Bronchoscopic treatment

Instillation of epinephrine (1:20 000) is advocated to control bleeding, although its efficacy in life threatening haemoptysis is uncertain.2 The topical application of thrombin and thrombin-fibrinogen solutions has also had some success, but further study is required before widespread use can be recommended.28

In massive haemoptysis, isolation of a bleeding segment with a balloon catheter may prevent aspiration of blood into the large airways, thereby maintaining airway patency and oxygenation. Having identified the segmental bronchus that is the source of bleeding, the bronchoscope is wedged in the orifice. A size 4-7 Fr 200 cm balloon catheter is passed through the working channel of the bronchoscope and the balloon is inflated in the affected segment, isolating the bleeding site (fig 7).2 A double lumen balloon catheter (6 Fr, 170 cm long) with a detachable valve at the proximal end has recently been designed that passes through the bronchoscope channel and allows the removal of the bronchoscope without any modification of the catheter.29 The second channel of the catheter may also be used to instil vasoactive drugs to help control bleeding. The bronchoscope can then be removed over the catheter, which is left in place for 24 hours. The balloon may be deflated under controlled conditions with bronchoscopic visualisation and the catheter removed if the bleeding has stopped. The prolonged use of balloon tamponade catheters should be avoided to prevent ischaemic mucosal injury and post-obstructive pneumonia. Endobronchial tamponade should only be applied as a temporary measure until a more definitive therapeutic procedure can be deployed.

Neodymium-yttrium-aluminium-garnet (Nd-YAG) laser photocoagulation has been used with some success in the management of massive haemorrhage associated with directly visualised endobronchial lesions.30 However, targeting the culprit vessel with the laser beam can be difficult in the presence of ongoing bleeding.

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