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Control of Hemorrhage in Emergency Pulmonary Resection for Massive Hemoptysis
clinical and roentgenographic features of unknown etiology is categorized as chronic eosinophilic pneumonia. 3 Radiographically, the characteristics of this entity have been well described in adults and include the finding of dense pulmonic infiltrates which progress with time and are arranged in an unusual pattern in that they are found peripherally rather than centrally. Carrington and associates" refer to this as a "photographic negative" of the shadow seen in pulmonary edema. In our patient, the progressive nature of this disease was well documented over an eight-month period. At no time was there evidence of clearing on antibiotic therapy prior to the institution of steroid treatment. It was significant to note the dramaticresponse to corticosteroid therapy and no recurrence of the disease process after cessation of steroid therapy.
1 LoefBer W: Zur Differential Diagnose Der Lungen Infiltriemngen: Uber Fluchtige Succedan-InJiltrate (Mit Eosinophilia) Beitr Z Klin D Tuberk 79: 368, 1932 2 Crofton JW, Livingstone JL, Oswald NC, et al: Pulmonary eosinophilia. Thorax 7: 1, 1952 3 Carrington CD, Addington WW, Goff AM, et al: Chronic eosinophilic pnewnonia. N Eng} J Moo 280:787, 1969 4 Reeder WH, Goodrich BD: Pulmonary infiltration with eosinophilia. Ann lot Moo 36: 1217, 1952 5 Hennell H, Sussman ML: Roentgen features of eosinophilic infiltrations in lungs. Radiology 44:328, 1945 6 Citro LA, Gordon ME, Miller wr: Eosinophilic lung disease. Am J Roentgenol, Rad Ther, Nuc Moo 117:787, 1973 . 7 Cuthbert RT: Loeffler's syndrome occurring during streptomycin and PAS therapy. Br Moo J 2:388, 1954 8 Glueck MA, Janower .M: Nitrofurantoin lung diseaseclues to pathogenesis. Radiology 107 :818, 1969 9 Weingarten RJ: Tropical eosinophilia. Lancet 1: 103, 1943 10 Donohugh DL: Tropical eosinophilia; etiologic inquiry, N EnglJ Moo 269:1357, 1963 11 Webb JK, Job CK, Gault EW: Tropical eosinophilia: Demonstration of microfilariae in lung, liver and lymph nodes. Lancet 1:835, 1960 12 Ford RM: Transient pulmonary eosinophilia and asthma; Review of 20 Cases in 5712 asthma sufferers. Am Rev Resp Dis 93:797, 1965 13 Rose GA, Spencer H: Polyarteritis nodosa. Quart J Moo 101:43, 1957 14 Divertie MD, Olsen AM: Pulmonary infiltration associated with blood eosinophilia (PIE): Clinical study of Loeffler's syndrome and periarteritis nodosa with PIE syndrome. Dis Chest 37 :340, 1960 15 Jackson D, Yow E: Puhnonary infiltration with eosinophilia: Report of two cases of farmer's lung. N Engl J Med 264:1271, 1961 16 Frazer RG, Pare JAP: Diagnosis of Disease of the Chest: An integrated study based on the abnormal roentgenogram. Philadelphia, WB Sanders Company, 1970 pp 915
120 GOURIN, GARZON
Control of Hemorrhage in Emergency Pulmonary Resection for Massive Hemoptysis* Anatole Gourin, M.D., F.C.C.P., and Antonio A. Garzon, M.D.
Emellency pulmonary resection for hemoptysis during ... episode of lDM.IIve intrabroDchial bleeding requires
protection of the contnlateral lung from 88pint1on of blood. We describe • method of selective unilatenl ventilation appled to 15 patients, without mortaDty attributable to this factor. pulmonary hemorrhage the rate of bleeding into the I ntracheobronchial tree poses a greater threat to life
than the total amount of blood loss. Patients tend to drown in their own blood and asphyxiate rather than exsanguinate. 1 At our institution we operate on all patients who expectorate a minimum of 600 ml of blood in 24 hours or less and are able to tolerate thoracotomy. This aggressive approach resulted in reduction of mortality from massive hemoptysis from over 75 percent in the patients managed conservatively to 18 percent in the patients treated surgically.v" In the past ten years 64 patients underwent pulmonary resection for massive hemoptysis. In 22 patients hemoptysis persisted after the initial 600 ml of blood had been expectorated, and emergency pulmonary resection had to be performed during an episode of massive intrabronchial bleeding. Early in our experience we utilized Carlens double-lumen tubes to protect the nonbleeding lung from aspiration of blood. Four of seven patients so managed died as a result of massive aspiration of blood during operation. In more recent years, a technique of endobronchial intubation with use of a balloon catheter blocker proved more effective in protecting the contralateral IWlg from blood °From the Department of Surgery, State University of New York-Downstate Medical Center, Brooklyn, N.Y. Reprint requests: Dr. Gourin, Department of Surgefl/, 450 Clarkson Avenue, Brooklyn 11203
A
FIGURE 1. Right-sided bleeding. (A) Cuffed tube in left main bronchus protects left lung from spillage of blood in early phase of operation. (B) Bronchus of bleeding lobe has been cross clamped and cuffed tube is withdrawn into trachea.
CHEST, 68: 1, JULY, 1975
the bronchoscope is removed and immediately replaced by a single-lumen cuffed tube which is advanced into the left main bronchus; the cuff is then inflated (Fig 1A) . The patient is anesthetized and positioned for lateral thoracotomy in a Trendelenburg position. allowing blood to run out of the trachea around the tube . As soon as the bronchus of the bleeding lobe is dissected and cross-clamped the tube is deflated momentarily and withdrawn from the left main bronchus into the trachea (Fig 1B). All residual blood is aspirated from the tracheobronchial tree, and the operation is completed with bilateral ventilation. Bleeding Left Lung
FIGURE 2. Left-sided bleeding. (A) Balloon occlusion catheter in left main bronchus blocks bleeding and protects right lung from spillage of blood in early phase of operation. Right lung alone is ventilated through cuffed endotracheal tube. (B) Bronchus of bleeding lobe has been cross clamped and balloon catheter deflated and removed. spillage in the early phase of pulmonary resection. This method has now been applied in 15 patients, 9 of whom bled from the right lung and 6 from the left lung. There were no deaths attributable to aspiration of blood among these 15 patients. The tracheobronchial tree is normally asymmetric. The main stem bronchus is significantly longer on the left side, the left upper lobe bronchus originating more distally than the right. This normal anatomic asymmetry necessitates a different approach for each lung. MATERIALS AND METHODS
Bleeding Right Lung
The source of bleeding is always confirmed by bronchoscopy under topical anesthesia . After thorough suctioning,
After confirmation of the source of bleeding by bronchoscopy -a Fogarty occlusion catheter, size 8/14 F, 80 em long and equipped with a 10 ml balloon is inserted through the bronchoscope into the left main bronchus to block the bleeding into the left lung. Plastic tubing, 30-40 em long is interposed between the proximal end of the hub and the Luer-lok 6tting of the Fogarty catheter to facilitate removal of the bronchoscope without displacement of the catheter from its position in the left main bronchus . The bronchoscope is removed and replaced by a cuffed endotracheal tube (Fig 2A) . Correct position of the balloon catheter can be confirmed by a chest roentgenogram taken on the operating table (Fig 3). The patient is anesthetized and positioned for left lateral thoracotomy. As soon as the bronchus of the bleeding lobe is dissected and cross-clamped. the balloon catheter is deflated and removed by the anesthesiologist (Fig 2B ). All residual blood is aspirated from the tracheobronchial tree and the operation is completed with bilateral ventilation.
REFERENCES 1 Crocco lA, Rooney II, Fanlcushen DS, et al: Massive hemoptysis . Arch Intern Med 121:495-4Q8, 1968 2 Garzon AA, Cerruti M, Gourin A, et al: Pulmonary resection for massive hemoptysis. Surgery frl :633-638, 1970 3 Gourin A, Garzon AA: Operative treatment of massive hemoptysis. Ann Thorac Surg 18:52-60,1974
FIGURE 3. Chest x-ray 6lm of 34-year-old woman with 6brocavitary tuberculosis of left upper lobe. Patient was brought to operating room after measured hemoptysis of 800 ml. Bleeding continued on 'operating table. Roentgenogram (supine position) taken on operating table, with diagrammatic illustration of balloon catheter 6lled with radiopaque dye in correct position in left main bronchus .
CHEST, 68: 1, JULY, 1975
CONTROL OF HEMORRHAGE IN EMERGENCY PULMONARY RESECnON 121
1 LoefBer W: Zur Differential Diagnose Der Lungen Infiltriemngen: Uber Fluchtige Succedan-InJiltrate (Mit Eosinophilia) Beitr Z Klin D Tuberk 79: 368, 1932 2 Crofton JW, Livingstone JL, Oswald NC, et al: Pulmonary eosinophilia. Thorax 7: 1, 1952 3 Carrington CD, Addington WW, Goff AM, et al: Chronic eosinophilic pnewnonia. N Eng} J Moo 280:787, 1969 4 Reeder WH, Goodrich BD: Pulmonary infiltration with eosinophilia. Ann lot Moo 36: 1217, 1952 5 Hennell H, Sussman ML: Roentgen features of eosinophilic infiltrations in lungs. Radiology 44:328, 1945 6 Citro LA, Gordon ME, Miller wr: Eosinophilic lung disease. Am J Roentgenol, Rad Ther, Nuc Moo 117:787, 1973 . 7 Cuthbert RT: Loeffler's syndrome occurring during streptomycin and PAS therapy. Br Moo J 2:388, 1954 8 Glueck MA, Janower .M: Nitrofurantoin lung diseaseclues to pathogenesis. Radiology 107 :818, 1969 9 Weingarten RJ: Tropical eosinophilia. Lancet 1: 103, 1943 10 Donohugh DL: Tropical eosinophilia; etiologic inquiry, N EnglJ Moo 269:1357, 1963 11 Webb JK, Job CK, Gault EW: Tropical eosinophilia: Demonstration of microfilariae in lung, liver and lymph nodes. Lancet 1:835, 1960 12 Ford RM: Transient pulmonary eosinophilia and asthma; Review of 20 Cases in 5712 asthma sufferers. Am Rev Resp Dis 93:797, 1965 13 Rose GA, Spencer H: Polyarteritis nodosa. Quart J Moo 101:43, 1957 14 Divertie MD, Olsen AM: Pulmonary infiltration associated with blood eosinophilia (PIE): Clinical study of Loeffler's syndrome and periarteritis nodosa with PIE syndrome. Dis Chest 37 :340, 1960 15 Jackson D, Yow E: Puhnonary infiltration with eosinophilia: Report of two cases of farmer's lung. N Engl J Med 264:1271, 1961 16 Frazer RG, Pare JAP: Diagnosis of Disease of the Chest: An integrated study based on the abnormal roentgenogram. Philadelphia, WB Sanders Company, 1970 pp 915
120 GOURIN, GARZON
Control of Hemorrhage in Emergency Pulmonary Resection for Massive Hemoptysis* Anatole Gourin, M.D., F.C.C.P., and Antonio A. Garzon, M.D.
Emellency pulmonary resection for hemoptysis during ... episode of lDM.IIve intrabroDchial bleeding requires
protection of the contnlateral lung from 88pint1on of blood. We describe • method of selective unilatenl ventilation appled to 15 patients, without mortaDty attributable to this factor. pulmonary hemorrhage the rate of bleeding into the I ntracheobronchial tree poses a greater threat to life
than the total amount of blood loss. Patients tend to drown in their own blood and asphyxiate rather than exsanguinate. 1 At our institution we operate on all patients who expectorate a minimum of 600 ml of blood in 24 hours or less and are able to tolerate thoracotomy. This aggressive approach resulted in reduction of mortality from massive hemoptysis from over 75 percent in the patients managed conservatively to 18 percent in the patients treated surgically.v" In the past ten years 64 patients underwent pulmonary resection for massive hemoptysis. In 22 patients hemoptysis persisted after the initial 600 ml of blood had been expectorated, and emergency pulmonary resection had to be performed during an episode of massive intrabronchial bleeding. Early in our experience we utilized Carlens double-lumen tubes to protect the nonbleeding lung from aspiration of blood. Four of seven patients so managed died as a result of massive aspiration of blood during operation. In more recent years, a technique of endobronchial intubation with use of a balloon catheter blocker proved more effective in protecting the contralateral IWlg from blood °From the Department of Surgery, State University of New York-Downstate Medical Center, Brooklyn, N.Y. Reprint requests: Dr. Gourin, Department of Surgefl/, 450 Clarkson Avenue, Brooklyn 11203
A
FIGURE 1. Right-sided bleeding. (A) Cuffed tube in left main bronchus protects left lung from spillage of blood in early phase of operation. (B) Bronchus of bleeding lobe has been cross clamped and cuffed tube is withdrawn into trachea.
CHEST, 68: 1, JULY, 1975
the bronchoscope is removed and immediately replaced by a single-lumen cuffed tube which is advanced into the left main bronchus; the cuff is then inflated (Fig 1A) . The patient is anesthetized and positioned for lateral thoracotomy in a Trendelenburg position. allowing blood to run out of the trachea around the tube . As soon as the bronchus of the bleeding lobe is dissected and cross-clamped the tube is deflated momentarily and withdrawn from the left main bronchus into the trachea (Fig 1B). All residual blood is aspirated from the tracheobronchial tree, and the operation is completed with bilateral ventilation. Bleeding Left Lung
FIGURE 2. Left-sided bleeding. (A) Balloon occlusion catheter in left main bronchus blocks bleeding and protects right lung from spillage of blood in early phase of operation. Right lung alone is ventilated through cuffed endotracheal tube. (B) Bronchus of bleeding lobe has been cross clamped and balloon catheter deflated and removed. spillage in the early phase of pulmonary resection. This method has now been applied in 15 patients, 9 of whom bled from the right lung and 6 from the left lung. There were no deaths attributable to aspiration of blood among these 15 patients. The tracheobronchial tree is normally asymmetric. The main stem bronchus is significantly longer on the left side, the left upper lobe bronchus originating more distally than the right. This normal anatomic asymmetry necessitates a different approach for each lung. MATERIALS AND METHODS
Bleeding Right Lung
The source of bleeding is always confirmed by bronchoscopy under topical anesthesia . After thorough suctioning,
After confirmation of the source of bleeding by bronchoscopy -a Fogarty occlusion catheter, size 8/14 F, 80 em long and equipped with a 10 ml balloon is inserted through the bronchoscope into the left main bronchus to block the bleeding into the left lung. Plastic tubing, 30-40 em long is interposed between the proximal end of the hub and the Luer-lok 6tting of the Fogarty catheter to facilitate removal of the bronchoscope without displacement of the catheter from its position in the left main bronchus . The bronchoscope is removed and replaced by a cuffed endotracheal tube (Fig 2A) . Correct position of the balloon catheter can be confirmed by a chest roentgenogram taken on the operating table (Fig 3). The patient is anesthetized and positioned for left lateral thoracotomy. As soon as the bronchus of the bleeding lobe is dissected and cross-clamped. the balloon catheter is deflated and removed by the anesthesiologist (Fig 2B ). All residual blood is aspirated from the tracheobronchial tree and the operation is completed with bilateral ventilation.
REFERENCES 1 Crocco lA, Rooney II, Fanlcushen DS, et al: Massive hemoptysis . Arch Intern Med 121:495-4Q8, 1968 2 Garzon AA, Cerruti M, Gourin A, et al: Pulmonary resection for massive hemoptysis. Surgery frl :633-638, 1970 3 Gourin A, Garzon AA: Operative treatment of massive hemoptysis. Ann Thorac Surg 18:52-60,1974
FIGURE 3. Chest x-ray 6lm of 34-year-old woman with 6brocavitary tuberculosis of left upper lobe. Patient was brought to operating room after measured hemoptysis of 800 ml. Bleeding continued on 'operating table. Roentgenogram (supine position) taken on operating table, with diagrammatic illustration of balloon catheter 6lled with radiopaque dye in correct position in left main bronchus .
CHEST, 68: 1, JULY, 1975
CONTROL OF HEMORRHAGE IN EMERGENCY PULMONARY RESECnON 121