In patients presenting with massive hemoptysis, it is often challenging to control bleeding. Uncontrolled bleeding can lead to hemodynamic instability and high mortality. We present case of a patient who presented with massive hemoptysis where fibrin sealant was effective in controlling the bleeding.
A 67 year old female with stage IV recurrent non-small cell lung cancer presented with massive hemoptysis. The patient was treated with six course of Taxol/Carboplatin two years prior to presentation, but continued to have non -respectable malignancy in the left upper lobe. Patient also had history of recurrent pneumonia in left upper lobe. She complained of sudden onset of hemoptysis and reported about 1000 cc blood loss prior to arrival to emergency department. She also gave history of chronic DVT in left leg. Her medications included Coreg, Protonix, Hydromorphone and Warfarin. On examination, patient appeared anxious. Her vital signs included: temperature 36.4 C, BP 121/76 mmHg, heart rate 103 beats/minute, and respiratory rate 20/minute. Chest examination showed normal respiratory pattern, lung auscultation showed diffuse scattered rhonchi throughout the lung fields and the cardiac evaluation was also within normal limits. Initial investigation reveled an INR of 1.07 and CBC as well as electrolytes within normal limits. She underwent emergent flexible bronchscopy. It revealed extensive hemorrhage from the left upper lobe bronchial segment. A cold saline and epinephrine solution did not stop the bleeding. Approximately 2cc of fibrin sealant (TISSEEL VH by Baxter Healthcare Corporation) was injected into the left upper lobe. Following its administration bleeding stopped. A bronchial arteriogram revealed bleeding from superior right bronchial artery adjacent to medial margin of the left upper lobe tumor. Coil embolisation was performed successfully. After three days a repeat flexible bronchoscopy was performed. The left upper lobe segments did not show further bleeding. Another fibrin sealant around 3 cc was administered into the left upper lobe segments. After two more days of recovery she was discharged from the hospital and at a follow up visit after three weeks she did not report further hemoptysis.
Massive hemoptysis due to pulmonary hemorrhage is a complication of localized lung lesions. They are not only a source of hemodynamic compromise but can also lead to fatal airway obstruction and ARDS. Massive hemoptysis is classically defined as expectoration of 100–600ml of blood in 24 hours. The common etiologies include: pulmonary tuberculosis, bronchiectasis, fungal and other infections, arterio-venous malformations, cardiovascular diseases, immunologic diseases and bronchiogenic Carcinoma. The fibrin sealant has been reported to be used in neurosurgical, ophthalmic, liver, kidney and bronco pleural fistulas. The sealant contains fibrinogen and thrombin. These factors when react, undergo a cascade of events and form a fibrin clot, further stabilized by factor XIII. This clot as any other clot in the human body is not permanent is under dynamic change due to enzymes which degrade the fibrin clot. The role of the fibrin sealant is thus to provide a temporary but stable clot, or a bond and thus to assist the body in healing the lesion. In our patients use of fibrin sealant played a vital role in controlling bleeding from left upper lobe.
Fibrin sealant was effective in management of bleeding in patient with massive hemoptysis. It can be as a bridging agent until bronchial arteriogram and coiling can be performed.
Chirag Pandya, No Financial Disclosure Information; No Product/Research Disclosure Information