Ann Thorac Surg 2009;88:284-287. doi:10.1016/j.athoracsur.2008.12.038
© 2009 The Society of Thoracic Surgeons
Case Reports
Managing Pulmonary Artery Catheter-Induced Pulmonary Hemorrhage by Bronchial Occlusion
René Schramm, MD, PhD*,
Ahmad Abugameh, MD,
Dietmar Tscholl, MD,
Hans-Joachim Schäfers, MD
Department of Thoracic and Cardiovascular Surgery, University Hospital Homburg/Saar, Homburg/Saar, Germany
Accepted for publication December 1, 2008.
* Address correspondence to Dr Schramm, Department of Thoracic and Cardiovascular Surgery, University Hospital Homburg/Saar, Kirrbergerstrasse, Homburg/Saar, D-66421, Germany (Email: reneschramm{at}live.de).
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Abstract
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A 76-year-old woman underwent mitral valve repair and coronary artery bypass grafting. Intrabronchial bleeding occurred after inflation of the balloon tip of the pulmonary artery catheter in the wedge position. A Forgaty catheter was introduced into the trachea parallel to the endotracheal tube and advanced under bronchoscopic vision into the intermediate bronchus. Tamponade of the bleeding was achieved by by filling the Forgaty balloon tip with saline. Weaning from extracorporeal circulation was uneventful. On the first postoperative day, the Forgaty catheter was removed and bronchial lavage of the middle and lower lobe was performed without any additional bleeding complication.
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Introduction
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Pulmonary artery catheters (PAC) for determination of cardiac output have been used for more than 30 years [1]. This invasive method for monitoring critically ill patients bears certain risks and the reported rate of severe complications (ie, life-threatening, which is believed to be less than 5%) [2, 3]. Abreu and coworkers [2] reviewed the literature and found an incidence of PAC-dependent pulmonary artery rupture ranging between 0.03% and 0.2% [2]. The associated mortality rate in these patients could be as high 70%.
Management of PAC-dependent pulmonary artery ruptures may be accomplished by direct arterial repair, angiographic pulmonary artery embolization, lobectomy, pneumonectomy, or as recently reported by instituting extracorporeal membrane oxygenation for circulatory and ventilatory support, as well as for control and discontinuation of airway hemorrhage [4]. We present herein a case of pulmonary artery rupture due to false inflation of the PAC after open heart surgery. Successful management was achieved by advancing a Forgaty catheter parallel to the endotracheal tube into the upper airways and occluding the intermediate bronchus with the ballon tip under bronchoscopic vision.
A 76-year-old woman was admitted to our clinic with severe coronary three-vessel disease, reduced left ventricular function (ejection fraction, 45%), and high-grade mitral valve regurgitation. Significant co-morbidities included renal insufficiency, diabetes, chronic obstructive pulmonary disease, generalized atherosclerosis and pulmonary hypertension (systolic pulmonary artery pressure, 75 mm Hg). In addition, laboratory results indicated irregular antibodies that would allow only Jk(a) negative transfusions.
Elective cardiac surgery was performed using extracorporeal circulation for coronary artery revascularization and mitral valve repair. A PAC had been inserted for detailed perioperative hemodynamic monitoring through a right jugular vein sheeth and had been advanced with the inflated balloon tip to the wedge position, reached after approximately 58 cm from the skin surface level according to the pulmonary artery pressure signal. The ballon tip was then deflated and kept that way during surgery. After completing the surgical procedures, weaning from the extracorporeal circulation could be performed with mild catecholamine support.
Within the first minutes after re-establishing mechanical ventilation, severe hemoptysis was noted, accompanied by slowly decreasing peripheral oxygen saturation and an increasing need for vasopressor support. Because both pleural cavities had not been opened before, leaving the lungs untouched, the airway hemorrhage was suspected to be secondary to PAC manipulation and was derived from pulmonary circulation rather than from a bronchial artery. Most probably, the catheter had been further advanced accidentally during final placement of the patient on the surgical table. Thus, pulmonary hemorrhage might have been attributed to inflation of the balloon tip, presumably being beyond the wedge position. In fact, after opening the pleural cavities, no blood collection in the pleural cavities was found. Cardiopulmonary bypass was re-established to reduce pulmonary blood flow. Immediate intraoperative bronchioscopy was performed showing the origin of the bleeding in the right lower lobe downstream from the bifurcation into the right upper lobe. More detailed information could not be obtained under these conditions. Considering the extensive co-morbidity of the patient, including chronic obstructive pulmonary disease, lobectomy or even more extensive surgical intervention to control the bleeding seemed inappropriate. Instead, we decided to limit the consequences of endotracheal hemorrhage by excluding the right lower lobe. We introduced a Forgaty balloon tip catheter (arterial embolectomy catheter, CE 0680 ST, 6-French x 80 cm; maximum liquid volume, 2.0 cc [Bard, Olen, Belgium]) into the trachea after deflating the cuff of the endotracheal tube. Under bronchoscopic vision, the Forgaty catheter was advanced into the intermediate bronchus, and the balloon tip was carefully filled with approximately 1.2 mL saline. Complete filling was omitted so that the bronchial wall would not be damaged. Bronchoscopy revealed that the proximal end of the Forgaty's balloon tip was placed approximately 2 mm distal to the origin of the right upper lobe bronchus (Fig 1A). In contrast to a conventional airway blocker, the saline filling of the Forgaty balloon yields more constant pressure against the bronchus wall than would be established by air inflation. Surgery could be regularly completed with uneventful weaning from cardiopulmonary bypass. The circulatory status of the patient was stable when transferring her to the surgical intensive care unit.
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Fig 1. (A) Immediate postoperative chest roentgenogram with the Forgaty catheter balloon tip positioned in the intermediate bronchus (arrow). The middle and right lower lobe show consolidation indicating filling with blood and atelectasis. The left lung is ventilated regularly through the patent left main bronchus (indicated by the asterisk). (B) Chest roentgenogram on the first postoperative day. The Forgaty catheter had been withdrawn under bronchoscopic vision, and the middle and right lower lobes (indicated by the asterisk) have been carefully lavaged free from blood clods. They clearly show less consolidation and atelectasis indicating recovery and restoring ventilation.
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A postoperative chest roentgenogram showed consolidation of the presumably blood-filled middle and lower lobes with atelectasis. The balloon tip of the Forgaty catheter could be seen in the intermediate bronchus (Fig 1A). Importantly, exclusion of only the middle and right lower lobes allowed continuous undisturbed ventilation of the right upper lobe. Ventilation of the left lung was unaffected presenting a patent left main bronchus apart from basal dystelectasis. Postoperative laboratory findings showed restored blood coagulation on the first postoperative day, after substitution of thrombocytes and administration of tranexam acid. In addition, the thoracic drainage tubes did not show significant blood losses during the postoperative period. Thus, we removed the Forgaty catheter, which by then had been approximately 15 hours in situ. Under bronchoscopic vision, the Forgaty balloon tip was carefully deflated. No persistent bleeding was seen. The catheter was withdrawn and the middle and right lower lobes were carefully lavaged to remove remnant blood clods and to allow re-ventilation of the middle and right lower lobes. The subsequent chest roentgenogram (Fig 1B) presented resolving atelectasis in the re-ventilated middle and right lower lobes. No recurrence of airway hemorrhage occurred in the following postoperative course. The patient remained in stable respiratory and circulatory condition.
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Comment
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This clinical case reports a seldom complication of pulmonary artery catheterization. Direct pulmonary artery repair is believed to be the most appropriate way of dealing with this dramatic complication; however, it is often not feasible. Exclusion of the bleeding site from the ventilated airways should therefore be the basic principle. Lobectomy or even pneumonectomy may help to control such situations, but remarkably, increased mortality [5, 6]. In our case, the pulmonary artery bleeding was noted in a patient who had just undergone complex mitral valve repair and coronary artery bypass grafting (preoperative logistic EuroScore, 44.1%). As also previously recommended [2], re-establishing cardiopulmonary bypass reduced the pulmonary flow and thus facilitated to localize the intrapulmonary bleeder. In view of the co-morbidities of the patients, in specific pre-existing pulmonary hypertension and chronic obstructive pulmonary disease, we believed that additional extensive lung resection was too risky. Bronchoscopy revealed that the bleeder was localized in the right lower lobe, and no blood collection was noted in the pleural cavities. Thus, intra-airway "packing" seemed the most appropriate means to control the situation. Insertion of the Forgathy catheter in parallel to the endotracheal tube allowed undisturbed ventilation in parallel to continuous bronchoscopy. In addition, favoring this catheter instead of a conventional bronchus blocker, it also allowed ventilation of the right upper lobe, which was not effected by the bleeding. Moreover, filling the Forgaty catheter balloon tip with saline allowed stable tamponade of the bronchial wall, which would have not been the case, when air would have been used instead. However, the instillation of saline into the ballon tip must be handled with great care not to risk damage to the bronchial wall.
In conclusion, pulmonary artery rupture attributed to inflation of a PAC balloon tip that may cause fatal bleeding. Immediate intervention is needed, considering the high mortality rate of massive hemoptysis [5, 6], particularly in freshly operated and already critically ill cardiac surgery patients. In our case, a second pump run plus blocking the intermediate bronchus with a Forgaty catheter was effective and allowed prompt control of the bleeding. The fact that the temporarily excluded airway segments became available for respiration after removal of the intrabronchial block and careful lavage is additionally favorable, particularly in patients with relevant pulmonary disease, which may not allow lobectomy or even pneumonectomy. However, we must be mindful that bronchial occlusion may be associated with secondary complications, such as bronchial wall damage, hypoxia, and pneumonia.
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References
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- Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter N Engl J Med 1970;283:447-451.[Medline]
- Abreu AR, Campos MA, Krieger BP. Pulmonary artery rupture induced by a pulmonary artery catheter: a case report and review of the literature J Intensive Care Med 2004;19:291-296.[Abstract/Free Full Text]
- Swan HJ, Ganz W. Complications with flow-directed balloon-tipped catheters Ann Intern Med 1979;91:494.[Abstract/Free Full Text]
- Bianchini R, Melina G, Benedetto U, Rossi M, Fiorani B, Iasenzaniro M, Sinatra R. Extracorporeal membrane oxygenation for Swan-Ganz induced intraoperative hemorrhage Ann Thorac Surg 2007;83:2213-2214.[Abstract/Free Full Text]
- Fartoukh M, Khalil A, Louis L, et al. 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 Respir Res 2007;8:11.[Medline]
- Jougon J, Ballester M, Delcambre F, et al. Massive hemoptysis: what place for medical and surgical treatment Eur J Cardiothorac Surg 2002;22:345-351.[Abstract/Free Full Text]
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Abstract
Introduction
