Life-threatening Hemoptysis Research Articles

The emergency department evaluation and management of massive hemoptysis.

Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management. Recognition of this deadly condition, knowledge of the initial resuscitation and diagnostic evaluation, and communication with consultants capable of definitive management are key to successful treatment. The objective of this narrative review is to provide an evidence-based review on the management of massive hemoptysis for the emergency clinician. Rapid diagnosis and management of life-threatening hemoptysis is key to patient survival. The majority of cases arise from the bronchial arterial system, which is under systemic blood pressure. Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram. Bronchial artery embolization with interventional radiology has become the mainstay of treatment; however, unstable patients may require advanced bronchoscopic procedures to treat or temporize while additional information and treatment can be directed at the underlying pathology. Massive hemoptysis is a life-threatening condition that emergency clinicians must be prepared to manage. Emergency clinicians should focus their management on immediate resuscitation, airway preservation often including intubation and isolation of the non-bleeding lung, and coordination of definitive management with available consultants including interventional radiology, interventional pulmonology, and thoracic surgery.

The effects of antifungal therapy on the recurrence of aspergillus infection after pulmonary aspergilloma resection: a study protocol for a single-center, prospective, non-blind, randomized, 24-month, parallel group study

BackgroundIn recent years, the incidence of pulmonary aspergilloma has increased. The harm of aspergilloma is life-threatening massive hemoptysis, and the conventional treatment is surgical treatment. However, whether the antifungal treatment after surgery is required and the course of treatment before and after surgery are still unclear.MethodsIn this study, patients with pulmonary aspergilloma confirmed pathologically after surgery will be selected as subjects to conduct a single-center, randomized, parallel grouping, prospective, 2-year clinical study. Through regular visits, the recurrence of aspergillus infection, quality of life, lung function indicators, safety of antifungal therapy and other indicators were recorded to evaluate the recurrence risk of aspergillus infection and safety of antifungal agents. Cox proportional risk regression model was used to analyze the influencing factors of antifungal therapy on aspergillus infection recurrence after aspergillus bulbectomy. Cox multiple regression model was used for optimal model fitting, and regression coefficient (β), relative risk (RR) and 95% confidence interval of RR were calculated.DiscussionThe study will explore whether antifungal therapy could improve the quality of life, reduce the recurrence of aspergillus infection, and ultimately improve the prognosis of patients with aspergilloma. The study results will provide high-quality evidence-based medical evidence for the formulation, revision and optimization of international and domestic clinical guidelines and expert consensus on chronic aspergillus lung disease, effectively improve the clinical treatment effect of aspergilloma, and form the latest concept of diagnosis and treatment of aspergilloma.Trial registration: The trial was registered on the Chinese Clinical Trial Registry website (https://www.chictr.org.cn/showprojen.aspx?proj=33231). Registration number: ChiCTR1800019990.

Management of life-threatening hemoptysis in the ICU.

Life-threatening hemoptysis is commonly encountered in the ICU and its management can be challenging even for experienced clinicians. Depending on the etiology and severity, one can tailor the treatment modality and therapeutic intervention(s). The grading of severity of hemoptysis varies greatly in the literature; however, unlike hemorrhage in other scenarios, small amounts of blood can significantly impair oxygenation and ventilation leading to cardiovascular collapse. Importantly, the initial evaluation and management should focus on airway and hemodynamic stabilization along with maintenance of oxygenation and ventilation. In this review, we discuss commonly encountered etiologies, vascular anatomy, diagnostic evaluation, and therapeutic interventions. We examine the evolving trends in etiologies of life-threating hemoptysis over the years. The role of flexible and rigid bronchoscopy as both a diagnostic and therapeutic modality is explored, as well as the use and indications of several bronchoscopic techniques, such as topical hemostatic agents, endobronchial tamponade, and tranexamic acid (TXA). In addition, we assess the use of multi-row detector computed tomography as the initial rapid diagnostic method of choice and its use in planning for definitive treatment. The efficacy and long-term results of bronchial artery embolization (BAE) are evaluated, as well as indications for surgical intervention. Furthermore, the importance of a multidisciplinary approach is emphasized. The necessary interplay between intensivists, consultative services, and radiologists is described in detail and an algorithmic management strategy incorporating the above is outlined. Given the complexity in management of life-threatening hemoptysis, this paper aims to summarize the available diagnostic and therapeutic methods and provide a standardized approach for the management of patients with this often difficult to treat condition.

Surgical Treatment of Pulmonary Aspergilloma: A 13-year Experience From a Single Clinical Center

BackgroundPulmonary aspergilloma is chronic and invasive, potentially leading to life-threatening massive hemoptysis. The role of surgery for treating pulmonary aspergilloma and its effect on long-term survival needs more study. MethodsWe reviewed 166 patients with aspergillomas treated at Shanghai Pulmonary Hospital from 2004 to 2017. Surgery indications included destroyed lung parenchyma, recurrent hemoptysis, despite appropriate medical treatment, and isolated pulmonary nodules suspected to be aspergilloma. Pulmonary aspergillomas are classified as simple (in an isolated thin-walled cavity, ≤3 mm) or complex (a thick-walled cyst, >3 mm) based on computed tomographic scan findings. ResultsAspergilloma was complex in 100 patients (60.2%) and simple in 66 (39.8%). The median (interquartile range) size of complex aspergillomas (2.5 [0.3-8.0] cm) was larger than that (2.0 [0.2-6.0] cm) of simple types (P < .001). Hemoptysis occurred in 72 patients (72%) with complex disease and in 35 (53%) with simple disease (P = .014). Video-assisted thoracoscopic surgery was performed in 42 patients (63.6%) with simple aspergillomas, and 75 patients (75%) with of complex aspergillomas underwent thoracotomy. Prolonged air leakage (>7 days) was the most common (17 [10.2%]) postoperative complication. A bronchopleural fistula developed postoperatively in 1 patient (0.6%). One patient (0.6%) died of respiratory failure within 30 days postoperatively. Two patients (1.2%) experienced recurrence during follow-up. The overall 10-year survival rates were 87.7% for complex aspergillomas and 94.97% for simple aspergillomas (P = .478). Diabetes (12 [7.2%]; hazard ratio, 13.15; 95% CI, 1.12-154.46) was associated with a worse prognosis. ConclusionsThe perioperative morbidity and mortality of pulmonary aspergillomas are acceptable. Overall survival rates of simple and complex types are comparable.

Hemoptysis Associated With Percutaneous Transthoracic Needle Biopsy: Development of Critical Events Checklist and Procedure Outcomes

BackgroundA percutaneous transthoracic needle biopsy (PTNB) is performed to obtain tissue for a pathologic diagnosis. A PTNB is necessary before the initiation of many cancer treatments. There is a risk of hemoptysis, the expectoration of blood, with the possibility for adverse, life-threatening outcomes. A critical event checklist is a cognitive aid used in an emergency to ensure critical steps are followed. To date, there are no known checklists published for management of PTNB-related, life-threatening hemoptysis. The purpose of this report is to describe the development and implementation of a critical event checklist and the adoption of the checklist into hemoptysis management. MethodsIn March 2017, a process improvement team convened to evaluate the hemoptysis response using the Plan-Do-Study-Act methodology. The checklist was evaluated and updated through September 2019. The team educated interventional radiology (IR) clinicians on the new checklist and conducted simulations on its use. A retrospective chart review was performed on hemoptysis events between the 10-year period of October 1, 2008 and September 30, 2018 to evaluate the adoption of the checklist into practice. ResultsThere were 231 hemoptysis events occurring in 229 patients (2 with repeat biopsies). Before implementing the protocol and checklist, there were 166 (71.9%) hemoptysis events. After implementation, there were 65 (28.1%) events. The median amount of documented blood expectorated with hemoptysis was 100 mL (IQR 20.0-300.0). Twenty-six patients were admitted after PTNB for reasons related to the hemoptysis event (11.3%). During the procedure, four (1.7%) patients with hemoptysis suffered a cardiac arrest. Before implementation of the protocol and critical events checklist, nurses positioned patients in the lateral decubitus (LD) position in 40 of 162 (24.7%) cases. After implementation of the critical events checklist, nurses positioned patients in the LD position 42 of 65 cases (64.6%) (OR = 5.57(95% CI 2.99-10.367), p < .001). DiscussionIR nurses successfully adopted the checklist into management of hemoptysis events. The reported incidence of hemoptysis suggests a need for IR teams to prepare for and simulate hemoptysis events. Future research is needed to evaluate the change in patient outcomes before and after critical events checklist implementation.

Life-threatening hemoptysis accompanied by internal thoracic artery aneurysms in a 28-year-old perinatal woman: a case report

BackgroundLife-threatening hemoptysis presents an immediate diagnostic and therapeutic challenge, especially during the perinatal period.Case presentation A 28-year-old perinatal woman with no significant past medical or surgical history presented with repeating hemoptysis and respiratory failure. Computed tomography revealed a 2.1 × 3.2 cm2 inhomogeneous tumorous lesion in the right superior mediastinum and a right main bronchus obstruction along with atelectasis of the right lung. Bronchoscopy showed a tumorous protrusion blocking the right main bronchus with active hemorrhage, and malignancy was suspected. Bronchial artery embolization (BAE) was performed to control the bleeding. The arteriogram revealed tortuosity, dilation and hypertrophy of the right bronchial arteries and aneurysms of the internal thoracic artery (ITA). The bleeding completely stopped after BAE. Bronchoscopy was performed again to remove residual blood clots. The patient recovered soon after the procedure and was discharged.ConclusionsLife-threatening hemoptysis concomitant with ITA aneurysms, which may have a misleading clinical diagnosis and treatment options, has not been reported previously in perinatal women. BAE could be used as a first-line treatment irrespective of the underlying causes.

Surgical management of pulmonary aspergilloma-12 years' experience from a tertiary care centre in India.

Pulmonary aspergilloma is the formation of saprophytic colonies of fungus in pre-existing pulmonary cavities. They may cause life-threatening haemoptysis. As medical treatment often fails, surgery is the mainstay of treatment in symptomatic patients. Earlier studies had reported high levels of mortality and morbidity with surgery while more recent studies have shown better results. Hence, being in a large tertiary care centre in India, we decided to analyse the details of our own experience in the surgical management of pulmonary aspergilloma. Details of all adult patients treated surgically for pulmonary aspergilloma, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analysed. There were 102 patients in the study. The average age was 40years. There was a male (M: F, 3:1) and right side preponderance. Pulmonary tuberculosis (TB) was the commonest cause for cavities in which aspergilloma developed as identified in 84 (82%) patients and diabetes mellitus, the commonest comorbidity present in 28 (27.5%) patients. Parenchyma-preserving lung resections (PPLRs) were feasible in 8 (44%) of the non-tubercular patients, but only in 14 (17%) of the TB patients. Post-operative complications (11.7%) were higher among the patients with TB. There were 2 (1.9%) post-operative mortalities. Though surgery is technically complex in the presence of pulmonary aspergilloma, it is yielding better results with improvements in treatment strategies. Surgery for aspergilloma in patients with prior or current pulmonary TB has more morbidity and mortality when compared to the non-TB patients.

Surgery for Life-Threatening Massive Hemoptysis; Does the Time of Performed Surgery and the Timing of Surgery Affect the Rates of Complication and Mortality?

The changing of clinical and surgical presentation over the course of years and the effect of the timing of surgery for the massive hemoptysis were investigated. Between 2000 and 2015, 67 patients with life-threatening massive hemoptysis who underwent surgical treatment were analyzed. The timing of surgery was defined as urgent (n=6) and planned-delayed (n=61). The time of performed surgery was divided into two parts: the previous period (2003 to 2010) (n=48) and the recent period (2010 to 2017) (n=19). There were 25 patients (37.3%) with no preoperative diagnoses. The most common postoperative diagnosis was tuberculosis (n=20, 29.8%). The rate of operation for massive hemoptysis in patients who were admitted to the hospital for hemoptysis was lower in the recent period than the previous period (2.7% versus 7.9%, p<0.001). The urgent surgery group had a higher overall complication rate than the planned-delayed surgery group (66.7% versus 38.3%). Complication in patients with tuberculosis was not different than the remaining patients (p=0.254). Major complication rate was a trend downward in the recent period (22.7 to 10.5%). Mortality increased in the presence of urgent surgery (p=0.003) and in patients who were transferred to the intensive care unit (ICU) with intubation after surgery (p<0.001). There was a tendency to significant difference between two periods in regards of mortality rate (16.7% in the previous period, 0% in the recent period, p=0.09). Our results support a trend toward improved surgical outcomes in massive hemoptysis. High mortality indicators are the presence of urgent surgery and returning to the ICU with postoperative intubation.

Pulmonary artery pseudoaneurysms: endovascular management after adequate imaging diagnosis.

Pulmonary artery pseudoaneurysms(PAPs) are rare serious vascular abnormalities mostly due to infections and trauma, although other conditions such as vasculitis, neoplasms, or inflammatory lung diseases can also predispose to this entity. Endovascular techniques such as embolization or covered stent placement have mostly substituted surgical approaches, for their lower invasiveness and greater security, mainly in patients with life-threatening hemoptysis. The purpose of this manuscript is to describe the imaging findings of pulmonary artery pseudoaneurysms and their endovascular management including tips to help interventional radiologists. PAP should be diagnosed as accurately and early as possible in order to prompt endovascular management of further life-threatening hemoptysis. KEY POINTS: • Pulmonary artery pseudoaneurysms (PAPs) are rare serious vascular abnormalities that may represent a life-threatening condition, mainly due to Staphylococcus, Streptococcus, or Mycobacterium tuberculosis. • Radiologists should know the imaging findings of PAP in order to make an accurate and early diagnosis to prompt endovascular management of further life-threatening hemoptysis.

Bronchial Dieulafoy Disease with Recurrent Life-threatening Hemoptysis

Bronchial Dieulafoy Disease with Recurrent Life-threatening Hemoptysis

Bronchial Artery Embolization in Life-Threatening Hemoptysis: Outcome and Predictive Factors.

Purpose:To determine the outcome and predictive factors of clinical success of bronchial artery embolization in life-threatening hemoptysis.Material and Methods:We reviewed all bronchial artery embolization procedures performed for life-threatening hemoptysis between January 2008 and December 2018. The outcomes and predictive factors of clinical success following embolization were evaluated.Results:One hundred and eighty-four bronchial artery embolization procedures performed in 145 patients were eligible for the study. The technical and clinical success rates of the procedures were 170/184 (92.4%) and 129/184 (70.1%), respectively. The unstable hemodynamics and prothrombin time/international normalized ratio >1.5 was associated with lower clinical success rate, while embolization of more than one vessel was associated with higher clinical success rate.Conclusion:Bronchial artery embolization is a safe and effective procedure for controlling bleeding in life-threatening hemoptysis. However, low clinical success rate was noted in patients with unstable hemodynamics and coagulopathy, while multiple vessel embolization was associated with higher clinical success.

Life-Threatening Hemoptysis in a Pediatric Referral Center.

Hemoptysis is uncommon in children, even among the critically ill, with a paucity of epidemiological data to inform clinical decision-making. We describe hemoptysis-associated ICU admissions, including those who were critically ill at hemoptysis onset or who became critically ill as a result of hemoptysis, and identify predictors of mortality. Retrospective cohort study. Demographics, hemoptysis location, and management were collected. Pediatric Logistic Organ Dysfunction-2 score within 24 hours of hemoptysis described illness severity. Primary outcome was inhospital mortality. Quaternary pediatric referral center between July 1, 2010, and June 30, 2017. Medical/surgical (PICU), cardiac ICU, and term neonatal ICU admissions with hemoptysis during or within 24 hours of ICU admission. No intervention. There were 326 hemoptysis-associated ICU admissions in 300 patients. Most common diagnoses were cardiac (46%), infection (15%), bronchiectasis (10%), and neoplasm (7%). Demographics, interventions, and outcomes differed by diagnostic category. Overall, 79 patients (26%) died inhospital and 109 (36%) had died during follow-up (survivor mean 2.8 ± 1.9 yr). Neoplasm, bronchiectasis, renal dysfunction, inhospital hemoptysis onset, and higher Pediatric Logistic Organ Dysfunction-2 score were independent risk factors for inhospital mortality (p < 0.02). Pharmacotherapy (32%), blood products (29%), computerized tomography angiography (26%), bronchoscopy (44%), and cardiac catheterization (36%) were common. Targeted surgical interventions were rare. Of survivors, 15% were discharged with new respiratory support. Of the deaths, 93 (85%) occurred within 12 months of admission. For patients surviving 12 months, 5-year survival was 87% (95% CI, 78-92) and mortality risk remained only for those with neoplasm (log-rank p = 0.001). We observed high inhospital mortality from hemoptysis-associated ICU admissions. Mortality was independently associated with hemoptysis onset location, underlying diagnosis, and severity of critical illness at event. Additional mortality was observed in the 12-month posthospital discharge. Future directions include further characterization of this vulnerable population and management recommendations for life-threatening pediatric hemoptysis incorporating underlying disease pathophysiology.

Preemptive non-selective bronchial artery angioembolization to reduce recurrence rate of hemoptysis.

BackgroundMassive hemoptysis which is presented in advanced lung diseases is a life-threatening condition. Bronchial artery embolization as a minimally invasive procedure is the treatment of choice either in first or recurrent hemoptysis. This study aimed to assess the early and late efficacy of bronchial angioembolization (BAE) without microcatheter.MethodsIn this prospective cohort study, all patients with hemoptysis who had undergone BAE from August 2018 to March 2019 were included. Angiographic patterns including bleeding sources, number of involved vessels, the underlying etiology, and recurrence rate were evaluated in a one-year follow up.Results153 patients were included with mean age of 55 ±16 years. 68% of them were male and 58% had life-threatening massive hemoptysis. Three distinct angiographic patterns were recognized. The culprit bleeding vessel was bronchial in 126 (92%), intercostal in 4 (3%), and both vessels in 7 (5%) of cases (p<0.05). One vessel involvement was seen in 56 patients; however it was observed in 69% of non-cystic fibrosis lobar bronchiectasis patients. In 1, 3 and 12 months follow up, recurrent hemoptysis was reported in 15 (11%), 4 (2.5%), and 24 (15.5%), respectively. In 52% of cases, no abnormal vessels were observed during aorta injection, but culprit bronchial or intercostal arteries were found in selective investigational angiography.ConclusionBAE was successful in the control of hemoptysis and resulted in a low rate of recurrence in different types of lung diseases. This could be due to the embolization of all pathological arteries found during angiography which might have prevented recurrent bleeding.

Early Arterial Embolization and Mortality in Mechanically Ventilated Patients With Hemoptysis: A Nationwide Retrospective Cohort Study.

Hemoptysis, a symptom common across various respiratory diseases, can cause airway obstruction leading to a life-threatening condition. Arterial embolization has been used to control bleeding from the lower airways. However, limited studies have evaluated its effects on in-hospital mortality in patients with hemoptysis requiring mechanical ventilation. The objective of this study was to clarify whether early intervention by arterial embolization reduced mortality in mechanically ventilated patients with hemoptysis. Retrospective cohort study from July 2010 to March 2017. More than 1,200 acute-care hospitals, comprising approximately 90% of all tertiary-care emergency hospitals in Japan. The study cohort was patients with pulmonary diseases hospitalized for hemoptysis and mechanically ventilated within 2 days of admission. We compared patients who had undergone arterial embolization within 3 days of endotracheal intubation (early embolization group) with patients who did not (control group). A total of 12,287 patients with hemoptysis requiring mechanical ventilation were analyzed. After 1:4 propensity score matching, there were 226 and 904 patients in the early embolization and control groups, respectively. The early embolization group was associated with lower 7-day and 30-day mortalities (7-d mortality: 1.3% vs 4.0%; odds ratio, 0.39; 95% CI, 0.16-0.97; p = 0.044 and 30-d mortality: 7.5% vs 16.8%; odds ratio, 0.45; 95% CI, 0.28-0.73; p = 0.001) and shorter duration of mechanical ventilation (median 6 d, interquartile range 4-13 d vs 8 d, interquartile range 4-19 d; p = 0.003) compared with the control group. Our results show that early intervention by arterial embolization may be effective in reducing 7-day and 30-day mortalities in patients with life-threatening hemoptysis requiring mechanical ventilation.

Bronchial Artery Embolization for Hemoptysis in Cystic Fibrosis Patients: A 17-Year Review

To review safety and efficacy of bronchial artery embolization (BAE) for treatment of hemoptysis in adult patients with cystic fibrosis (CF) and to report 30-day, 1-year, and 3-year outcomes. Between January 2001 and April 2018, 242 patients with CF were evaluated for hemoptysis. Thirty-eight BAEs were performed in 28 patients with hemoptysis. Technical success was defined as freedom from repeat embolization and hemoptysis-related mortality. Clinical success was defined as freedom from repeat embolization and mortality from any cause. Technical and clinical success were examined at 30 days, 1 year, and 3 years after initial BAE. Mean patient age was 32 years, and median follow-up was 4.8 years (range, 10 mo to 16.7 y). Technical and clinical success rates at 30 days were 89% (25/28) and 82% (23/28), respectively. Success rates at 1 year were 86% (24/28) and 79% (22/28), respectively, and at 3 years were 82% (23/28) and 75% (21/28), respectively. The 30-day overall complication rate was 7.9% (3/38) with 2.6% (1/38) major complication rate and 5.2% (2/38) minor complication rate. Overall 3-year mortality rate was 25% (7/28). BAE is safe and effective in patients with CF presenting with life-threatening hemoptysis. BAE results in high rates of long-term technical and clinical success in this patient population despite progressive chronic disease. Repeat embolization is necessary only in a minority of patients.

Bronchial artery embolization. What further we can offer?

IntroductionMassive hemoptysis is the most feared of all respiratory emergencies, with many underlying causes. In 90% of cases, the source of hemoptysis is the bronchial circulation. Despite high recurrence rates, bronchial artery embolization (BAE) remains the first-line treatment in management of hemoptysis.AimTo establish pre-procedure and procedural protocols for BAE.Material and methodsThe study included a total of 50 patients referred to the Department of Radiology for complaints of hemoptysis. Pre-procedure computed tomography (CT) angiography for determination of responsible circulation was performed as a regular protocol except in cases presenting with life-threatening hemoptysis. Polyvinyl alcohol (PVA size, 300–500 μm and 500–700 μm) particles combined with gel foam embolization was performed. Successful catheterization and embolization of the targeted vessel was considered technical success and the cessation of hemoptysis to minimal levels was labeled clinical success.ResultsThirty-two (64%) male and 18 (36%) female subjects comprised the study group. Forty (80%) patients had moderate to severe hemoptysis. Tuberculosis (80%) was the most common etiology. Five patients had severe AV shunting and were embolized with decremental particle size (500–700 μm followed by 300–500 μm) to occlude the bed and then embolize the artery. Technical success was achieved in all the patients, but clinical success was achieved in 40 (80%) patients.ConclusionsBronchial artery embolization is a minimally invasive procedure recognized for primary management of hemoptysis. Preprocedure evaluation with CT angiography can add incremental value in management. Usage of decremental particle size is helpful to embolize large AV shunts.

PULMONARY ARTERY PLUG EMBOLIZATION FOR TREATMENT OF HEMOPTYSIS

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Pulmonary artery plug embolization (PAE) is a procedure routinely used for treatment of AVMs and Rasmussen’s aneurysm. In theory it should be able to help reduce symptoms of refractory hemoptysis with other etiologies as well1. A review of the literature showed no other cases of PAE for refractory hemoptysis in the setting of advanced lung cancer in the United States. CASE PRESENTATION: This case report is to showcase an 83-year-old male who presented with massive hemoptysis and was treated using a novel and unconventional method.The patient had a known history of non-small cell lung cancer (NSCLC), Stage IIIA (T4N1M0) of the right upper lobe who had completed seven rounds of chemotherapy with Carboplatin and Gemzar. Massive hemoptysis led to hypoxemia with oxygen saturation in the 40’s and was intubated for airway protection. Emergent bronchoscopy was unsuccessful with airways full of bright red blood. Right upper lobe bronchus showed a large amount of active bleeding preventing distal visualization. Chest CT showed a new cavitary lesion, likely malignant from NSCLC. CT angiogram of chest without contrast concluded that the right upper lobe hemoptysis was likely secondary to pulmonary artery pseudoaneurysm. IR proceeded with a right PAE to control bleeding. After right PAE, fiberoptic bronchoscopy was repeated. The right upper lobe opening was visualized with no blood clot, and bronchus intermedius, middle and lower lobe openings were visualized. Acute respiratory failure resolved and patient was successfully extubated. Patient was discharged to have an outpatient CT scan to determine if a bronchoscopy with biopsy would be needed prior to proceeding with any further oncological treatment. DISCUSSION: Marcelin et al evaluated 19 patients treated for massive or recurrent hemoptysis with transarterial pulmonary artery embolization in France. Primary and assisted technical success rates were 73.7% (14/19) and 84.2% (16/19), respectively. They concluded that embolization is an effective and safe treatment of lung tumors with pulmonary arterial bleeding2. CONCLUSIONS: In our patient, PAE succeeded in controlling the massive hemoptysis and patient was successfully extubated. The extent to which this procedure affected the overall survival of this patient is unclear. However, respiratory failure resolved with control of the hemoptysis and patient was successfully extubated. PAE should at least be considered in similar cases when refractory hemoptysis is present. While bronchial artery embolization is the first line treatment in most cases of massive hemoptysis, our patient did not have dilated bronchial arteries to attempt this3. Reference #1: Yoon, W., Kim, J. K., Kim, Y. H., Chung, T. W., & Kang, H. K. (2002). Bronchial and Nonbronchial Systemic Artery Embolization for Life-threatening Hemoptysis: A Comprehensive Review. RadioGraphics, 22(6), 1395-1409. https://doi.org/10.1148/rg.226015180 Reference #2: Marcelin, C., Soussan, J., Desmots, F., Gaubert, J., Vidal, V., Bartoli, J. M., & Izaaryene, J. (2018). Outcomes of Pulmonary Artery Embolization and Stent Graft Placement for the Treatment of Hemoptysis Caused by Lung Tumors. Journal of Vascular and Interventional Radiology, 29(7), 975-980. https://doi.org/10.1016/j.jvir.2018.01.773 Reference #3: Barben J, Robertson D, Olinsky A, Ditchfield M Radiology. 2002 Jul; 224(1):124-30. DISCLOSURES: No relevant relationships by Raju Abraham, source=Web Response No relevant relationships by Naina Chandan, source=Web Response Scientific Medical Advisor relationship with Access Vascular Inc. Please note: $1001 - $5000 Added 03/13/2019 by Arun Jagannathan, source=Web Response, value=Ownership interest Scientific Medical Advisor relationship with IV Access Technologies Please note: $1001 - $5000 Added 03/13/2019 by Arun Jagannathan, source=Web Response, value=Ownership interest No relevant relationships by Kyle Kopatich, source=Web Response No relevant relationships by Dhaval Patel, source=Web Response

THE CASE OF THE FUNGUS IN THE HONEYCOMB

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Aspergillomas are fungal balls that typically develop in pre-existing pulmonary cavities such as those caused by tuberculosis, sarcoidosis, histoplasmosis, cystic fibrosis and lung abscesses but are rarely associated with UIP. Aspergillomas are typically distributed as either multiple bilateral pulmonary aspergillomas or as an isolated aspergilloma. The most commonly reported cases of aspergillomas have been found in post-tuberculosis cavities, accounting for 11 to 17% of cases, with an increased incidence in areas of high tuberculosis prevalence. For this reason, aspergillomas are typically found in the upper lobes with lower/middle lobe findings often associated with other cavitary pulmonary diseases. CASE PRESENTATION: We present an unusual case of multiple, unilateral aspergillomas in a non-immunocompromised patient with usual interstitial pneumonia (UIP). Patient is a 73-year-old female with seropositive rheumatoid arthritis (not on immunosuppressive therapy) who was evaluated for weight loss and minor hemoptysis. Chest CT showed classic bibasilar honeycomb changes typical of UIP. There were nodular opacities within the honeycomb changes suggestive of mycetomas seen exclusively in the right lung base. These were subsequently identified as aspergillomas by correlating the chest CT with bronchoscopic cultures that grew A. fumigatus. The patient’s symptoms resolved spontaneously after 6 months without treatment for either aspergillomas or UIP. At follow up after 2 years, the patient remained symptom free without further episodes of hemoptysis and her weight was stable. DISCUSSION: This case is a unique presentation for several reasons. First, aspergillomas are rarely associated with UIP. Second, multiple aspergillomas usually occur in immunocompromised patients whereas our patient was not immunocompromised. Third, despite the bilateral distribution of honeycombing in this patient, the aspergillomas were strictly unilateral. Finally, whereas aspergillomas are usually upper lobe predominant, our patient’s aspergillomas were localized to the right lower lobe. CONCLUSIONS: Chronic aspergillomas increase the risk of local tissue invasion which may result in potentially life-threatening hemoptysis. Fortunately, this patient’s hemoptysis spontaneously resolved and she subsequently remained asymptomatic. Such a presentation should be kept in mind when taking care of similar patients. Reference #1: Kumar N, Mishra M, Singhal A, Kaur J, Tripathi V. Aspergilloma coexisting with idiopathic pulmonary fibrosis: A rare occurrence. J Postgrad Med 2013;59:145-8 Reference #2: Moodley L, Pillay J, Dheda K. Aspergilloma and the surgeon. J Thorac Dis. 2014;6(3):202-9. Reference #3: Regis Gothard Bopaka, Hasna Jabri, Wiam El Khattabi, Hicham Afif European Respiratory Journal 2015 46: PA2650; DISCLOSURES: No relevant relationships by Nina Chan, source=Web Response No relevant relationships by Peter Sloane, source=Web Response

Prosthetic pulmonary valve and conduit endocarditis in congenital heart disease.

Pulmonary valve replacement is one of the most common procedures in patients with congenital heart disease. Little is known about prosthetic valve endocarditis in this population. To review management and outcomes of pediatric and adult patients with a prosthetic pulmonary valve or right ventricle-to-pulmonary artery conduit infective endocarditis. A multiinstitutional cohort of 10 patients is reported. Median age at endocarditis was 24 years (range 8-41 years). The most common causative organisms were Staphylococcus ( n = 4) and Streptococcus species ( n = 2). In addition to medical treatment, 5 patients required surgery. Majors complications such as renal damage, life-threatening hemoptysis, and septic shock were observed. No patient died in hospital or during follow-up. Pulmonary prosthetic valve endocarditis is a rare condition associated with significant morbidity and a high risk of requiring operative intervention. Larger studies are required to optimize the management.

Protocolo diagnóstico y tratamiento de la hemoptisis

Hemoptysis is the expectoration of blood. The identification of life-threatening hemoptysis is a challenge to clinicians. The keys for etiological diagnosis are both careful history and directed physical examination, and test selection. The cornstone diagnostic test is the multidetector computed tomography angiography (MDCT angiography). Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis of any origin or amount. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Bronchoscopy is the procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis. By the isolation of not affected bronchial tree from the bleeding area, this procedure allows to achieve the control of bleeding and the clearance of airways. Surgery is reserved for selected cases.