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Index >  Indications  > Hemorrhage
Hemorrhage

Fiberoptic bronchoscopy in a patient with hemoptysis should be performed with the affected lung down. In case, the origin of the bleeding is unknown, the procedure should begin with the patient supine, and as soon as the bleeding lung is identified, the patient should be repositioned in order to avoid flooding of the healthy lung during the procedure. Lavage with saline (plus or minus epinephrine) followed by aspiration generally stops the bleeding in a matter of minutes. In our view, tamponade with endobronchial balloons is generally inadequate. If the bleeding persists despite conservative measures, one should not hesitate to proceed with rigid bronchoscopy under general anesthesia.

Patients with hemoptysis are usually not at risk of exsanguinating.

The endoscopist should concentrate instead in avoiding airway obstruction by clot which can lead to catastrophic hypoxemia.

This risk is obviously greatest in patients with respiratory compromise or those who have undergone pneumonectomy.

Bronchoscopy should aim to keep the airway patent.

These two films illustrate the importance of proper patient positioning during the bronchoscopic evaluation of hemoptysis. Despite the severity of the bleeding, notice that the contralateral lung is kept free of blood.



The following film documents the endoscopic treatment of a cavernous angioma causing bleeding at two distinct sites.



The following film illustrates endoscopic treatment of an arterial peripheral endobronchial hemorrhage. The method of coagulation is always the same. We use low power settings and the YAP laser to treat the area surrounding the bleeding artery, in order to sclerose it.



Seeing a pulsatile jet of blood in the airway is always worrisome.

Such bleeding can be encountered spontaneously or following removal of endobronchial clot during bronchoscopy.

Controlling such hemorrhages with the fiberoptic endoscope is very difficult.

Using the rigid bronchoscope, a suction catheter may be advanced right up against the jet, aspirating all of the blood, while the laser is used to treat the surrounding area, causing tissue retraction and hemostasis.



What should be done with a clot in the airway ? In our opinion, the endoscopist using a fiberoptic bronchoscope should abstain from manipulating the clot and plan rigid bronchoscopy instead. Besides risking massive bleeding, which can be very difficult to control with the fiberoptic instrument, clots are not easily removed with this bronchoscope.



The treatment of sub-glottic angiomas in the adult or infant is very simple using laser at low power.

The vascular anomaly can be seen disappearing out of sight as a result of treatment.

 
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