Management of haemoptysis : a retrospective analysis of the efficacy of current treatment modalities.

Abstract

Massive haemoptysis is a life-threatening condition that requires timeous and appropriate intervention. Bronchial artery embolisation (BAE) has been advocated as initial therapy, in preference over lung resection, in all patients presenting with massive and minor haemoptysis. This is despite the relatively high incidence of early recurrence of haemoptysis following treatment with BAE. Though emergency lung resection for active massive haemoptysis has been associated with a high mortality, the literature has failed to detail the pre-operative evaluation which may have been inadequate and resulted in unsuitable surgical candidates. This has diminished enthusiasm for lung resection as a primary treatment modality for active massive haemoptysis. Case records from 01 January 2005 to 31 October 2007 of all patients admitted with haemoptysis, to the Department of Cardiothoracic Surgery, Inkosi Albert Luthuli Central Hospital were reviewed retrospectively and analysed. The decision regarding the type of emergency treatment was at the discretion of the attending Cardiothoracic Consultant. Following clinical examination and basic investigations patients were treated accordingly. Those who were haemodynamically stable were discussed at a Consultant forum and treatment was based on consensus. Group 1 included 281 patients with massive haemoptysis and group 2 included 222 with minor haemoptysis. Group one 15 of the 20 patients who were temporised with BAE (75%) had recurrent haemoptysis whereas 1 of the 41 patients (2.44%) who underwent lung resection without BAE developed recurrent haemoptysis (p-value < 0.0001). In patients undergoing BAE and lung resection, there was 1 death and 2 patients developed a post resection empyema thoracis (5% mortality; 10% morbidity) compared to 2 deaths; 1 post resection empyema thoracis and 1 deep thoracotomy wound infection in patients’ undergoing lung resection alone (4.88% mortality; 4.88% morbidity). This was not statistically significant (p-value 0.6736). Group 2 7 of the 8 patients who were temporised with BAE (87.50%) had recurrent haemoptysis. None of the 44 patients who underwent lung resection alone, developed recurrent haemoptysis (p-value < 0.0001). There were no deaths or surgical complications other than recurrent haemoptysis in patients who underwent BAE prior to lung resection. Though there were no deaths in patients who underwent lung resection alone, 2 patients developed a post resection bronchopleural fistula and 1 patient developed a post resection empyema thoracis (6.82% morbidity). This was not statistically significant (p-value 1.0000). 3 These preliminary data suggests that patients presenting with radiologically localised disease and massive haemoptysis, who are deemed suitable for surgery, should undergo emergency lung resection. This data also suggests that BAE is probably best utilised as a temporising measure in patients unsuitable for emergency lung resection. This also appears applicable to patients presenting with minor haemoptysis. In this scenario however, lung resection may be electively undertaken. Furthermore, this study emphasises the need for further prospective studies to clarify these issues.