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Abstract
Bronchoscopy-related bleeding is often encountered and is usually self-limiting or controllable by conservative measures. However, major bleeds can be life threatening for the patient as well as challenging for the physician to manage. There are several methods to achieve adequate haemostasis should a significant airway bleed occur. In this context, we describe a patient who had a post-bronchoscopic debulking bleed which persisted despite use of all available measures, and we deployed a self-expanding metallic stent in an attempt to control it. To the best of our knowledge, this is the first instance of a metallic airway stent being used to control bronchoscopy associated bleeding, though reports of its usage in management of intractable haemoptysis exist in the literature.
- Cancer intervention
- Lung cancer (oncology)
- Respiratory cancer
- Respiratory medicine
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Background
Bleeding during bronchoscopy is not uncommon and usually manageable. However, the accurate quantification of airway bleed is often challenging due to a lack of standardised guidelines and clear definitions for the classification of bronchoscopy-related bleeding and also due to the simultaneous usage of saline and other haemostatic agents in the attempt for bleeding control.1 Life-threatening bleeding is rare and is associated with poor clinical outcomes.1–3
Various modalities exist to control bronchoscopy-related bleeding but all of them may not always be readily available at every centre. Moreover, a ‘one-size-fits-all’ strategy to achieve haemostasis seems unreasonable and impractical. In all such scenarios, a meticulous preprocedure plan with anticipation of complications, together with prompt and appropriate usage of available haemostatic measures, is possibly the best way out to prevent airway bleeding-related morbidity and mortality.
We hereby describe a patient in whom a metallic stent was placed in order to control post-bronchoscopic debulking ooze that had persisted despite use of other available bleeding control measures. To the best of our knowledge, this is the first instance of a metallic airway stent being used to control bronchoscopy associated bleeding, though reports of its upfront usage in management of intractable massive haemoptysis do exist in the literature.
Case presentation
A previously healthy man in his late 50s, who was a reformed smoker, presented to the emergency department with complaints of breathlessness, dry cough and difficulty in swallowing for last 2 months. Over the past 2 weeks, he also noticed noisy breathing that accompanied worsening of his other symptoms. At presentation, the patient was in mild respiratory distress with a respiratory rate of 22/min, oxygen saturation 95% on ambient air and audible stridor.
Investigations
Baseline routine blood work and chest radiograph were normal. However, CT scan of the neck and thorax showed a heterogeneously enhancing soft tissue attenuation lesion involving the trachea and oesophagus, suggestive of a mass lesion (figure 1A, arrow).
(A) Axial section of CT scan of the thorax and (B) bronchoscopy image of the mid-tracheal mass lesion. (C) Cryoextracted debulked specimen. (D) Persistent oozing from the tumour bed and accumulation of blood in the airways. (E) Reduced ooze following stent deployment. (F) No bleeding at bronchoscopy on day 5, stent removed.
Treatment
In view of clinico-radiologically evident central airway obstruction, screening bronchoscopy was promptly performed with a paediatric bronchoscope (Olympus BF-P190, outer diameter 4.2 mm, Olympus Medical Systems, Japan). It revealed an approximately 3 cm long mid-tracheal tumour beyond which the scope could be snugly negotiated to identify patent distal airways (figure 1B). The patient was subsequently taken up for tracheal tumour debulking under general anaesthesia using rigid bronchoscopy.
The lesion was initially photocoagulated with LASER and then mechanically cored with the rigid bronchoscope. Following cryoextraction of the debulked tissue (figure 1C), instillation of iced saline, epinephrine and tranexamic acid, together with application of suction and argon plasma coagulation, was done to achieve airway haemostasis. We could not use hot ablation therapies more aggressively given the lesion’s location on the posterior wall of the trachea. Thereafter, rigid barrel was used to tamponade the site for several minutes. However, despite all these measures, a persistent ooze was noted from the lower margin of the tumour bed, accumulating in the trachea within approximately 5 s (figure 1D).
Having exhausted all available methods of bleeding control, we decided to deploy a straight self-expanding metallic tracheal stent (Ultraflex tracheobronchial stent system, Boston Scientific, Massachusetts, USA, 18×60 mm) to cover the bleeding area, presuming that the stent’s expandability and tensile strength would possibly facilitate haemostasis by persistent tamponade of the site.
Outcome and follow-up
Following stent deployment, the ooze gradually reduced in amount, now taking up to 30 s to reaccumulate in the trachea and eventually became minimal (figure 1E). The patient was then extubated, initiated on haemostatics and cough suppressants and shifted to the respiratory intensive care unit for monitoring. Thereafter, although he complained of occasional streaking initially, he remained clinically stable over the next 5 days. A check bronchoscopy at this time showed complete cessation of bleeding, hence the stent was carefully removed (figure 1F). Histopathological review of the tumour identified it as a poorly differentiated squamous cell carcinoma, for which definitive treatment was planned.
Discussion
The British Thoracic Society has classified bleeding during bronchoscopy into no bleeding, mild, moderate and severe bleeding, based on the type of clinical intervention required to achieve haemostasis.1 2 Although a range of bleeding control measures may be available, the cornerstone of appropriate and adequate management of significant bronchoscopy-related bleeding broadly entails two types of measures—prophylactic and procedural. Prophylactic measures involve ensuring ready availability of resuscitation equipment and adequate staff, should an unexpected event occur. Intraprocedural measures involve the application of various drugs1 2 4 and instruments to achieve haemostasis like bronchial balloon, argon plasma coagulation, LASER and electrocautery.3 The use of stents is a newer and unexplored modality for the control of endobronchial bleeding/haemoptysis. With the present case, we propose the novel use of a metallic stent for achieving haemostasis in bronchoscopy-related haemorrhage.
Airway stenting is often a temporary bridging measure to allow the patient undergo definitive therapy for the underlying primary disease. Stents have been mostly used to establish patency of a stenotic airway, to maintain patency of a reopened airway and to seal fistulous openings within the airway. Descriptions of airway stent placement to treat pulmonary haemorrhage from lung cancer exist as anecdotal case reports.5–8 Brandes et al used two bronchial stents to control massive haemoptysis from a cavitating lung mass which was not amenable to coil embolisation.5 In another report by Chung et al, use of a stent to manage bleeding from a left lung central tumour not only helped achieve haemostasis but also led to early extubation of their patient.6 Kambali et al used an airway stent in distal left main bronchus to manage massive haemoptysis arising from an adenocarcinoma of the left lung lower lobe.7 In yet another report, Lee et al reported three cases of lung cancer presenting with haemoptysis who underwent metallic airway stenting and all had good postprocedure bleeding control.8 The proposed rationale of stent usage for control of haemoptysis in these cases was by tamponade and isolation of the bleeding source so that the proximal large airways remained protected.5 8 We believe the stent may facilitate haemostasis by a delayed effect also due to a prolonged and sustained compression over the bleeding site, as was evident in our case. Nevertheless, despite the apparent benefits, complications associated with airway stenting should be anticipated. They can be of two types—procedural complications and stent-related complications. The former are uncommon and include perforation of the airway wall, pneumothorax/pneumomediastinum and malpositioning of the stent during deployment. Stent-related complications include migration, infection, fracture, blockade due to granulation tissue or mucoid impaction, airway erosion and bleeding.9 10 A thorough risk–benefit assessment must, therefore, be done before proceeding with stent insertion.
Removal of a stent may be considered when it is either not required anymore for the primary indication for which it was inserted or when a major complication is imminent.11 A specific timeline of removal has, however, not been mentioned. In our patient, we decided for removal of the stent for two reasons: First, the stent was primarily deployed for postprocedure bleeding control. Once this was adequately achieved, there was no obvious benefit of keeping the stent in situ. Also, the patient was planned for definitive treatment of the underlying disease. Second, the airway calibre after coring and debulking was adequate and our patient was no longer in symptomatic central airway obstruction. So, the need to maintain airway lumen patency by leaving the stent in place was also not there.
To conclude, there is no single best modality for management of bronchoscopy-related bleeding and a tailored approach probably works best. Airway stenting as a method to control persistent procedural bleeding appears to be a viable option to tamponade the bleeding area and may be tried as a last resort in selected cases, although there is limited data supporting this indication.
Patient’s perspective
Stated by the patient’s son: My father had significant improvement in his acute symptoms after undergoing the procedure successfully. In the following days, he was discharged home with an advice to consult the hospital’s oncology team for further management of the underlying cancer.
Due to personal reasons, however, my father could not consult the oncologist until after 40 days post procedure. At this time, he was planned for best supportive care owing to his poor general condition. Unfortunately, he succumbed to his primary disease 4 months after the procedure.
Learning points
Bronchoscopy-related bleeding is common but mostly manageable with usual conservative measures.
Severe bleeding, although rare, must be anticipated in every case and arrangements for its control must be made prior to the procedure.
Systematic checklists should be used to assess preprocedure risks and adequate preventive measures planned in advance to prevent morbidity and mortality.
Massive/intractable bleeding, persistent desaturation and haemodynamic instability during the procedure should be viewed as warning signs requiring the assistance of a resuscitation team.
Stent placement may be helpful in controlling persistent airway bleeding in carefully selected cases.
Ethics statements
Patient consent for publication
Footnotes
Contributors MM: Concept, design, definition of intellectual content and guarantor. PSi: Literature search and preparation of first draft. All authors: Manuscript review, editing and approval of final draft.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.