Severe Hemoptysis Associated with Pulmonary Aspergilloma: Percutaneous Intracavitary Treatment

doi:10.1378/chest.94.6.1225

Chest

Volume 94, Issue 6, December 1988, Pages 1225-1231

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Surgical therapy for massive hemoptysis associated with pulmonary aspergilloma carries a high morbidity and mortality in patients with limited pulmonary reserve. Bronchial artery embolization has proven ineffective in treating and in preventing recurrent episodes of hemoptysis in this group of patients. Over a four-and-one-half year period, we have successfully treated six episodes of acute hemoptysis in four patients using a percutaneously placed catheter and intracavitary instillation of amphotericin B, N-acetylcysteine, and aminocaproic acid. Advantages of this method of treatment for patients with severely compromised pulmonary reserve include: (1) no further loss of lung function; (2) ease and rapidity of catheter insertion; (3) prompt response to treatment; (4) relatively short hospitalization; and (5) ability to repeat the procedure in the same or another cavity if necessary. (Chest 1988; 94:1225-31)

Section snippets

MATERIALS AND METHODS

Four patients with aspergilloma were treated for six episodes of hemoptysis from 1983 to 1987. There were three men and one woman, with a mean age of 54 years (range 48 to 63 years). Underlying lung diseases were sarcoidosis in three and bullous lung disease in one. Patient data are summarized in Table 1. Each patient had a chest roentgenogram documenting an upper lobe intracavitary mycetoma from three months to ten years prior to admission. Serum Aspergillus precipitins were positive in each

RESULTS

Six episodes of acute hemoptysis secondary to an aspergilloma were treated with percutaneous intracavitary instillation of amphotericin B and N-acetylcysteine. Table 1 contains treatment data summarized. In one case (Table 1, patient la), prior bronchial artery embolization was performed but was unsuccessful in controlling hemoptysis from a left upper lobe mycetoma. During another course of therapy in this patient (Table 1, patient 1c), aminocaproic acid was added to the regimen to control

CASE REPORT

A 49-year-old woman (Table 1, patient 1 a, b, c) with biopsy-proven sarcoidosis was admitted to the Hospital of the University of Pennsylvania with massive hemoptysis in March 1983. She first sought medical attention in 1972, when she complained of progressive dyspnea. After sarcoidosis was diagnosed, she started alternate day prednisone therapy. She experienced several limited episodes of scant hemoptysis during the next five years for which she did not seek medical attention. In 1977, a chest

DISCUSSION

Although the treatment of choice for patients with symptomatic pulmonary aspergilloma is surgical resection of the involved segments, this therapy suffers from several drawbacks. The most significant of these is the very high operative morbidity and mortality which occurs in the setting of reduced pulmonary reserve and especially when diffuse underlying disease is present.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 22, 23 Israel et al² reviewed their surgical experience with aspergillomas in

ACKNOWLEDGMENTS

We would like to thank Dr. Howard Eisen (Hospital of the University of Pennsylvania) for his assistance in this study and Mr. Henry Way for his skillful preparation of the manuscript.

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Cited by (82)

Non-surgical treatment options for pulmonary aspergilloma
2020, Respiratory Medicine
Citation Excerpt :
Most importantly, lung function is preserved in the process of treatment, making this a good alternative to surgery for patients with limited pulmonary reserve. Length of hospital stay is significantly shorter for patients receiving intracavitary instillation of amphotericin B (ICAB) than those who were treated by surgery [54]. Furthermore, intracavitary instillation of antifungals can be done on an outpatient basis.
Aspergilloma, also known as mycetoma or fungus ball, is the most common manifestation of pulmonary involvement by Aspergillus species. The fungal ball typically forms within preexisting cavities of the lungs. Diagnosis requires both radiographic evidence along with serologic or microbiologic evidence of Aspergillus species involvement. While clinical features such as hemoptysis, chest pain, shortness of breath, cough, and fever are helpful in diagnosis, they are non-specific symptoms. Surgery is currently the mainstay of treatment for aspergilloma but is associated with considerable mortality and morbidity. Alternative options exist for patients who are poor surgical candidates and for those who prefer a less invasive treatment modality. Systemic treatment with amphotericin B is ineffective and is not recommended as a monotherapy, but systemic azoles is effective in approximately 50–80% of patients. Potential alternatives to surgery include intracavitary instillation or endobronchial administration of antifungal medication, as well as direct transbronchial aspergilloma removal. Bronchial artery embolization and radiotherapy are options to manage hemoptysis until definite eradication of the aspergilloma. More rigorous studies are needed to better establish non-surgical treatment paradigm for inoperable patients.
Bronchoscopic delivery of aminocaproic acid as a treatment for pulmonary bleeding: A case series
2020, Pulmonary Pharmacology and Therapeutics
Bronchoscopy is an essential therapeutic modality in the treatment of pulmonary bleeding. Although numerous endoscopic treatments exist, topical ε-aminocaproic acid has not been described in the literature. This study documents the use of this novel treatment for pulmonary bleeding and compares it to available evidence for tranexamic acid, a similar anti-fibrinolytic agent.
Case-series study.
ICU and general inpatient floors of a tertiary medical center.
Forty-six patients receiving endobronchial ε-aminocaproic acid for the treatment or prevention of pulmonary bleeding.
Of the 46 patients included in the study, 41.6% and 13% presented with non-massive and massive hemoptysis, respectively. In patients with active pulmonary bleeding, endobronchial application of ε-aminocaproic acid and accompanying therapies resulted in cessation of bleeding in 94.7% of cases. A total of six patients received ε-aminocaproic acid monotherapy; in three patients with active bleeding, 100% achieved hemostasis after treatment. Of the 36 patients successfully treated for active pulmonary bleeding, 27.8% had recurrent bleeding within 30 days. Thirty-day adverse events were as follows: death (10 patients), deep vein thrombosis (2 patients), renal failure (2 patients), and stroke (2 patients).
Endobronchial administration of ε-aminocaproic acid during bronchoscopy may be a safe and efficacious option in the treatment and prevention of pulmonary bleeding. Further studies are necessary to better define ε-aminocaproic acid's safety profile, optimal routes of administration, and comparative effectiveness to tranexamic acid.
Exacerbation of chronic pulmonary aspergillosis was associated with a high rebleeding rate after bronchial artery embolization
2019, Respiratory Investigation
Hemoptysis is a common symptom associated with chronic pulmonary aspergillosis (CPA). While surgery is the primary choice to manage hemoptysis, it is often avoided because patients with CPA are more likely to have complications such as respiratory insufficiency and low pulmonary function. Bronchial artery embolization (BAE) may be considered one of the treatments of massive and persistent hemoptysis for such patients.
We retrospectively reviewed medical records of 41 patients, admitted to National Hospital Organization Tokyo National Hospital, Tokyo, Japan with hemoptysis arising from CPA between January 2011 to December 2016, who were considered inoperable and had undergone BAE.
Out of the 41 cases analyzed in this study, 21 (51.2%) developed rebleeding after BAE within the mean follow-up duration of 24 months. The non-rebleeding rate of patients after BAE was 92.7% within a month and 65.8% within a year. Patients who developed rebleeding had significantly more non-bronchial systemic arteries responsible for the bleeding compared with patients who did not develop rebleeding (mean of 2.55 vs. 4.86, respectively, P = 0.011). Patients with stable or improved radiological findings demonstrated significantly lower rebleeding rates than those with radiological deterioration (P < 0.001). The non-rebleeding patients had significantly better survival than those with rebleeding (79.7% vs. 39.9% over 5 years, P = 0.046).
Bronchial artery embolization was effective in controlling hemoptysis in patients with CPA, especially those who could not undergo surgical resection. However, disease control of CPA was important to prevent rebleeding over the long term and to improve survival after BAE.
Diagnosis and Treatment of Hemoptysis
2016, Archivos de Bronconeumologia
La hemoptisis es la expectoración de sangre proveniente del árbol traqueobronquial. Las enfermedades que más frecuentemente la originan son las bronquiectasias, la bronquitis crónica y el carcinoma broncogénico. Las arterias bronquiales son el origen de la mayoría de las hemoptisis. Ante un paciente con sospecha de hemoptisis se debe confirmar su existencia, establecer su gravedad, localizar el origen y determinar su causa. La radiografía de tórax posteroanterior y lateral es la primera prueba de imagen que debe realizarse, aunque la existencia de una radiografía de tórax normal no excluye la posibilidad de malignidad u otra patología de base. Debe realizarse TC multidetector (TCMD) de tórax en todos los pacientes con hemoptisis franca, en los que presentan esputo hemoptoico y sospecha de bronquiectasias o factores de riesgo de carcinoma broncogénico, y en los que tienen radiografía de tórax patológica. La angio-TCMD ha sustituido a la arteriografía como método diagnóstico de las arterias que son fuente de sangrado en las hemoptisis. La angio-TCMD es una técnica de imagen no invasiva que identifica correctamente la presencia, el origen, el número y el trayecto de las arterias sistémicas torácicas, bronquiales y no bronquiales, y de las arterias pulmonares que pueden ser fuente del sangrado. El tratamiento más seguro y eficaz para detener el sangrado en la mayoría de los casos de hemoptisis masiva o recurrente es la embolización endovascular. La embolización está indicada en todos los pacientes con hemoptisis amenazante o recurrente en los que se detectan arterias patológicas en la angio-TCMD. La broncoscopia flexible juega un papel primordial en el diagnóstico de la hemoptisis, tanto de la expectoración hemoptoica como de la hemoptisis franca. Puede ser realizada rápidamente en la cama del paciente (UCI) y, además de su utilidad en el control inmediato de la hemorragia, tiene una alta rentabilidad en la localización del sangrado. La broncoscopia flexible es el procedimiento inicial de elección en pacientes con hemoptisis amenazante e inestabilidad hemodinámica, donde el control de la hemorragia es vital. La cirugía en estos casos tiene una tasa de mortalidad muy alta, por lo que la indicación actual de cirugía en la hemoptisis amenazante está reservada para aquellas situaciones en las que la causa de la misma sea tributaria de tratamiento quirúrgico y haya una localización concreta y fiable del origen de la hemorragia.
Hemoptysis is the expectoration of blood from the tracheobronchial tree. It is commonly caused by bronchiectasis, chronic bronchitis, and lung cancer. The expectorated blood usually originates from the bronchial arteries. When hemoptysis is suspected, it must be confirmed and classified according to severity, and the origin and cause of the bleeding determined. Lateral and AP chest X-ray is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology. Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray. MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding. MDCT angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding. Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis. The procedure can be performed rapidly at the bedside (intensive care unit); it can be used for immediate control of bleeding, and is also effective in locating the source of the hemorrhage. Flexible bronchoscopy is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis, in whom control of bleeding is of vital importance. In these cases, surgery is associated with an extremely high mortality rate, and is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located.
A modern series of percutaneous intracavitary instillation of amphotericin B for the treatment of severe hemoptysis from pulmonary aspergilloma
2013, Chest
Citation Excerpt :
Nearly 50% of all hemoptysis episodes resolved during or following ICAB without BAE. This is consistent with previous literature suggesting that ICAB is useful for acute, severe hemoptysis from aspergillomas.28–30,33,39 However, the fact that patients who received BAE and ICAB had a trend toward a lower rate of recurrence than those who had ICAB alone suggests that the combination of these two procedures may delay or prevent recurrent significant hemoptysis.
Pulmonary aspergillomas may cause life-threatening hemoptysis. The treatment of this condition is problematic because poor pulmonary function often precludes definitive surgical resection.
We retrospectively reviewed all patients hospitalized at our institution for hemoptysis associated with an aspergilloma over an 8-year period and who underwent percutaneous intracavitary instillation of amphotericin B (ICAB). ICAB consisted of catheter placement into the aspergilloma cavity with subsequent instillation of 50 mg amphotericin B in 20 mL 5% dextrose solution daily for 10 days.
ICAB was attempted for 23 distinct episodes of severe hemoptysis in 20 individual patients. Catheter placement was successful in 21 of the 23 episodes (91%), and of these, ICAB instillation was successfully completed in 20 episodes (95%). In these 20 episodes, hemoptysis ceased by hospital discharge in 17 of 20 patients (85%) and in all 18 who survived until a follow-up visit 1-month after treatment. Pneumothorax occurred in six of 23 (26%) catheter placement attempts without long-term complications. Recurrence of serious hemoptysis occurred after six of 18 episodes for which follow-up was available. Potential risk factors associated with severe, recurrent hemoptysis were a size increase or reappearance of the aspergilloma on a chest CT scan (P = .001), bleeding diathesis (P = .08), and lack of bronchial artery embolization during index hospitalization (P = .07).
Our data suggest that ICAB is an effective short-term treatment to control severe hemoptysis caused by pulmonary aspergilloma. The long-term benefit of this procedure is unknown. We identified several potential risk factors for recurrent hemoptysis after ICAB that could be examined prospectively in future trials.
Pulmonary aspergilloma. Clinical aspects and surgical treatment outcome
2012, Thoracic Surgery Clinics
Citation Excerpt :
Residual pleural space: obliteration of the residual pleural cavity reduces the risk of pleural empyema from incomplete filling of the pleural space by the remaining lobes (Fig. 10) Despite high recurrence rates, direct intracavitary administration of antifungal agents should be reserved for inoperable patients.39 Amphotericin-B, miconazole, nystatin, N-acetylcysteine, sodium iodide, and natamycin can be instilled through either percutaneous or intrabronchial catheters.

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Chest

Clinical InvestigationsSevere Hemoptysis Associated with Pulmonary Aspergilloma: Percutaneous Intracavitary Treatment

Section snippets

MATERIALS AND METHODS

RESULTS

CASE REPORT

DISCUSSION

ACKNOWLEDGMENTS

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Am J Med

Tubercle (London)

Chest

Chest

Chest

Chest

Clinical Investigations
Severe Hemoptysis Associated with Pulmonary Aspergilloma: Percutaneous Intracavitary Treatment