an aggressive surgical approach to significant

AN AGGRESSIVE SURGICAL APPROACH TO SIGNIFICANT HEMOPTYSIS IN PATIENTS WITH PULMONARY TUBERCULOSIS

M. AMIRANA, R. FRATER, P. TIRSCHWELL, M. JANIS, A. BLOOMBERG, AND D. STATE

Reprinted

from

AMERICAN

REVIEW

OF RESPIRATORY

Vol. 9i, No.2, February 1968 Printed in U.S.A.

DISEASE

Reprinted from

AMERICAN

REVIEW

OF RESPIRATORY

DISEASE

Vol. 97. No.2. February 1968 Printed in U.S.A.

AN AGGRESSIVE SURGICAL APPROACH TO SIGNIFICANT HEMOPTYSIS IN PATIENTS WITH PULMONARY TUBERCULOSISl. 2. 3 M. AMIRANA.

R. FRATER,

P. TIRSCHWELL, ANDD. STATE

M. JANIS, A. BLOOMBERG,

(Received for publication September 5, 1967) INTRODUCTION

The conventional management of hemoptysis associated with pulmonary tuberculosis is primarily nonoperative. Treatment usually consists of bed rest, sedatives, cough suppressants, and other drugs such as intravenous pituitrin (1) and estrogens (2). Pneumothorax and pneumoperitoneum are also used in some cases to control hemoptysis. This form of treatment suffices for the usual patient with hemoptysis, but in the patient with significant bleeding, the results are not satisfactory. The purpose of this study is to evaluate the efficacy of nonoperative therapy in significant hemoptysis associated with tuberculosis and to compare it with an aggressive surgical approach that has been used in this institution since 1964. For the purpose of evaluation, hemoptysis of 100 ml. or more per day, as measured in the hospital, has been defined as significant. MATERIALS

AND METHODS

N onoperaiiue therapy: During an 18-month period, July 1962 through December 1963. 722 patients with tuberculosis were admitted to the Chest Medical Service of the Albert Einstein Co1lep;e of Medicine-Bronx Municipal Hospital CenFrom the Department of Surgery, Albert Einstein College of Medicine, New York. New York. , This project was supported in part by a Clinical Cancer Training Grant, CA 8067, from the National Cancer Institute, U. S. Department of Health. Bethesda, Maryland. 3 Presented in part before the Medical Session, as part of Section 2B, at the annual meeting of the American Thoracic Society, Pittsburgh. Pennsylvania, May 23,1967. 1

tel' (table 1). One hundred-fifty of these patients had hemoptysis. Using the criterion indicated, 17 of the 150 patients had significant hemoptysis. Five of the 17 patients died; two of the five fatalities had had no more than two episodes of hemoptysis in which only 50 to 100 ml. of blood were lost. At autopsy, the direct cause of death in all patients was found to be aspiration of blood rather than exsanguination. The results of massive aspiration of blood in the tracheobronchial tree are clearly illustrated in figure 1. Surgical therapy for hemoptysis: On the basis of the above experience. a new policy of therapy was formulated. Instituted in 1964, the primary' treatment for hemoptysis continues to be nonoperative, but those patients who appear to be in particular danger of aspirating blood are now selected for emergency surgery. Criteria for selection of patients with significant hemoptysis for emergency surgery are: (1) patients with localized site of bleeding; (2) patients with aspiration, as determined by repeat roentgenograms; (3) patients with threatened aspiration-the presence of a large blood-filled cavity (figure 2) is taken as additional indication for surgery; serious aspiration has occurred when such a cavity emptied into the remainder of the lung; (4) patients with previously marginal respiratory reserve. In this group the consequences of aspiration would be even more serious than usual; hence they were chosen for early surgery. Using the above criteria, 45 patients with significant hemoptysis secondary to tuberculosis have been evaluated, 15 of whom were selected for surgery (table 2). OBSERVATIONS

The age range, sex ratio, and racial distribution were no different for the 15 patients than for the general population of tuberculous patients in this hospital (table 3). The volume of blood coughed up and meas-

AMERICANREVIEW OF RESPIRATORYDISEASE, VOLUME97, 1968

187

188

AMIRANA, FRATER, TIRSCHWELL,

ured in the hospital prior to surgery is given in table 4. Tachypnea and tachycardia were of greater clinical value in evaluating these patients than the volume of blood lost and the changes in blood pressure. More often, hypertension because of hypoxia secondary to aspiration was noted in these patients rather t 11:1nhypotension from blood loss. The extent of pulmonary disease is indicated in table 5. Nine patients had bilateral disease and 6 had unilateral disease. Ten patients had sputum positive for tubercle bacilli at the time of surgery, 3 of whom had not been previously treated with antituberculous drugs. Five of these 15 patients had proved tuberculosis in the past, but had sputum negative for tubercle bacilli at the time of surgery. Reactivation of tuberculosis was considered the cause of bleeding in these patients. However, in 2, the source of bleeding was old tuberculous TABLE HEMOPTYSIS:

Conservative IS-month Patients Hemoptysis Significant hemoptysis Deaths

I

TUBERCULOSIS

Approach Period 722 150 17 5

JANIS,

BLOOMBERG, AND STATE

bronchiectasis, and in 3 saprophytic aspergilli growing in old cavities were the cause. All patients were operated upon in the prone position using an Overholt table. A large single lumen endotracheal tube was used to maintain a patent airway during surgery. RESULTS

Thirteen lobectomies, one segmental resection, and one pneumonectomy were performed. There were no deaths in this series. Complications were few. In 2 patients with proved tuberculosis in the past, but no active disease at the time of emergency surgery, bronchopleural fistula developed. It is of interest that bronchopleural fistulas did not develop in 3 patients with active disease in the bronchus at the line of transection. One patient had a major wound infection (nontuberculous), and a right middle lobe infarct developed in one patient after right upper lobectomy. This latter patient required a subsequent right middle lobectomy but made a complete recovery (table 6). Two patients with vital capacities of 1 liter and maximal midexpiratory flow of 0.1 and 0.2 liter per minute, respectively, needed assisted ventilation postoperatively, but both recovered.

FIG. 1. Massive aspiration of blood in the tracheobronchial

tree.

189

SURGERY IN PULMONARY TUBERCULOSIS WITH HEMOPTYSIS

FIG. 2. A. Large blood-filled pulmonary cavity. B. Cavity partially emptied. TABLE 2 H:E1MOPTYSIS: TUBERCULOSIS Conservative Therapy (18 months)

Significant hemoptysis Operations Deaths

17

o 5

Surgery (36 months)

45 15

aspergillosis following old fibrocavitary tuberculosis are additional causes of significant hemoptysis, as was seen in 5 of our cases. In deciding whether surgery is feasible, the localization of the bleeding site is, of course, of prime importance. Serial, upright, portable chest films, and bronchoscopy are the keys to

o TABLE 3 HEMOPTYSIS:

All patients had sputum negative for tubercle bacilli within four weeks of surgery, including the 3 previously untreated. These patients have remained· noninfectious for periods of time ranging from four weeks to two years after surgery. DISCUSSION

The source of bleeding in pulmonary tuberculosis is usually a pulmonary arterial aneurysm, as shown by Fern (3), Rasmussen (4), and Auerbach (5). Occasionally, serious hemorrhage may arise from highly vascularized granulation tissue in the periphery of fresh tuberculous cavities, as was observed in 3 of our previously untreated patients. Less frequent causes of pulmonary hemorrhage in tuberculosis are cavernoliths and broncholiths (6) perforating the wall of both the bronchus and the artery. Bronchiectasis (7, 8) and

TUBERCULOSIS·

15 Patients No. of Patien ts

Age Range

4 2

20-30 30-40 40-50 .50-60 60-70

4 4

1

Sex

r

I Male, 10 \ Female, 5

l TABLE 4

HEMOPTYSIS:

TUBERCULOSIS

Blood Loss Measured in Hospital Volume No. of Patients

3 3 4 1 4

(mI.)

100-200 200-400 400-600 800-1,000 1,000 or more

190

AMIRANA, FRATER, TIRSCHWELL,

TABLE 5 HEMOPTYSIS:

TUBERCULOSIS

15 Patients Exten t of Disease

Conditionof

Bilateral in 9 patients Unilateral in 6 patients

Positive Treated Untreated (new cases) Negative Aspergillosis Bronchiectasis

Sputum

10 7 3 5 3 2

TABLE 6 HEMOPTYSIS:

TUBERCULOSIS

Morbidity and Mortality Operative mortality Bronchopleural fistula " Right middle lobe infarct Major wound infection

None 2 1

1

localizing the lesion. Our experience shows no ill effects from bronchoscopy in patients with hemoptysis. Indeed it was helpful in the localization of the site of bleeding, especially in the presence of bilateral disease. Bronchoscopy was performed as early as possible in potential surgical candidates, hopefully before any aspiration had occurred. Serial, interval, portable upright- chest

FIG.

JANIS,

BLOOMBERG, AND STATE

films have also been found very useful; not only did they help in locating the site of bleeding, but they also demonstrated the presence of aspiration. Once aspiration takes place, tl~e physical findings may be misleading and must be interpreted with caution. All too frequently localized wheezes, rales, or rhonchi reflect the presence of aspirated blood, whereas the primary lesion may remain clinically silent. In figure 3 the value of an interval, portable chest film in a patient in whom the presence, location, and the extent of aspiration of blood may be seen is clearly demonstrated. Until recently much emphasis has been laid upon the amount of blood expectorated rather than aspirated. The severity of hemoptysis has been judged and classified according to the amount of blood coughed up, and attempts have been made to establish the mode of therapy on this basis. We have found this criterion of little help. Many patients cough up only small amounts of blood and yet aspirate massively. In addition, expectorated blood is often swallowed and thus cannot be measured. Most of our patients had guaiacpositive stools. In evaluating these' patients, our experience has led us to emphasize the presence or risk of aspiration rather than the volume of blood expectorated.

3. A. Chest film demonstrating hemoptysis. B. Extent of aspiration of blood..

SURGERY IN PULMONARY 'l'UBERCULOSIS WITH HEMOPTYSIS

Little has been written recently regarding the emergency surgical therapy of hemoptysis. Rzepecki (9, 10) considers pulmonary hemorrhage in tuberculosis an urgent indication for pulmonary resection, provided the site of hemorrhage is accurately determined. He has recently published an analysis of 8 patients operated upon for pulmonary hemorrhage. There were no deaths, but bronchopleural fistula developed in 2 patients. We agree with him that bilateral pulmonary tuberculosis does not contraindicate resection, provided the site of bleeding can be well established prior to surgery. Nine of our 15 patients had bilateral disease, but the bleeding site could be determined accurately prior to surgery. Yabuki and associates (11) analyzed resections in 28 patients (with three deaths). Four of their patients had small amounts of hemoptysis postoperatively. In comparison none of our patients had recurrence of hemoptysis once the bronchus clamp was applied. Those writers recommend the lateral position during surgery and the use of double lumen endotracheal tubes. (Carlens' tube). We did not use Carlens' tube because we had found that the individual small lumina of the Carlens' tube do not easily take suction catheters and can readily become blocked with blood clots. We favor the prone position over the lateral one in that it brings the bronchus into an excellent anatomic position for early clamping. Lately;' we have performed bronchoscopy at the end of the procedure. We have found that the postoperative course becomes smoother if the aspirated blood clots are removed completely from the tracheobronchial tree immediately after surgery. These patients are placed on prolonged chemotherapy postoperatively, as recommended by Ross (12). Ten patients with tubercle bacilli in the sputum at the time of surgery have remained noninfectious postoperatively for periods of time ranging from four weeks to two years. SUMMARY

In a group of 45 patients with significant hemoptysis due to pulmonary tuberculosis, 15 were selected for emergency surgery. Criteria used for the selection of these patients are described. The importance of the hazard of

191

aspiration rather than the quantity of blood lost is stressed. The results of surgery were excellent in that there were no deaths and bronchopleural fistula. developed in only 2 patients. The sputum of the 10 patients with active disease has remained negative for tubercle bacilli since surgery for periods ranging from four weeks to two years. The writers believe that the features of the surgical therapy that have been of particular importance in the successful outcome are (1) early selection of the patient before aspiration has occurred; (2) serial chest films to determine the extent of disease and the detection of aspiration; (3) bronchoscopy for determination of the site of bleeding and, postoperatively, for satisfactory bronchial lavage; (4) prone position for surgery; (5) use of large single lumen endotracheal tube for maintenance of a patent airway during surgery; and (6) continuation of antituberculous therapy postoperatively for prolonged periods of time. RESUME

T

Tratamienio QUiTUTgicoAg?·esivo de las Hemoptisis Seueras en la Tuberculosis Pulmonar En un grupo de 45 pacientes con hemoptisis sever as causadas por tuberculosis, 15 fueron seleccionados para cirugia de emergencia. Se describe el criterio empleado para seleccionar estos pacientes. Se recalca el peligro de la neumonitis por aspiraci6n el cual se considera mayor que el de la sangria. Los resultados quinirgicos fueron excelentes ya que no hubo muertes y s610 2 pacientes revelaron fistulas broncopleurales. EI esputo en 10 de los pacientes con enfermedad activa ha permanecido negativo al Bacilo de Koch desde la intervenci6n, por periodos de 4 semanas a 2 afios. Se sefialan los siguientes detalles de la terapia quirurgica como de singular importancia en los resultados favorables obtenidos: (1) pronta intervenci6n antes de que ocurra la aspiraci6n; (2) rontgenogramas seriados para determinar la extension de la lesion y la posible existencia de la aspiracion ; (3) broncoscopia para determinar el origen de la hemorragia y para hacer aspiracion bronquial; (4) posicion en decubito ventral durante el acto operatorio; (5) mantener vias respiratorias lib res mediante el uso de tuba traqueal de luz amplia; (6) continuar la terapia antituberculosa por tiempo prolongado. -

192

AMIRANA, FRATER, TIRSCHWELL, RESUME

A pproche chirurqical aggressif pOW' les hemopiusies imporumiee chez les malades atteints de tuberculose pulmonaire Dans un groupe de 45 malades presentant des hemoptysies importantes dues it une tuberculose pulmonaire, on en a choisi 15 afin de les traiter par des methodes chirurgicales d'urgence. On deer it les criteres utilises pour la selection de ces malades. On insiste fortement sur l'importance presentee par le risque d'aspiration plutot que sur la quan tite de sang perdue. Les resultats de la chirurgie ont ete excellents; on n'a eu a deplorer aucun deces, une fistule broncho-pleurale s'est developpee chez 2 malades seulement. Les expectorations de lO patients atteints de maladie active sont res tees negatives pour les bacilles de la tuberculose depuis l'intervention chirurgicale, ceci pour des periodes s'etendant de quatre semaines it deux ans. Les auteurs estiment que les caracteristiques de la therapeutique chirurgicale, qui ont revetu une importance part.iculiere pour l'issue favorable, sont les suivantes: (1) une selection precoce du malade avant qu'il ne se soit produit une aspiration; (2) des examens radiologiques en serie du thorax afin de determiner I'etendue de la maladie, et de detector une aspiration; (3) la pratique de la bronchoscopie pour reconnaltre Ie lieu du saignement, ainsi qu'une bronchoscopie post-operatoire en vue de permettre un lavage bronchique satisfaisant; (4) une position favorable pour l'intervention chirurgicale: (5) l'utilisation d'un tube large it simple orifice pour maintenir l'ouverture du conduit aerien au cours de la chirurgie; (6) le maintien d'une therapeu tique anti tuberculeuse postoperatoire pour de longues periodes de temps.

JANIS,

BLOOMBERG, AND STATE

REFERENCES (1) Trimble, H. G., and Wood, J. R.: Pulmonary hemorrhage: Its control by use of rv pituitrin, Dis. Chest, 1950,18,345. (2) Pursel, S. E., and Lindskog, G. E.: A clinical evaluation of lO5 patients examined consecutively on a thoracic surgical service, Amer. Rev. Resp. Dis., 1961,84,329. (3) Fern, S. VV.: Aneurysm of the pulmonary artery (letter to the Editor), 1840-1841, Lancet, 1, 679. (4) Rasmussen, V.: On hemoptysis, especially when fatal in its anatomical and clinical aspects, Edinburgh Med. J., 1868, 1~, 384; 486. (5) Auerbach, 0.: Pathology and pathogenesis of pulmonary arterial aneurysm in tuberculous cavities, Amer. Rev. Tuberc., 1939,39, 99. (61 Cooley, D. A.: The clinical significance of cavernoliths, J. Thorac. Cardiov. Surg., 1953,25, 246. (7) Ehrenhaft, J. L., and Taber, R. E.: Management of massive hemoptysis not due to pulmonary tuberculosis or neoplasm, J. Thorac. Cardiov. Surg., 1955, 30, 275. (8 ) Waterman, D. H.: Discussion of reference 7 by Ehrenhaft and Taber, J. Thorac. Cardiov. Surg., 1955,30,275. (9) Rzepecki, W. : Wskazania do Wyciecia Miazscu Bluenego w Chirurgicznym Leczeniu Gruzlicy Plue, Gruzlica, 1956, 24, 763. (10) Rzepecki, W., and Badmazew, P.: Hemorrhage in tuberculosis as an urgent indication for resection of pulmonary tissue, Dis. Chest, 1962,41,372. (ll) Yabuki, S., Chin S., Ikeuchi, H., and Jasuda, S.: Methods and results of pulmonary resection for massive and frequent hemoptysis, Tohoku J. Exp. Med., 1965, 85, 201. . (12) Ross, C. A.: Emergency pulmonary resection for massive hemoptysis in tuberculosis, J. Thorac. Cardiov. Surg., 1953,26,435.