergently. Once airway control is established, the lumen of the rigid bronchoscope can also allow other diagnostic and therapeutic maneuvers such as fiberoptic examination of the more distal airway or deployment of balloon catheters [10]. The benefits of rigid bronchoscopy in these reports were obvious, as in all instances, airway control was rapidly established and at least temporary weaning from CPB was accomplished.
What about forgoing rigid bronchoscopy and moving directly to emergent surgical intervention for massive or exsanguinating hemoptysis during CPB? In the literature, the outcome of these endeavors has been uniformly poor. Even under the best circumstances, when an anatomic lung resection has been performed in a planned fashion before or after an open heart procedure requiring CPB, the perioperative mortality rate can reach 20% [11, 12]. Certainly there are times when an emergent surgical procedure cannot be avoided, but in the case of profound anticoagulation during CPB, it would seem prudent to first gain control of the airway. In many instances, the apparent need to emergently remove the involved lung or portion of lung can be obviated, as in patient 1, once coagulation is normalized. Nevertheless, it may be important to definitively deal with the precipitating factor, if possible, prior to hospital discharge. An occult preexisting condition such as a carcinoma, arteriovenous malformation, or cavitary lung lesion can lead to late death in up to one third of patients discharged from the hospital after recurrent hemoptysis [14].
In summary, critical hemoptysis during CPB is best dealt with initially by rapid airway control and cessation of CPB in an expeditious manner if possible. Alternatively, it may be necessary to prolong or even reestablish CPB if initial airway control maneuvers are unsuccessful. A potential algorithm for management of this challenging clinical problem is shown in Figure 1. The rigid bronchoscope is the optimal tool for immediate management, and the cause and the persistence of bleeding once these maneuvers have been performed determine more definitive treatment. All practicing thoracic surgeons should have either a working knowledge of the "lost art" of rigid bronchoscopy or access to others who are trained in its use[13].
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