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Endobronchial Thrombolysis With Streptokinase for Airway Obstruction Due to Blood Clots
Case Report Endobronchial Thrombolysis With Streptokinase for Airway Obstruction Due to Blood Clots ZOLTAN VAJO,
M.D., AND JAMES M.
PARISH,
M.D.
To our knowledge, only four reports have previously described endobronchial thrombolysis with streptokinase for airway obstruction due to blood clots; the highest dose used was 80,000 U. Herein we describe a 21-year-old woman with pulmonary embolism who experienced life-threatening airway obstruction due Endobronchial bleeding can result from various causes, including pulmonary embolism, adenoma, carcinoma, broncholiths, foreign bodies, trauma, sarcoidosis, cavitary histoplasmosis, multiple myeloma, Kaposi's sarcoma, and spontaneous hemoptysis, or it can occur after fiberoptic bronchoscopy, biopsy, and suctioning.!? Airway obstruction caused by blood clots is a rare but potentially lifethreatening complication of endobronchial hemorrhage. Treatment methods include manual removal by forceps extraction, suctioning, saline solution lavage, balloon-tip embolectomy, and coude catheter manipulation. Rigid bronchoscopic methods are usually effective but cannot be performed through an endotracheal tube; therefore, mechanical ventilation can be a problem.
REPORT OF CASE A 21-year-old woman with a history of subacute bacterial endocarditis was admitted to a hospital because of hemoptysis and mild shortness of breath. The patient was found to have right subclavian vein thrombosis due to an indwelling central venous catheter. Shortly after admission, the patient experienced pronounced hemoptysis, severe dyspnea, tachypnea, and agitation due to pulmonary embolism. The respiratory rate was 38/min, and the oxyhemoglobin saturation decreased to 70% on pulse oximetry. A physical examination revealed decreased breath sounds and wheezing over the right lung. A non-rebreather mask with 100% oxygen was used, but no improvement was noted. From the Department of Medicine (Z.V.l, Maricopa Medical Center, Phoenix, Arizona; and Division of Thoracic Diseases and Critical Care (J.M.P.l, Mayo Clinic Scottsdale, Scottsdale, Arizona. Address reprint requests to Dr. Zoltan Vajo, Department of Medicine, Maricopa Medical Center, 2601 E. Roosevelt, Phoeniz, AZ 85008. Mayo Clin Proc 1996; 71 :595-596
to a large blood clot in the distal trachea. Streptokinase (120,000 U), injected through a fiberoptic bronchoscope, partially dissolved the clot. The rest of the clot was removed easily with forceps and suctioning. No complications occurred. (Mayo Clin Proc 1996; 71:595-596) Emergency chest roentgenography showed atelectasis of the lower and middle lobes of the right lung. The patient continued to have hemoptysis, and her respiratory status worsened; intubation and mechanical ventilation were necessary. After initiation of mechanical ventilation, the tidal volume and oxygen saturation decreased, and the peak airway pressure increased. Fiberoptic bronchoscopy revealed a firm blood clot that was obstructing about 90% of the distal trachea and was completely obstructing the right main stem bronchus. Rigid bronchoscopy was considered but was not performed. Repeated manual extraction methods with forceps and baskets failed to remove the clot. Streptokinase, 1,000 U/mL of isotonic saline, was then instilled into the clot in 10- to l5-mL aliquots for a total dose of 120,000 U during a 90-minute period. This strategy partially dissolved the clot, and the rest was removed easily with biopsy forceps and suctioning. Ventilatory factors improved dramatically, and repeated chest roentgenography showed resolution of the atelectasis. The patient was subsequently extubated and dismissed from the hospital. No complications occurred.
DISCUSSION To our knowledge, use of endobronchial thrombolysis with streptokinase has been previously reported four times. The doses, which ranged from 30,000 to 80,000 U in 5- to 20-mL aliquots of isotonic saline solutions and contained 1,000 to 2,000 U of streptokinase per milliliter, were administered for 30 to 60 minutes.t" The highest total dose given was 80,000 U.6 In the current case, we were able to use endobronchial streptokinase therapy safely, even in a substantially higher dose than has previously been reported. Endobronchial use of other thrombolytics has been reported only once.' Botnick and Brown? administered a total 595
© 1996 Mayo Foundationfor Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
596
Mayo Clin Proc, June 1996, Vol 71
ENDOBRONCHIAL STREPTOKINASE THERAPY
of 15,000 U of urokinase (5,000 U/mL in sterile water in 2.5 mL aliquots) during a 3D-minute period. Their attempt to resolve the obstruction caused by the thrombus was also successful; however, removal of the rest of the clot necessitated rigid bronchoscopy. They observed no complications. Endobronchial use of tissue plasminogen activator has not been reported. The use of endobronchial streptokinase therapy for airway obstruction caused by blood clots seems to be appropriate when rigid bronchoscopy is not immediately available, manual extraction methods are unsuccessful, and immediate intervention is indicated. Moreover, we believe that, once the optimal dosage and route of administration are established, it may become the treatment of choice in the aforementioned conditions. Furthermore, we agree with Maxwell and Stauffer" that, based on the limited information available, the use of streptokinase in a solution of 1,000 U/mL of normal saline, which is instilled in 10- to 15-mL aliquots every 5 to 10 minutes through the fiberoptic bronchoscope, seems to be adequate. Occasionally, with this approach, rigid bronchoscopy may be unnecessary, and thus continu-
ous mechanical ventilation is possible through an endotracheal tube. Further experience with urokinase may demonstrate similar results.
REFERENCES
1. Chang JC, Cregler LL. Hemoptysis in a patient with conges-
2. 3. 4. 5. 6. 7.
tive heart failure and pulmonary emboli. J Nat! Med Assoc 1994; 86:383-386 Cahill BC, Ingbar DR. Massive hemoptysis: assessment and management. Clin Chest Med 1994 Mar; 15:147-167 Greenberg lE, Fischl MA, Berger JR. Upper airway obstruction secondary to acquired immunodeficiency syndromerelated Kaposi's sarcoma. Chest 1985;88:638-640 Cole RP, GrossmanGJ. Endobronchial streptokinase for bronchial obstructionby blood clots [letter]. N Engl J Med 1983; 308:905-906 Thomson DB. Endobronchial streptokinase to dissolvea right mainstemclot [letter]. Chest 1986; 89:904 Maxwell SL, Stauffer JL. Endobronchial streptokinase for relief of tracheobronchial obstruction by blood clots [letter]. Chest 1992; 101:1738-1739 BotnickW, BrownH. Endobronchial urokinasefor dissolution of massive clot following transbronchial biopsy. Chest 1994; 105:953-954
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
M.D., AND JAMES M.
PARISH,
M.D.
To our knowledge, only four reports have previously described endobronchial thrombolysis with streptokinase for airway obstruction due to blood clots; the highest dose used was 80,000 U. Herein we describe a 21-year-old woman with pulmonary embolism who experienced life-threatening airway obstruction due Endobronchial bleeding can result from various causes, including pulmonary embolism, adenoma, carcinoma, broncholiths, foreign bodies, trauma, sarcoidosis, cavitary histoplasmosis, multiple myeloma, Kaposi's sarcoma, and spontaneous hemoptysis, or it can occur after fiberoptic bronchoscopy, biopsy, and suctioning.!? Airway obstruction caused by blood clots is a rare but potentially lifethreatening complication of endobronchial hemorrhage. Treatment methods include manual removal by forceps extraction, suctioning, saline solution lavage, balloon-tip embolectomy, and coude catheter manipulation. Rigid bronchoscopic methods are usually effective but cannot be performed through an endotracheal tube; therefore, mechanical ventilation can be a problem.
REPORT OF CASE A 21-year-old woman with a history of subacute bacterial endocarditis was admitted to a hospital because of hemoptysis and mild shortness of breath. The patient was found to have right subclavian vein thrombosis due to an indwelling central venous catheter. Shortly after admission, the patient experienced pronounced hemoptysis, severe dyspnea, tachypnea, and agitation due to pulmonary embolism. The respiratory rate was 38/min, and the oxyhemoglobin saturation decreased to 70% on pulse oximetry. A physical examination revealed decreased breath sounds and wheezing over the right lung. A non-rebreather mask with 100% oxygen was used, but no improvement was noted. From the Department of Medicine (Z.V.l, Maricopa Medical Center, Phoenix, Arizona; and Division of Thoracic Diseases and Critical Care (J.M.P.l, Mayo Clinic Scottsdale, Scottsdale, Arizona. Address reprint requests to Dr. Zoltan Vajo, Department of Medicine, Maricopa Medical Center, 2601 E. Roosevelt, Phoeniz, AZ 85008. Mayo Clin Proc 1996; 71 :595-596
to a large blood clot in the distal trachea. Streptokinase (120,000 U), injected through a fiberoptic bronchoscope, partially dissolved the clot. The rest of the clot was removed easily with forceps and suctioning. No complications occurred. (Mayo Clin Proc 1996; 71:595-596) Emergency chest roentgenography showed atelectasis of the lower and middle lobes of the right lung. The patient continued to have hemoptysis, and her respiratory status worsened; intubation and mechanical ventilation were necessary. After initiation of mechanical ventilation, the tidal volume and oxygen saturation decreased, and the peak airway pressure increased. Fiberoptic bronchoscopy revealed a firm blood clot that was obstructing about 90% of the distal trachea and was completely obstructing the right main stem bronchus. Rigid bronchoscopy was considered but was not performed. Repeated manual extraction methods with forceps and baskets failed to remove the clot. Streptokinase, 1,000 U/mL of isotonic saline, was then instilled into the clot in 10- to l5-mL aliquots for a total dose of 120,000 U during a 90-minute period. This strategy partially dissolved the clot, and the rest was removed easily with biopsy forceps and suctioning. Ventilatory factors improved dramatically, and repeated chest roentgenography showed resolution of the atelectasis. The patient was subsequently extubated and dismissed from the hospital. No complications occurred.
DISCUSSION To our knowledge, use of endobronchial thrombolysis with streptokinase has been previously reported four times. The doses, which ranged from 30,000 to 80,000 U in 5- to 20-mL aliquots of isotonic saline solutions and contained 1,000 to 2,000 U of streptokinase per milliliter, were administered for 30 to 60 minutes.t" The highest total dose given was 80,000 U.6 In the current case, we were able to use endobronchial streptokinase therapy safely, even in a substantially higher dose than has previously been reported. Endobronchial use of other thrombolytics has been reported only once.' Botnick and Brown? administered a total 595
© 1996 Mayo Foundationfor Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
596
Mayo Clin Proc, June 1996, Vol 71
ENDOBRONCHIAL STREPTOKINASE THERAPY
of 15,000 U of urokinase (5,000 U/mL in sterile water in 2.5 mL aliquots) during a 3D-minute period. Their attempt to resolve the obstruction caused by the thrombus was also successful; however, removal of the rest of the clot necessitated rigid bronchoscopy. They observed no complications. Endobronchial use of tissue plasminogen activator has not been reported. The use of endobronchial streptokinase therapy for airway obstruction caused by blood clots seems to be appropriate when rigid bronchoscopy is not immediately available, manual extraction methods are unsuccessful, and immediate intervention is indicated. Moreover, we believe that, once the optimal dosage and route of administration are established, it may become the treatment of choice in the aforementioned conditions. Furthermore, we agree with Maxwell and Stauffer" that, based on the limited information available, the use of streptokinase in a solution of 1,000 U/mL of normal saline, which is instilled in 10- to 15-mL aliquots every 5 to 10 minutes through the fiberoptic bronchoscope, seems to be adequate. Occasionally, with this approach, rigid bronchoscopy may be unnecessary, and thus continu-
ous mechanical ventilation is possible through an endotracheal tube. Further experience with urokinase may demonstrate similar results.
REFERENCES
1. Chang JC, Cregler LL. Hemoptysis in a patient with conges-
2. 3. 4. 5. 6. 7.
tive heart failure and pulmonary emboli. J Nat! Med Assoc 1994; 86:383-386 Cahill BC, Ingbar DR. Massive hemoptysis: assessment and management. Clin Chest Med 1994 Mar; 15:147-167 Greenberg lE, Fischl MA, Berger JR. Upper airway obstruction secondary to acquired immunodeficiency syndromerelated Kaposi's sarcoma. Chest 1985;88:638-640 Cole RP, GrossmanGJ. Endobronchial streptokinase for bronchial obstructionby blood clots [letter]. N Engl J Med 1983; 308:905-906 Thomson DB. Endobronchial streptokinase to dissolvea right mainstemclot [letter]. Chest 1986; 89:904 Maxwell SL, Stauffer JL. Endobronchial streptokinase for relief of tracheobronchial obstruction by blood clots [letter]. Chest 1992; 101:1738-1739 BotnickW, BrownH. Endobronchial urokinasefor dissolution of massive clot following transbronchial biopsy. Chest 1994; 105:953-954
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.