Alistair D. Gascoigne

The pulmonary physician in critical care • Illustrative case 7: Assessment and management of massive haemoptysis

The unpredictable and potentially lethal course of massive haemoptysis requires prompt resuscitation, airway protection, and correction of coagulopathy. Early investigation with bronchoscopy is recommended for localisation and control of bleeding by the application of topical adrenaline, balloon tamponade, or selective lung intubation. There is increasing acceptance of bronchial artery embolisation as the treatment of choice for acute massive haemoptysis not controlled by conservative treatment, when a bronchial artery can be identified as the source of bleeding. Surgical resection remains the treatment of choice for particular conditions where the bleeding site is localised and the patient is fit for lung resection. Haemoptysis may be the presenting symptom of a number of diseases,1,2 with an associated mortality ranging from 7% to 30%.3–5 Although fewer than 5% of patients presenting with haemoptysis expectorate large volumes of blood, the explosive clinical presentation and the unpredictable course of life threatening haemoptysis demands prompt evaluation and management. We have reviewed the aetiology of massive haemoptysis and alveolar haemorrhage, with particular reference to current diagnostic and therapeutic strategies. A 69 year old woman was an emergency admission with large volume haemoptysis which did not settle spontaneously. She had previously undergone a left mastectomy for breast carcinoma. Alveolar shadowing was noted in the left mid zone on the chest radiograph, consistent with recent pulmonary haemorrhage (fig 1A). A thoracic computed thoracic (CT) scan confirmed consolidation and volume loss in the left upper lobe and lingula, but also showed a mass anteriorly eroding through the chest wall, consistent with local recurrence of the breast neoplasm (fig 1B). Pulmonary angiography showed no abnormality, but bronchial angiography identified a trunk that supplied a moderate pathological circulation anteriorly in the left upper lobe in the region of the abnormality on the CT scan. The artery was successfully embolised …

Upper gastrointestinal dysmotility in heart-lung transplant recipients

Recipient pneumonectomy and the necessity for meticulous hemostasis in heart-lung transplantation can result in injury to the vagus nerves as they course through the posterior mediastinum, with consequent delay in gastric emptying. This has been reported to lead to chronic aspiration and associated pulmonary sequelae. To study the association between delayed gastric emptying, bronchiectasis, and bronchiolitis obliterans after heart-lung transplantation, we performed esophageal manometry, 24-hour pH monitoring, and radioisotopic gastric emptying in 10 patients who underwent heart-lung transplantation. Three patients had grossly delayed liquid and solid emptying that was compatible with complete vagotomy. Six other patients had delayed liquid but normal solid emptying--an unexplained finding that is the reverse of what one would expect from vagal injury. Two of these 9 patients had esophageal dysmotility, but none demonstrated gastroesophageal reflux. One remaining patient had faster than normal gastric emptying for both solids and liquids. Of the 10, 2 patients have radiologic changes of bronchiectasis and 3 have biopsy evidence of obliterative bronchiolitis. There is no relationship between these sequelae and the occurrence of esophageal dysmotility, gastroesophageal reflux, or vagotomy. We conclude that gastric emptying abnormalities can occur after heart-lung transplantation, but such abnormalities are not associated with gastroesophageal reflux and the development of pulmonary sequelae, as previously reported.

MHC class II and ICAM-1 expression and lymphocyte subsets in transbronchial biopsies from lung transplant recipients.

The expression of MHC class II antigens and ICAM-1 and the composition of lymphocyte infiltrates have been studied in frozen sections of transbronchial biopsies from lung transplant recipients. First, biopsies obtained from patients who showed acute rejection, OB, and normal features were compared. Second, we compared first-year biopsies from patients developing OB and patients with a good clinical outcome. HLA-DR was widely expressed on epithelia and vascular endothelium. Increased vascular HLA-DP expression was found in OB biopsies. In OB patients there was a significantly increased frequency of bronchial HLA-DP and vascular HLA-DQ expression. Expression of ICAM-1 by bronchial and bronchiolar basal cells, a phenomenon not reported previously in humans, was seen in a small number of biopsies. CD8 predominant lymphocytic infiltrates were present in all groups and were increased in OB biopsies and OB patients. Increased numbers of CD4-positive cells were found in rejection and OB when compared with normal biopsies. These findings support an immunological basis for the development of OB.

Organizing pneumonia following pulmonary transplantation and the development of obliterative bronchiolitis

Twelve patients receiving lung transplants between 1988 and 1992 who developed clinical and histological features of obliterative bronchiolitis (OB) were compared with a group of 13 patients with good stable lung function (FEV1 more than 80% of predicted). Histological features of 180 biopsies were studied from the first postoperative year in order to assess whether any were associated with the development of OB. Clinically and histologically defined pulmonary rejection occurring after the first month was more frequent in OB patients (P=0.03). Organizing pneumonia that was associated with acute rejection but not with nonviral infection was also seen more frequently in OB patients (P=0.003). When all available lung transplant recipients surviving beyond 18 months were included in analyses, organizing pneumonia in the first year was associated with an increased relative risk of developing OB of 2.26 (95% CL 1.19–4.29), and the occurrence of coexistent organizing pneumonia and pulmonary rejection gave a relative risk for OB of 6.33 (95% CL 1.61–24.94). An increased incidence of histologically defined organizing pneumonia in OB patients has not been described previously. Furthermore the coexistence of organizing pneumonia with pulmonary rejection in the first year posttransplantation is a strong predictive factor for the development of OB.

Ciliary beat frequency in transplanted lungs.

BACKGROUND--Patients with lung transplantation are prone to respiratory infections. Generally this is attributable to the effects of immunosuppressive drugs but mucociliary clearance has been found to be impaired in these subjects. A study was performed to determine whether this finding is accompanied by a reduction in ciliary beat frequency (CBF). METHODS--Six patients who had undergone single lung transplantation for fibrosing lung disease were investigated. CBF was measured in mucosal samples from native and transplanted bronchi by a videophotometry method. RESULTS--The CBF was reduced in the transplanted bronchi in all cases when both fastest and slowest beating cilia were examined. The fastest beating cilia on the native side had a mean (SD) CBF of 12.1 (1.3) Hz compared with 9.6 (2.0) Hz on the transplanted side. The slowest beating cilia also had reduced CBF on the transplanted side. CONCLUSION--In patients with fibrotic lung disease, CBF is reduced in transplanted bronchi in comparison with native bronchi.

Airway complications after pulmonary transplantation

Airway healing was identified initially as one of the fundamental limitations of pulmonary transplantation. Recent experience suggests that this is no longer the case. A series of 67 pulmonary transplants (27 heart-lung, 31 single-lung, 9 double-lung) in 66 patients surviving more than 14 days was reviewed with reference to airway complications. There were 75 anastomoses at risk in two groups as defined by anastomotic location: 47 anastomoses in 38 patients in a bronchial group and 28 anastomoses in 28 patients in a tracheal group. A total of 10 airway complications developed (stenosis in 5 patients [4 bronchial group, 1 tracheal group] and dehiscence in 5 patients [1 bronchial group, 4 tracheal group]) causing two airway-related deaths (2 of 67) in the series. However, no significant correlation could be identified with either ischemic interval, suture technique, type of wrap, preoperative or postoperative steroid therapy, or date of first rejection episode. Airway complications are no longer a major limitation of pulmonary transplantation. Satisfactory airway healing can occur in both the presence of steroid therapy and the absence of an omental or pericardial wrap.

Mononuclear phagocyte populations in the transplanted human lung

BACKGROUND Dendritic cells (DC) are essential for the development of alloreactivity, however, little has been published regarding the distribution and phenotype of these and related mononuclear cells in human lung transplantation. METHODS Lung frozen sections were examined for the presence of CD1a+ DC and for mononuclear cells and alveolar macrophages expressing CD11b and CD68. The effects of transplantation and immunosuppression were assessed by comparison of normal transplant transbronchial biopsy specimens to specimens from unused donor lungs; the normal transbronchial biopsy specimens also were compared with those showing rejection or obliterative bronchiolitis. RESULTS All biopsy specimens, including those with obliterative bronchiolitis, showed a marked depletion of CD1a+ DC in lung allografts. This has not been described previously. In addition, transplantation and immunosuppression reduced alveolar macrophage coexpression of CD68 and CD11b, and this was reversed in acute rejection. CONCLUSION The roles of pulmonary DC and other mononuclear phagocyte subpopulations need to be further defined, and data from animal models of lung transplantation should be interpreted with caution.

Culture of Mycobacterium kansasii in the blood of an HIV negative patient.

A 23 year old man with a congenital myelodysplastic disorder and fibrosing lung disease received treatment with prednisolone. After nine months his condition deteriorated and Mycobacterium kansasii was isolated from blood cultures and lymph node biopsy specimens. He responded to antituberculous treatment. M kansasii has not previously been isolated from the blood stream of HIV negative patients.