Massive Hemoptysis in Post-Tubercular Sequelae: A Multidisciplinary Critical Care Team in Action

Neeraj Kumar Gupta; Rohit Kumar; Puneet Garg; Pranav Ish; Vipin Aggarwal; Nitesh Gupta

doi:10.4103/mamcjms.mamcjms_35_21

CASE REPORT

Year : 2022 | Volume : 8 | Issue : 2 | Page : 174-177

Massive Hemoptysis in Post-Tubercular Sequelae: A Multidisciplinary Critical Care Team in Action

Neeraj Kumar Gupta¹, Rohit Kumar¹, Puneet Garg², Pranav Ish¹, Vipin Aggarwal¹, Nitesh Gupta¹
¹ Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi, India
² Department of Radiodiagnosis, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission	04-May-2021
Date of Decision	11-Jun-2021
Date of Acceptance	11-Jul-2022
Date of Web Publication	08-Aug-2022

Correspondence Address:
MBBS, MD, DM Pranav Ish
Assistant Professor, Department of Pulmonary, Critical care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi 110029
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/mamcjms.mamcjms_35_21

Abstract

Massive hemoptysis can lead to respiratory failure and life-threatening hypoxia in patients with underlying post-tubercular fibrocavitary disease. In the absence of urgent surgical interventions in a resource-poor country, interventional bronchoscopy and bronchial artery embolization (BAE) can be lifesaving in critical care management of such patients. We present a young male who required mechanical ventilation, emergency bronchoscopic intervention, and BAE, and showed recovery.

Keywords: bronchial artery embolization, hemoptysis, lifesaving, post-tubercular sequelae

How to cite this article:
Gupta NK, Kumar R, Garg P, Ish P, Aggarwal V, Gupta N. Massive Hemoptysis in Post-Tubercular Sequelae: A Multidisciplinary Critical Care Team in Action. MAMC J Med Sci 2022;8:174-7

How to cite this URL:
Gupta NK, Kumar R, Garg P, Ish P, Aggarwal V, Gupta N. Massive Hemoptysis in Post-Tubercular Sequelae: A Multidisciplinary Critical Care Team in Action. MAMC J Med Sci [serial online] 2022 [cited 2022 Sep 26];8:174-7. Available from: https://www.mamcjms.in/text.asp?2022/8/2/174/354400

Introduction

Massive hemoptysis is defined as expectoration of ≥500 mL blood over 24 hours or bleeding at a rate ≥100 mL/hour, any abnormal gas exchange, or hemodynamic instability. Severity of massive hemoptysis can be estimated by volume of expectorated blood that is life-threatening by virtue of airway obstruction, hypotension, or blood loss.^[1],[2] Tuberculosis, bronchiectasis, lung abscesses, and mycetoma, which are common in India, can cause life-threatening massive hemoptysis.^[1] We present a case of massive hemoptysis in a post-tubercular patient who was managed successfully with bronchoscopy and bronchial artery embolization (BAE) in the critical care unit.

Case Report

A 44-year-old male, treated for a case of smear-positive pulmonary tuberculosis (PTB) 5 years ago, presented with an episode of massive hemoptysis. Patient was in an altered sensorium (Glasgow Coma Scale of 9/15) with respiratory distress. Vitals were: pulse rate of 139/minute, blood pressure of 98/66 mm Hg, and peripheral oxygen saturation of 82% with oxygen at 8 L flow. Patient was intubated and put on invasive mechanical ventilation with tidal volume of 380 mL, flow rate of 50 L/minute, and positive end-expiratory pressure of 6 cm H₂O. However, the peak pressure was 42 cm H₂O and plateau pressure was 32 cm H₂O. Patient was maintaining saturation of 82% on 100% oxygen. Chest radiograph was suggestive of right lung collapse [Figure 1]. Urgent bronchoscopy with flexible bronchoscope showed right main bronchus completely occluded by blood clots which were removed with the help of forceps [Figure 2] and [Figure 3]. Temporary hemostasis was achieved with cold saline lavage and instillation of adrenaline (1:10000) and tranexamic acid. This led to an improvement in oxygenation with a saturation of 90% on 0.4 FiO₂ and lung expansion [Figure 4]. The patient was taken for emergency BAE on transport ventilator. Contrast-enhanced computed tomography (CECT) thorax was suggestive of right upper lobe fibrocavitary lesion [Figure 5]. During the procedure, bronchial arteries along with collaterals from subclavian artery, lateral thoracic artery, and right internal mammary artery were found to be supplying the fibrocavitary region of right upper lobe. Embolization was done with 300 μm polyvinyl alcohol (PVA) particles [Figure 6]. Postembolization, parenchymal vascular blush was abolished [Figure 7]. Over next 24 hours, right lung showed signs of clinical and radiological expansion, and improvement in lung mechanics was seen with no recurrence of hemoptysis. Patient was successfully extubated and discharged after 5 days. After 1 and 3 months, no recurrence of hemoptysis was reported in the follow-up outpatient department (OPD) visits.

Figure 1 Chest X-ray showing features of collapse of right middle and lower lobe with heterogeneous opacities in right upper zone.

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Figure 2 The clot removed from the right main bronchus.

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Figure 3 Bronchoscopy image of carina after the clot removal.

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Figure 4 After therapeutic bronchoscopy, chest X-ray reveals reexpansion of right lung, along with right upper zone cavitation.

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Figure 5 Computed tomography cut showing right upper lobe cavity with middle and lower lobe collapse.

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Figure 6 Catheter angiography image showing selective angiogram of right intercostobronchial trunk (ICBT) which shows hypertrophy, tortuosity, and parenchymal blush.

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Figure 7 Catheter angiography image showing the pruned tree appearance of the intercostobronchial trunk (ICBT) with absence of any hypervascularity and parenchymal blush after it has been embolized with PVA particles.

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Discussion

In India, active tuberculosis as a cause of hemoptysis is showing a decreasing trend in last few decades due to strengthening of diagnosis and treatment strategies under revised national tuberculosis control program (RNTCP). Post-tubercular sequelae are unfortunately underestimated and often ignored.^[3]

Chronic inflammatory lung diseases like tuberculosis, bronchiectasis, and cystic fibrosis can develop markedly hypertrophied and fragile bronchial arteries, which may lead to massive hemoptysis. It usually arises from the high-pressure bronchial circulation (90%). In 5% of cases, it arises from the aorta (ruptured aneurysms and aortobronchial fistulae), or nonbronchial systemic circulation (intercostal arteries, coronary arteries, thoracic arteries originating from the axillary and subclavian arteries, and the upper and inferior phrenic arteries). In only around 5% cases, pulmonary vessels are the culprit.^[3],[4]

The treatment of choice for massive hemoptysis (>500 mL or any drop in hematocrit, saturation, or blood pressure) remains surgery and treating the etiology. BAE is indicated as a lifesaving procedure in massive hemoptysis to stabilize the patient before surgery or definite therapy. For persistent mild/moderate hemoptysis, BAE is used as a definite procedure, if surgery is contraindicated (bilateral lung disease and poor lung reserve), which is common in Indian patient of bronchiectasis or post-tubercular sequelae. In mild to moderate episodic hemoptysis can be managed conservatively along treatment of the underlying cause. There is no guideline on the time frame to decide when to switch to BAE in mild/moderate hemoptysis in view of absence of large studies. The consensus is BAE can be performed as a definite procedure if medical therapy fails and hemoptysis remains persistent.^{[5],[6],[7],[8]}

The success rate of BAE ranges from 60% to 90%, especially if the bronchial, pulmonary, and/or systemic arterial circulations are well defined during the procedure.^[9],[10] Arteriogram is performed usually via a femoral artery cannulation. Lesions indicating active extravasation of contrast are bronchial arterial hypertrophy and tortuosity, hypervascularity, aneurysm formation, and arteriovenous malformations. Embolization of the offending bronchial artery can be performed by using gelatin sponge, PVA particles, microspheres, n-butyl-2-cyanoacrylate, and metallic coil.^[11] Inability to cannulate the bronchial artery and failure to identify and embolize all collaterals may result in early technical failures.^[12] Rebleeding over the following 6 to 12 months may be due to revascularization or recanalization. Complications like ischemic myelopathy (paraplegia) due to inadvertent embolization of a spinal artery are rare in experienced hands that perform the procedure using superselective catheters and small PVA particles.^[13]The clinical, radiological, and pathological profile and treatment outcome of 102 patients with hemoptysis was studied by Joseph et al.^[14] Old PTB was the most common cause of hemoptysis. A total of 61 cases (59.80%) were managed conservatively with medicines (intravenous/oral ethamsylate, tranexamic acid, and cough suppressants). BAE was done in 39 patients (38.23%) for attaining hemostasis. The success rate of conservative treatment group was 67.21%, BAE group 82.05%, and surgical treatment group 100%. However, the number of patients undergoing surgery was only two. This highlights that surgery is the gold standard modality of therapy. However, its availability, patient choice, patient fitness, cost, and lack of expertise make it a rare option available to the patients at large.

Unfortunately, the availability of a pulmonologist trained in critical care as a superspecialist, an interventional vascular radiologist, and a thoracic surgeon are all scarce resources in India, where the population of post-tubercular sequelae and complications has endemic proportions. There is an urgent need for national programs to focus on upscaling the availability of these lifesaving interventions

Conclusion

BAE can be a lifesaving procedure in massive hemoptysis. In Indian perspective, this has a much more practical application, considering the post-tubercular sequelae, poor performance status of patients for surgery, and lack of surgical facilities in most centers. A critical care physician and an interventional radiologist can easily collaborate in such scenarios to reduce morbidity and mortality

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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