Massive Hemoptysis Associated with Foreign Body Removal

Massive Hemoptysis Associated with Foreign Body Removal

were found in PLM tissue.":" this has never been demonstrated, to our knowledge, in tuberous sclerosis. There are two previously published reports rel...

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were found in PLM tissue.":" this has never been demonstrated, to our knowledge, in tuberous sclerosis. There are two previously published reports related to the use of tamoxifen in PLM. 16,11 Both women had severe respiratory insufficiency and the drug was ineffective in arresting the course of the disease, but tamoxifen was given at a very late stage. One of them had cor pulmonale and the other, who had high level of estrogen receptor, was seriously ill and on mechanical ventilation at the start of therapy. The administration of pharmacologic doses of tamoxifen during 24 months and the use of tetracycline pleurodesis was associated with improvement of some clinical and laboratory manifestations and stabilization of the respiratory picture in our patient. Both measures seem to be effective therapies for this rare pulmonary disease and the response to tamoxifen is probably related to the presence of an estrogen receptor. Finding an estrogen receptor in this patient is new evidence that supports the association between PLM and tuberous sclerosis. ACKNOWLEDGEMENT: We are indebted to D r. J. C . Hogg for reviewing the histologic material.

REFERENCES

McCarty KS Jr, Mussier JA. McLelland R, Sieker HO. Pulmonary Iymphangiomyomatos is responsive to progesterone. N Eng! J Med 1980;303:1461-65 2 Kreisman H. Robitalle Y, Dionne GP, Palayew MJ. Lymphangiomyomatosis syndrome with hyperparathyroidism: a case report. Cancer 1972; 42:364-72 3 Valenzi QJ. Pulmonary lymphangiomyoma, a probable "forme frust" of tuberous sclerosis . Acase report and survey ofliterature, Am Rev Respir Dis 1973; 108:1411-15 4 Carrington CB. Cugell DW. Gaensler EA, Marks A. Redding RA, Schaaf JT, Tomasian A. Lymphangioleiomyomatosis. phys iologic-pathologic-radiologic correlations. Am Rev Respir Dis

1977; 116:977-95 5 Kitzsteiner KA, Mallen RG. Pulmonary Iymphangiomyomatosis; treatment with castration. Cancer 1980; 46:2248-49 6 Winter JA. Oophorectomy in Iymphangiomyomatosis and benign metastasizing leiomyoma. N Eng! J Med 1981; 305:1416-17 7 Banner AS, Carrington CB . Oophorectomy in Iymphangiomyomatosis and benign metastasizing leiomyoma. N Eng! J Med

1981; 305:1417 8 Monteforte WJ Jr, Kohnen PW: Angiomyolipomas in a case of 9 10

11 12 13

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Iymphangiomyomatosis syndrome. Relationships to tuberous scleros is. Cancer 1974; 34:317-21 [ao J, Gilbert S, Messer R. Lymphangiomyoma and tuberous sclerosis . Cancer 1972; 29:1188-91 Joliat G, Stadler H. Kapanci Y. Lymphangiomyomatosis: a clinico-anatomical entity. Cancer 1973; 31:455-61 Stovin PGl, Lum Le, Flower CDR, Darke CS , Beeley M. The lungs in Iymphangiomyomatosis and tuberous sclerosis . Thorax 1975; 30:497-509 Corrin B. Liebow AA, Friedman PJ. Pulmonary Iymphangiomyomatosis. Am J Pathol 1975; 79:348-67 Capron F, Amellei J, Leclerc P, Mornet P, Barbagellata M. Reynes M, Rochemaure J. Pulmonary Iymphangiomyomatosis and Bournevilles tuberous sclerosis with pulmonary involvement: the same disease? Cancer 1983; 52:851-55 Banner AS, Carrington CB . Kittle F, Leonard G. Ringus J, Taylor P, Addington ww: Efficacy of oophorectomy in Iymphangiomyomatosis and benign metastasizing leiomyoma. N Eng! J Med

1981; 305: 204-09

15 Brentani MM, Carvalho CRR, Saldiva PH, Pacheco MM , Oshima GTF. Steroid receptors in pulmonary Iyrnphangiomyomatosis . Chest 1984; 85:96-99 16 Graham ML , Spelsberg Te, Dines DE, Payne WS, Bjornson J, Lie JT. Pulmonary Iyrnphangiornyomatosis with particular reference to steroid-receptor assay studies and pathologic correlation. Mayo Clin Proc 1984;59:3-11 17 Tomasian A, Greenberg MS, Rumerman H. Tarnoxifen for lymphangioleiomyomatosis. N Eng! J Med 1982; 306:745-46

Massive Hemoptysis Associated with Foreign BOdy Removal* J. Richard Rees, M.D.,

F.C.C .P.t

Exsanguinating hemoptysis accompanied removal of an endobronchial foreign body in a 12-year-old child. Preparations to treat this complication should be made prior to removal of any foreign body of prolonged sojourn in the tracheobronchial tree.

common serious complication accompanyT heingmost bronchoscopy for removal of foreign bodies in

the tracheobronchial tree is cardiac arrest due to asphyxia.!" From a review of the literature, massive hemorrhage accompanying bronchoscopy for foreign body removal is an unusual complication . CASE REPORT

A 12-year-old white girl presented to the hosp ital with fever, chest pain and hemoptysis. An admitting chest x-ray film (Fig 1) demonstrated an infiltrate in the right lower lobe and a foreign body in the right main stem bronchus. The patient gave a vague history ofhaving swallowed a bullet seven years previously, The foreign body, an intact .22 short caliber cartridge casing, was removed easily through a rigid endoscope. Immediately after removal of the foreign body, massive hemorrhage into the right main stem bronchus ensued, which was then tamponaded with cotton and gauze . The patient was placed in the left lateral decubitus position and an emergency right thoracotomy was performed. The patient then sustained cardiopulmonary arrest. The right mainstem bronchus was opened proximal to the tamponade and a considerable amount of old blood was aspirated from the left main stem bronchus as successful cardiac massage was carried out. Postoperatively, the patient developed adult respiratory distress syndrome plus a bronchopleural fistula requiring prolonged mechanical ventilation and the construction of an Elosser flap. She subsequently recovered, underwent plastic repair of the chest wall with two artificial ribs and has done well. DISCUSSION

In their monumental work on foreign bodies in air and food passages, Jackson and Jackson described 343 patients with prolonged sojourn of foreign bodies in the air passages. 1 These same authors were able to remove most of these foreign bodies transbronchoscopically and, in most instances, noted resolution of the underlying inflammatory process in the *From the University of Utah College of Medicine, Salt Lake City.

t Assistant Clinical Professor of Surgery. Reprint requests: Dr. Bees, 425 East 5JS() South, Ogden, Utah 844()5 CHEST I 88 I 3 I SEPTEMBER. 1985

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FIGURE 1. Lateral and AP chest roentgenograms .

lung. No instance of massive hemorrhage accompanying bronchoscopy was noted. Linton" reported the results of treating longstanding foreign bodies in 16 patients. In six of these patients, the foreign body could be removed through the bronchoscope. One of the six required lobectomy because of abscess. One of the 16 patients required bronchocotomy for removal of the foreign body, and six required pulmonary resection . No instance of massive hemorrhage at the time of bronchoscopy was recorded. Foreign body bronchiectasis may require lung resection following prolonged sojourn of foreign bodies in the tracheobronchial tree. Cooley et aF reported on 14 such patients at the Mayo Clinic. As noted by Bogedain," foreign bodies in the pulmonary parenchyma may migrate to an intrabronchial position and be removed transbronchoscopically many years later. In a review of the over 2,500 documented cases,I.3.4.6,(;.11 the author was unable to find another instance of massive hemorrhage accompanying removal of an intrabronchial foreign body, whether performed acutely or after prolonged sojourn. CONCLUSION

The tracheobronchial endoscopist should have this possible complication in mind and manage to meet it by: 1) tamponading the bronchial system on the side that is bleeding; 2) carrying out endotracheal intubation; 3) suctioning the contralateral side for blood that has spilled over from the hemorrhage; and 4) and performing immediate thoracotomy on the affected side. REFERENCES 1 Jackson C , Jackson CL. Diseases of the air and food passages of

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foreign -body origin. Philadelphia: W. B. Saunders, 1936. 2 ClerfL. Foreign bodies in the air and food passages: observations on end-results in a series of nine hundred fifty cases. Surg Gynecol Obstet 1940; 328-39 3 Abdulmajid OA, Ebeid AM, Motawen MM , Kleibo IS. Aspirated foreign bodies in the tracheobronchial tree: report of 250 cases. Thorax 1965; 31 :635-40 4 Kosloske AM. Bronchoscopic extraction of aspirated foreign bodies in children. Am J Dis Child 1982 ; 136:924-27 5 Schloss, MD , Pham -Dang H, Rosales JK. Foreign bodies in the tracheobronchial tree-a retrospective study of 217 cases. J Otolaryn 1983; 12:212-16 6 Linton JSA. Long-standing intrabronchial foreign bodies. Thorax 1957; 12:164-70 7 Cooley JC , Ginsberg RL , Olsen AM , Kirklin Jw. Foreign body bronchiectasis. J Thorac Surg 1956 ; 51:615-17 8 Bogedain W. Migration of schrapnel from lung to bronchus. JAMA 1984; 251 :1862-1963 9 Aytac A, Yurdakul Y, Ikizler C , Olga R, Saylam A. Inhalation of fore ign bodies in children. Report of 500 cases. J Thorac Cardiovasc Surg 1977; 74:145-50 10 Cohen SR, Lewis GB Jr, Herbert WI, Geller KA. Foreign bodies in the airway. Five-year retrospective study with special reference to management. Ann Otoll960; 89 :437-42 11 Slim MS, Yacoubian HD. Complications offoreign bodies in the tracheobronchial tree. Arch Surg 1966 ; 92:388-93

Dissecting Aneurysm of the Ascending Aorta with Aorto-caval Fistula· Flberoptlc Oximetric Findings and Surgical Management ]. B. Martinot , M.D.;t O. Pedemonte, M.D.;t P. L. Baele, M.D .;:/: ]. Dautrebande, M.D .;§ P. ]aumin, M .D. ;~ and M. Coenen , M.D . t *From the Cliniques Universitaires Saint-Luc, Brussels, Belgium. tlntensive Care Unit. :/:Department of Anesthesiology. § Department of Radiology. ~Department of Thoracic and Cardiovascular Surgery.

Reprint requests: Dr: Goenen, Service Soins lntensifs, Cliniques Universitaires St. Luc, 10, Av Hippocrate , 1200 Brussels , Belgium Dissecting Aneurysm 01 Ascending Aorta (MlJf1inot et eI)