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CNAA / Theses / 2004 / June /

Pulmonary Hemorrhage: Diagnosis and surgical management


Author: Ali Lutf Ahmed Al Shawosh
Degree:doctor of medicine
Speciality: 14.00.27 - Surgery
Year:2004
Scientific adviser: Nicolae Gladun
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Institution: State University of Medicine and Pharmacy "Nicolae Testemitanu"

Status

The thesis was presented on the 16 June, 2004
Approved by NCAA on the 14 October, 2004

Abstract

Adobe PDF document0.26 Mb / in romanian

Keywords

pulmonary haemorrhage, etiology, diagnostic algorithm, management, medical treatment, surgical treatment

Summary

Author analyze 438 cases of pulmonary hemorrhages, treated in general thoracic surgery management of Republican Clinical Hospital, Kishinev, between years 1980 and 2002. Frequent causes of hemorrhage, with relative incidence between 5% and 15% in this study were: pulmonary tuberculosis, lung cancer, postinflammatory fibrosis of lung tissue, acute and chronic pulmonary abscesses, bronchiectasis. Gangrenous processes ot the lung caused pulmonary hemorrhages with relative incidence above 15%. Hemoptysis was observed in 186 patients (42,5%), pulmonary hemorrhages occurred in 175 patients (40%), recurrent bleeding was observed in 28 (6,3%) and massive (profuse) hemorrhages developed in 49 (11,2%) patients in this study. 1st degree hemorrhage (up to 100 ml in 24 hours) were observed in 125 patients, 2nd degree hemorrhage (100- 300 ml in 24 hours) was detected in 63 patients and in 64 patients 3rd degree or massive hemorrages developed. Established mortality in chronic lung processes was 7,1% versus 39,6% in acute pulmonary destructions.

A diagnostic algorithm was elaborated, which permitted etiological and topographic diagnosis in great majority of pulmonary hemorrhage patients. It also diferrentiated two types of pathologies in these patients: non-surgical and surgical; this approach influenced treatment decisions.

Guided by the etiology of pulmonary pathology, homeostatic status of the patients, type and volume of hemorrhage, an management algorithm was developed by the author, which directioned treatment into two tactics: non-surgical and surgical. In 217 patients (51,4%) were performed radical hemostatic interventions, including 85 lobectomies, 41 pneumonectomies, 5 bilobectomies, 16 segmentectomies, echinococectomies – 4 cases, marginal lung resections – 10. Pneumotomies were performed in 56 patients. Emergency operations were 87 (40%), elective ones – 130 (60%); iterative interventions were performed in 34 (15,7%) cases.

Author analyze 2 study periods: 1st period – 1980–1992 and 2nd period – 1993–2002, which were divergent in treatment decisions. Emergency pulmonary resections were the cornerstone of the treatment in 1st period. In this case observed mortality was above 70%, including 1/2 of deaths occurring during active hemorrhage or in first 72 hours after the operation. A new tactic was adopted in the 2 nd period by using methods of temporary hemostasis: bronchial occlusion by porolon obturator during rigid bronchoscopy, performed in active hemorrhage episode, bronchial artery embolization, sewing hemorrhagic vessel in destructive pulmonary cavity after drainage pneumotomy. This approach permitted to lower the number of emergency pulmonary resections and significantly rise number of elective operations, performed after cessation of bleeding and hemodynamic stabilization of the patients.

This approach considerably changed the results of the surgical treatment in pulmonary hemorrhage patients: general mortality in the second period was 8,4% versus 28,8% in 1 st period and established mortality in gangrenous pulmonary processes was 47,6% during 1993–2002 versus 75% in the 1 st period of study.