Jorge Montessi

Controle da hemoptise maciça com broncoscopia rígida e soro fisiológico gelado

BACKGROUND: Massive hemoptysis is a high morbidity and high mortality condition, independently of the treatment administered. A variety of methods are used to control the acute bleeding. The instillation of iced saline solution through a rigid bronchoscope was described in 1980. OBJECTIVE: To establish the efficacy of repeated instillations of iced saline solution (4oC) using a rigid bronchoscope for the acute control of massive hemoptysis. METHOD: A group of 94 patients with massive hemoptysis was treated with rigid bronchoscopy and lavage with iced saline solution of the actively bleeding lung. The absence of bleeding recurrence within the following 15 days was considered a therapeutic success. The causes of hemoptysis included: pulmonary tuberculosis: 78 (83%), among which 48 had active disease, and 30 had tuberculosis sequelae, bronchiectasis (6), lung cancer (5), intracavitary aspergilloma (3), and unknown (2). The bleeding site was found in 93 patients (99%). The mean saline volume used in the bronchoscopy was 528 mL, ranging from 160 mL to 2,500 mL. RESULTS: All patients stopped bleeding during the procedure. Fifteen patients were submitted to some kind of procedure (surgery, embolization, or radiation therapy) within 15 days, and the efficacy of lavage could not be assessed. Twenty of the 79 patients followed-up for more than 15 days had recurrence of hemoptysis. Cold saline lavage was repeated once in 13 patients, twice in 6 patients, and 3 times in one patient. CONCLUSION: The control of tracheobronchial hemorrhage through bronchoscopy and lavage with iced saline is an effective procedure and can be repeated in case of re-bleeding. It is a safe procedure, and allows the definitive treatment to occur in better clinical conditions.

Pseudotumor inflamatório do pulmão

Inflammatory pseudotumor of the lung is a rare condition that represents a dilemma because the radiographic, macroscopic and pathological aspects mimic a malignant process. Herein, we report the case of a patient complaining of respiratory difficulty who, after being appropriately assessed, was submitted to exploratory thoracotomy. An initial diagnosis of pseudotumor was subsequently confirmed through immunohistochemistry. In addition to presenting data relating to clinical history, we also discuss radiographic, histopathological and surgical aspects, as well as treatment options.

Lesões da traquéia e grandes brônquios

As lesoes traqueobronquicas sao raras, porem, no trauma de torax, envolvem grande risco de vida. As suas manifestacoes sao variaveis e nao e incomum o diagnostico ser protraido. O sucesso no diagnostico e tratamento, frequentemente, requer alto grau de suspeicao e a correcao cirurgica como metodo de escolha. Apos trauma fechado de torax, a ruptura da traqueia e dos bronquios principais, geralmente, ocorre nas proximidades da carina. O rompimento da arvore traqueobronquica, ocasionado por acidentes em alta velocidade, com alto impacto e grande liberacao de energia, geralmente esta associado a outras lesoes. Os sinais comumente presentes sao: enfisema subcutâneo, dispneia e hemoptise. Os achados radiologicos mais comuns incluem pneumotorax, pneumomediastino, fraturas de costelas e clavicula. As broncoscopias efetivamente rigida e flexivel sao considerados metodos diagnosticos eficazes, desde que manuseados por cirurgiao toracico treinado. O diagnostico precoce deve ser enfatizado, pois evita as complicacoes associadas ao reparo tardio das lesoes. O mecanismo etiologico, o diagnostico e os aspectos da terapeutica na literatura mundial sao revistos e discutidos.