Bronchial Infusion Therapy (BIT)
1989; Elsevier BV; Volume: 96; Issue: 3 Linguagem: Inglês
10.1378/chest.96.3.456
ISSN1931-3543
Autores Tópico(s)Nosocomial Infections in ICU
ResumoOf the many vexations facing chest physicians, certainly one of the more problematic and occasionally dramatic is the patient with persistent hemoptysis, particularly of the massive variety. What constitutes “massive” varies: in a respiratory cripple a small amount of blood may asphyxiate, whereas a previously healthy individual may tolerate hundreds of milliliters of respiratory blood loss. Besides therapies directed at the underlying disease process, a variety of nonsurgical interventions have evolved over the years with the primary aim of stopping the bleeding. These include IV pitressin,1Magee G Williams MH Treatment of massive hemoptysis with intravenous pitressin.Lung. 1982; 160: 165-169Crossref PubMed Scopus (16) Google Scholar, 2Trimble HG Wood JR Pulmonary hemorrhage: its control by the use of intravenous pituitrin.Dis Chest. 1950; 18: 345-351Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar double-lumen endotracheal tubes,3Shivaram U Finch P Nowak P Plastic endobronchial tubes in the management of life-threatening hemoptysis.Chest. 1987; 92: 1108-1110Crossref PubMed Scopus (17) Google Scholar Fogarty-type endobronchial balloon catheters,4Gourin A Garzon AA Control of hemorrhage in emergency pulmonary resection for massive hemoptysis.Chest. 1975; 68: 120-121Crossref PubMed Scopus (28) Google Scholar, 5Hiebert CA Balloon catheter control of life threatening hemoptysis.Chest. 1974; 66: 308-309Crossref PubMed Scopus (35) Google Scholar, 6Saw EC Gottlieb LS Yokoyama T Lee BC Flexible fiberoptic bronchoscopy and endobronchial tamponade in the management of massive hemoptysis.Chest. 1976; 70: 589-591Crossref PubMed Scopus (71) Google Scholar iced saline solution,7Conlan AA Hurwitz SS Management of massive hemoptysis with the rigid bronchoscope and cold saline lavage.Thorax. 1980; 35: 901-904Crossref PubMed Scopus (98) Google Scholar iced saline solution with thrombin,8Kobayashi J Kuratomi Y Matuoka R Kitamura S Local administration of cold saline and thrombin for the treatment of bleeding induced by transbronchial lung biopsy.Chest. 1987; 92: 1415Google Scholar laser therapy,9Edmonstone WM Nanson EM Woodcock AA Millard FJ Hetzel MR Life-threatening hemoptysis controlled by laser photocoagulation.Thorax. 1983; 38: 788-789Crossref PubMed Scopus (28) Google Scholar endobronchial irradiation,10Rabie T Wilson RK Easley JD Teague RB Bloom K Lawrence EC et al.Palliation of bronchogenic carcinoma with 198AU implantation using the fiberoptic bronchoscope.Chest. 1986; 90: 641-645Crossref PubMed Scopus (12) Google Scholar external beam irradiation,11Shneerson JM Emerson PA Phillips RH Radiotherapy for massive hemoptysis from an aspergilloma.Thorax. 1980; 35: 953-954Crossref PubMed Scopus (30) Google Scholar and endovascular therapy, which comprises primarily bronchial artery embolization (BAE).12Rabkin JE Astafjev VI Gothman LN Grigorjev YG Transcatheter embolization in the management of pulmonary hemorrhage.Radiology. 1987; 163: 361-365Crossref PubMed Scopus (164) Google Scholar The wide variety of therapies available leads one to conclude no therapy is uniquely efficacious, safe, available and durable, but BAE has the largest experience and is generally the procedure of choice, particularly when critical volumes of hemoptysis are present in a poor surgical candidate. However, BAE is “high tech,” has some infrequent but serious risk (spinal artery embolization) and requires an invasive radiologist who is readily available and experienced in the technique.The article in this issue of Chest by Tsukamoto and colleagues (see page 473) describes a simple technique of instilling thrombin alone or fibrinogen followed by thrombin through the channel of a fiberoptic bronchoscope directly into a bleeding bronchus. The appeal of this technique of bronchial infusion therapy (BIT) lies in the more widespread availability of bronchoscopes and bronchoscopists than invasive radiologists and the well-established record of fiberoptic bronchoscopy for ease and safety. However, a few cautionary notes are needed.First, commercial fibrinogen has not been available in this country since 1978,13FDA Drug Bulletin 1978; 8: 15Google Scholar because of the hepatitis risk then and the added risk of human immunodeficiency virus (HIV) now. Thus, the fibrinogen followed by thrombin method described as more effective than thrombin alone is not readily available to bronchoscopists here. This should not be a major problem, since thrombin alone should be effective if fibrinogencontaining blood is present in the bronchus. Alternatively, cryoprecipitate, with a lessened risk of hepatitis and HIV transmission, could be used if necessary.14Lupinett FM Stoney WS Alford WC Burrus GR Glassford DM Petracek MR et al.Cryoprecipitate—topical thrombin glue.J Thorac Cardiovasc Surg. 1985; 90: 502-505Google Scholar Second, it may be overstating the obvious to say that BIT should subtend the smallest order bronchus possible in order to maximize respiratory function. Third is the question of what role BIT will play in the diagnosis and therapy of patients with hemoptysis. In my practice and that of my colleagues, the patient with refractory hemoptysis of whatever amount is not seen very often. Over an eight-year period at my institution, there have been two patients referred for BAE, out of some 3,200 bronchoscopies of which approximately 10 percent were done for hemoptysis. In contrast, the authors had 33 cases in five years, probably reflecting a higher incidence of suppurative lung disease in their practice. Most hemoptysis simply stops if the patient is put at rest and effective therapy for his underlying condition is given. Even with idiopathic hemoptysis this occurs, and the prognosis is excellent.15Douglass BE Carr DT Prognosis in idiopathic hemoptysis.JAMA. 1952; 148: 764-765Crossref Scopus (13) Google Scholar These considerations aside, I concur with the authors' conclusion that BIT should be considered an effective alternative to BAE, but I would reserve its use for those refractory cases in which routine measures have failed. This approach potentially represents a standard primary therapy and may complement other medical, endobronchial, endovascular, and surgical therapies. However, the urgency of massive hemoptysis, the multiple etiologies thereof, and the varying availability of the differing therapies will limit attempts to prospectively establish what constitutes “optimal” primary treatment for persistent hemoptysis. Of the many vexations facing chest physicians, certainly one of the more problematic and occasionally dramatic is the patient with persistent hemoptysis, particularly of the massive variety. What constitutes “massive” varies: in a respiratory cripple a small amount of blood may asphyxiate, whereas a previously healthy individual may tolerate hundreds of milliliters of respiratory blood loss. Besides therapies directed at the underlying disease process, a variety of nonsurgical interventions have evolved over the years with the primary aim of stopping the bleeding. These include IV pitressin,1Magee G Williams MH Treatment of massive hemoptysis with intravenous pitressin.Lung. 1982; 160: 165-169Crossref PubMed Scopus (16) Google Scholar, 2Trimble HG Wood JR Pulmonary hemorrhage: its control by the use of intravenous pituitrin.Dis Chest. 1950; 18: 345-351Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar double-lumen endotracheal tubes,3Shivaram U Finch P Nowak P Plastic endobronchial tubes in the management of life-threatening hemoptysis.Chest. 1987; 92: 1108-1110Crossref PubMed Scopus (17) Google Scholar Fogarty-type endobronchial balloon catheters,4Gourin A Garzon AA Control of hemorrhage in emergency pulmonary resection for massive hemoptysis.Chest. 1975; 68: 120-121Crossref PubMed Scopus (28) Google Scholar, 5Hiebert CA Balloon catheter control of life threatening hemoptysis.Chest. 1974; 66: 308-309Crossref PubMed Scopus (35) Google Scholar, 6Saw EC Gottlieb LS Yokoyama T Lee BC Flexible fiberoptic bronchoscopy and endobronchial tamponade in the management of massive hemoptysis.Chest. 1976; 70: 589-591Crossref PubMed Scopus (71) Google Scholar iced saline solution,7Conlan AA Hurwitz SS Management of massive hemoptysis with the rigid bronchoscope and cold saline lavage.Thorax. 1980; 35: 901-904Crossref PubMed Scopus (98) Google Scholar iced saline solution with thrombin,8Kobayashi J Kuratomi Y Matuoka R Kitamura S Local administration of cold saline and thrombin for the treatment of bleeding induced by transbronchial lung biopsy.Chest. 1987; 92: 1415Google Scholar laser therapy,9Edmonstone WM Nanson EM Woodcock AA Millard FJ Hetzel MR Life-threatening hemoptysis controlled by laser photocoagulation.Thorax. 1983; 38: 788-789Crossref PubMed Scopus (28) Google Scholar endobronchial irradiation,10Rabie T Wilson RK Easley JD Teague RB Bloom K Lawrence EC et al.Palliation of bronchogenic carcinoma with 198AU implantation using the fiberoptic bronchoscope.Chest. 1986; 90: 641-645Crossref PubMed Scopus (12) Google Scholar external beam irradiation,11Shneerson JM Emerson PA Phillips RH Radiotherapy for massive hemoptysis from an aspergilloma.Thorax. 1980; 35: 953-954Crossref PubMed Scopus (30) Google Scholar and endovascular therapy, which comprises primarily bronchial artery embolization (BAE).12Rabkin JE Astafjev VI Gothman LN Grigorjev YG Transcatheter embolization in the management of pulmonary hemorrhage.Radiology. 1987; 163: 361-365Crossref PubMed Scopus (164) Google Scholar The wide variety of therapies available leads one to conclude no therapy is uniquely efficacious, safe, available and durable, but BAE has the largest experience and is generally the procedure of choice, particularly when critical volumes of hemoptysis are present in a poor surgical candidate. However, BAE is “high tech,” has some infrequent but serious risk (spinal artery embolization) and requires an invasive radiologist who is readily available and experienced in the technique. The article in this issue of Chest by Tsukamoto and colleagues (see page 473) describes a simple technique of instilling thrombin alone or fibrinogen followed by thrombin through the channel of a fiberoptic bronchoscope directly into a bleeding bronchus. The appeal of this technique of bronchial infusion therapy (BIT) lies in the more widespread availability of bronchoscopes and bronchoscopists than invasive radiologists and the well-established record of fiberoptic bronchoscopy for ease and safety. However, a few cautionary notes are needed. First, commercial fibrinogen has not been available in this country since 1978,13FDA Drug Bulletin 1978; 8: 15Google Scholar because of the hepatitis risk then and the added risk of human immunodeficiency virus (HIV) now. Thus, the fibrinogen followed by thrombin method described as more effective than thrombin alone is not readily available to bronchoscopists here. This should not be a major problem, since thrombin alone should be effective if fibrinogencontaining blood is present in the bronchus. Alternatively, cryoprecipitate, with a lessened risk of hepatitis and HIV transmission, could be used if necessary.14Lupinett FM Stoney WS Alford WC Burrus GR Glassford DM Petracek MR et al.Cryoprecipitate—topical thrombin glue.J Thorac Cardiovasc Surg. 1985; 90: 502-505Google Scholar Second, it may be overstating the obvious to say that BIT should subtend the smallest order bronchus possible in order to maximize respiratory function. Third is the question of what role BIT will play in the diagnosis and therapy of patients with hemoptysis. In my practice and that of my colleagues, the patient with refractory hemoptysis of whatever amount is not seen very often. Over an eight-year period at my institution, there have been two patients referred for BAE, out of some 3,200 bronchoscopies of which approximately 10 percent were done for hemoptysis. In contrast, the authors had 33 cases in five years, probably reflecting a higher incidence of suppurative lung disease in their practice. Most hemoptysis simply stops if the patient is put at rest and effective therapy for his underlying condition is given. Even with idiopathic hemoptysis this occurs, and the prognosis is excellent.15Douglass BE Carr DT Prognosis in idiopathic hemoptysis.JAMA. 1952; 148: 764-765Crossref Scopus (13) Google Scholar These considerations aside, I concur with the authors' conclusion that BIT should be considered an effective alternative to BAE, but I would reserve its use for those refractory cases in which routine measures have failed. This approach potentially represents a standard primary therapy and may complement other medical, endobronchial, endovascular, and surgical therapies. However, the urgency of massive hemoptysis, the multiple etiologies thereof, and the varying availability of the differing therapies will limit attempts to prospectively establish what constitutes “optimal” primary treatment for persistent hemoptysis.
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