From the Guidelines
The procedure of choice for controlling massive hemoptysis in a patient with pulmonary tuberculosis and recent anti-tuberculous treatment is bronchial artery embolization (BAE). This minimally invasive procedure involves identifying the bleeding vessels through angiography and selectively embolizing them using materials such as gelfoam, polyvinyl alcohol particles, or coils. For a patient with hemoptysis exceeding 250 ml (defined as massive hemoptysis), BAE offers the most effective immediate intervention to stop the bleeding, with a high initial success rate of 70-99% as demonstrated by studies such as those by Pei et al 1 and Agmy et al 1. While rigid bronchoscopy may help localize the bleeding site and temporarily control it through various techniques, BAE provides definitive treatment by directly occluding the abnormal, hypertrophied bronchial arteries that typically cause bleeding in tuberculosis patients. These vessels develop due to chronic inflammation and neovascularization in TB-affected lung tissue. The procedure can be performed under local anesthesia with conscious sedation, making it safer than surgical options for an acutely bleeding patient who may be hemodynamically compromised. Following BAE, the patient should continue their anti-tuberculous treatment regimen as the underlying TB infection must still be treated to prevent recurrence of hemoptysis. Some key points to consider in the management of massive hemoptysis include:
- The importance of securing and maintaining an adequate airway and optimal oxygenation, which may require endotracheal intubation 1
- The use of bronchoscopy for both diagnostic and therapeutic purposes, including tamponade of the segment, instillation of iced saline solution, and bronchoscopic-guided topical hemostatic tamponade therapy 1
- The consideration of bronchial artery embolization if these measures are unsuccessful, as it has been shown to be effective in temporizing the bleeding 1
From the Research
Procedure for Controlling Massive Hemoptysis
The procedure of choice for controlling massive hemoptysis in a patient with pulmonary tuberculosis (TB) and recent anti-tuberculous treatment, presenting with a large volume of fresh blood in sputum, estimated to be greater than 250 milliliters (ml), is:
- Bronchial artery embolization (BAE), as it is regarded as an effective approach for managing massive hemoptysis, regardless of the underlying pathological lesion 2, 3, 4, 5, 6
- BAE is a safe and minimally invasive technique that can be performed repeatedly, providing not only short-term but also prolonged effectiveness 2
- It is an excellent nonsurgical alternative to surgery, with a high success rate and low complication rate 3, 4, 5
Indications for BAE
BAE is indicated for patients with:
- Massive hemoptysis, defined as expectoration of more than 200-600 ml of blood in 24 hours 3
- Hemoptysis that is not controlled by conservative medical therapy 3, 4
- Underlying conditions such as bronchiectasis, tuberculosis, aspergilloma, lung cancer, and others 2, 3, 4, 5
Considerations
- Surgery may be recommended in patients with massive hemoptysis caused by thoracic vascular injury, arteriovenous malformation, leaking thoracic aneurysm with bronchial communication, hydatid cyst, and other conditions in which BAE would be inadequate 3
- Bronchial occlusion may be useful for emergency hemostasis, but it warrants careful follow-up with consideration of additional elective treatment such as BAE 2