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a Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, China
b Minimally Invasive Centre, Union Hospital, Hong Kong, China
(Email: swan{at}cuhk.edu.hk; yimap{at}cuhk.edu.hk).
Massive hemoptysis is an uncommon but life threatening event (ie, it occurs in less than 5% of patients with hemoptysis), which calls for immediate medical attention to control the airway and evacuate the clot by bronchial toileting, as well as to identify the source of bleeding. Andréjak and colleagues [1] are to be congratulated for reporting their surgical results in dealing with massive hemoptysis in 111 patients during an 11-year period. Their experience echoed nicely with our own [2], which emphasized the importance of a multidisciplinary approach (ie, involving surgeons, intensivists, and interventional radiologists) in improving outcome. Although their definition of "severe hemoptysis" varies from the "life-threatening massive hemoptysis" in our report (defined as an expectoration of 600 mL or more of blood during the course of 24 hours), surgical lung resection is no longer the single effective option in managing massive hemoptysis, as previously believed. Specifically, bronchial arterial embolization should be routinely attempted first to stabilize the critically ill patients, and surgical resection is reserved for only 14% [1] or 23% [2] of patients with massive hemoptysis.
One confounding factor in the management of massive hemoptysis is that it could recur any time without warning. Even after an initial successful attempt in controlling bleeding with bronchial arterial embolization, surgical lung resection often remains an indispensable part of the overall management. In regard to timing of the operation, the experience of Andréjak and colleagues [1] supported our own observations. The extremely high surgical mortality in patients undergoing emergency lung resection in this study (ie, 34 of 48 patients died, with "emergency" defined as within 5 ± 6 days of referral [1]), which once again highlighted the importance of this "temporizing" strategy. In addition, our own experience showed that the routine use of rigid bronchoscopy for preoperative bronchial toileting could improve surgical outcome [2].
Based on their multivariate analysis, Andréjak and colleagues [1] also recognized several independent predictors of poor outcome, such as chronic alcoholism, the need for mechanical ventilation, or vasoactive drugs on admission, and preoperative blood transfusion. These factors may be used prospectively to stratify patients into different risk categories in future studies. More importantly, they are to be validated among different patient populations. For instance, more than half of the patients in Andréjak and colleagues' [1] series had mycetoma or cancer, whereas active tuberculosis and bronchiectasis were the predominant cause in our location of the world [2].
Management of life-threatening massive hemoptysis elegantly reminds us that thoracic surgeons need not only focus on techniques, but also on the timing of an operation, particularly, when not to do a procedure.
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