Solunum Acillerinden Masif Hemoptizi
Özet
Masif hemoptizi, genellikle 24 saatte en az 600 ml kanın ekspektore edilmesiyle karakterize, hayatı tehdit eden acil bir klinik tablodur. Bu durumda hayati tehlike, kan kaybından ziyade büyük hava yollarının tıkanması sonucu gelişen asfikgiden kaynaklanır. Vakaların yaklaşık %90'ı, yüksek basınçlı bronşiyal arter sistemindeki patolojilerden köken alır. Etiyolojide kronik bronşektazi alevlenmeleri, aktif veya sekel tüberküloz, maligniteler ve nekrotizan akciğer enfeksiyonları ön plana çıkmaktadır. Tanısal süreçte, kanamanın üst hava yolu veya gastrointestinal sistem yerine akciğer kaynaklı olduğunu doğrulamak ilk adımdır. Kontrastlı Toraks Bilgisayarlı Tomografisi (BT) ve bronkoskopi kombinasyonu, kanama odağının saptanmasında %93'e varan yüksek bir duyarlılık sunar. Hastanın yönetiminde öncelik hava yolu açıklığının korunması ve klinik stabilizasyonun sağlanmasıdır; bu amaçla kanayan taraf altta kalacak şekilde lateral pozisyon tercih edilir. Tedavide, minimal invaziv bir yöntem olan bronşiyal arter embolizasyonu (BAE) %90'ın üzerinde akut başarı oranıyla ilk seçeneklerden biridir. Medikal ve endobronşiyal tedavilere dirençli, cerrahi endikasyonu olan komplikasyonlu durumlarda ise planlı cerrahi rezeksiyonlar mortaliteyi düşürmektedir. Masif hemoptizi, multidisipliner ve süratli bir yaklaşım gerektirir.
Massive hemoptysis is a life-threatening clinical emergency generally defined as the expectoration of at least 600 ml of blood within a 24-hour period. The primary threat to life arises from asphyxiation due to airway obstruction rather than hypovolemic shock from blood loss. Approximately 90% of cases originate from the high-pressure bronchial arterial system. The main etiological factors include acute exacerbations of bronchiectasis, active or sequelae tuberculosis, malignancies, and necrotizing pulmonary infections. In the diagnostic approach, the critical first step is confirming that the bleeding originates from the lower respiratory tract rather than the gastrointestinal tract or upper airways. The combination of contrast-enhanced Chest Computed Tomography (CT) and bronchoscopy provides a diagnostic success rate of up to 93% in localizing the bleeding source. Patient management prioritizes maintaining airway patency and achieving hemodynamic stabilization, which involves placing the patient in a lateral decubitus position with the bleeding side down. Bronchial artery embolization (BAE) serves as a highly effective, minimally invasive intervention with initial success rates exceeding 90%. For refractory cases secondary to vascular ruptures or trauma, planned surgical resection significantly reduces mortality compared to emergency surgery. Overall, managing massive hemoptysis demands a rapid, well-coordinated multidisciplinary strategy.
Referanslar
Anonymous. Life-threatening haemoptysis (Editorial). Lancet 1987;1: 1354-6.
Ibrahim WH. Massive haemoptysis: the definition should be revised. Eur Respir J 2008; 32:1131-2.
Chun JY, Morgan R, Belli AM. Radiological management of haemoptysis: A comprehensive review of diagnosticimaging and bronchial arterial embolization. Cardiovasc Intervent Radiol 2010; 33: 240-50.
Jean-Baptiste E. Clinical assessment and management of massive haemoptysis. Crit Care Med 2000; 28: 1642-7.
Khalil A, Parrot A, Nedelcu C, et al. Severe haemoptysis of pulmonary arterial origin: Signs and role ofmultidetector row CT angiography. Chest 2008; 133: 212-9.
Deffebach ME, Charan NB, Lakshminarayan S, et al. The bronchial circulation. Small, but a vital attribute of thelung. Am Rev Respir Dis 1987; 135: 463-81.
Mondoni M, Carlucci P, Job S, et al. Observational, multicentre study on the epidemiology of haemoptysis. Eur Respir J. 2018; 51:pii: 1701813.
Fartoukh M, Khoshnood B, Parrot A, et al. Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis. Respiration 2012;83:106-14.
Shee B, Rockoff BI. Hemoptysis (Pulmonary Hemorrhage). In: StatPearls [Internet]. StatPearls Publishing, 2019.
Rasmussen V, Moore WD. On haemoptysis, especially when fatal, in its anatomical and clinical aspects. Edinb Med J. 1868;14:486-503.
Arooj P, Bredin E, Henry MT, et al. Bronchoscopy in the investigation of outpatients with hemoptysis at a lung cancer clinic. Respir Med 2018;139:1-5.
Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis 2017;9:1069-86.
Bernasconi M, Koegelenberg CF, Koutsokera A, et al. Iatrogenic bleeding during flexible bronchoscopy: risk factors, prophylactic measures and management. ERJ open research 2017;3:00084-2016.
Davidson K and Shojaee S. Managing massive hemoptysis. Chest 2019: pii:S0012-3692(19):31386-8.
Cordovilla R, Bollo de Miguel E, Nunez Ares A, et al. Diagnosis and treatment of haemoptysis. Arch Bronconeumol 2016; 52: 368-77.
Jones KD, Davies RJ. Massive haemoptysis. Br Med J 1990;300:899-90.
Solomonov A, Fruchter O, Zuckerman T, et al. Pulmonary hemorrhage: A novel mode of therapy. Respir Med 2009;103:1196-200.
Hirshberg B, Biran I, Glazer M, et al. Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest 1997;112:440-4.
Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration 2010;80:38-58.
Landsberg JW, Hemoptysis. In: Manual for Pulmonary and Critical medicine. 1th ed. Elsevier; 2018: pp 567-582.
Larici AR, Franchi P, Occhipinti M, et al. Diagnosis and management of haemoptysis. Diagn Interv Radiol 2014; 20: 299-309.
Yendamuri S. Massive Airway Hemorrhage. Thorac Surg Clin 2015;25:255-60.
Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax 2003; 58: 814-9.
Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R. Massive hemoptysis. Review of 123 cases. J Thorac Cardiovasc Surg 1983; 85: 120-4.
Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15: 147-67.
de Gracia J, de la Rosa D, Catalán E, Alvarez A, Bravo C, Morell F. Use of endoscopic fibrinogen-thrombin in the treatment of severe hemoptysis. Respir Med 2003; 97: 790-5.
Chun JY, Morgan R, Belli AM. Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization. Cardiovasc Intervent Radiol 2010;33:240-50.
Fruchter O, Schneer S, Rusanov V, et al. Bronchial artery embolization for massive hemoptysis: long-term follow-up. Asian Cardiovascular and Thoracic Annals 2015;23:55-60.
Andréjak C, Parrot A, Bazelly B, et al. Surgical lung resection for severe haemoptysis. Ann Thorac Surg 2009; 88: 1556-65.
Paul S, Andrews W, Nasar A, et al. Prevalence and outcomes of anatomic lung resection for haemoptysis: Ananalysis of the nationwide inpatient sample database. Ann Thorac Surg 2013; 96: 391-8.
