Glue therapy in hemoptysis: A new technique.

Hemoptysis is defined as the spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage. There is a large chunk of patients with hemoptysis who do not respond to conservative treatment including use of cough suppressants, antibiotics, vitamin C, hemostatics, and anxiolytics. The advanced management of such a situation is bronchial artery embolization (BAE) or open thoracic surgery, which is often not possible. We have attempted a cheap, effective, and safe alternative in the form of intrabronchial instillation of glue (n-butyl cyanoacrylate) under vision with the help of a therapeutic video bronchoscope (OLYMPUS T-180). The glue is instilled through a polyethylene catheter placed through the working channel of the video bronchoscope.

TECHNIQUE

Only those patients were included who were clinically stable and not in a need of any blood transfusion or life-support system. First, patients were evaluated. Proper informed consent was obtained and the necessary investigations like hemoglobin, TLC, DLC, ESR, APTT, PT, BT, CT, chest X-ray, and sputum for AFB were done. Special investigations like CT scan were done as and when required.

Procedure

The bronchoscopies were performed in accordance with American Thoracic Society guidelines for bronchoscopy.[1] The bleeding sites were localized by direct visualization or confirmed after washing with saline. The procedure is as follows:

A polyethylene catheter was passed through the working channel of the bronchoscope and placed in the bleeding segment or into the clot [Figure 1].

Figure 1

Video bronchoscopic view of the catheter over the site of hemoptysis

A total dry condition was ensured by the bronchoscopist and the technician.

Acetone was kept ready in a covered sterile bowl.

A 0.5-ml vial of the glue (n-butylcyanoacrylate) was opened and filled in the syringe.

The bronchoscope was withdrawn 4–5 cm from the place where the glue needed to be injected but keeping the catheter in place and maintaining the vision.

The glue (0.5 ml) was injected while maintaining the dry conditions, and the whole assembly, i.e., the catheter and bronchoscope, is removed in toto immediately [Figure 2].

Figure 2

Video bronchoscopic view of the glue being injected at the site of hemoptysis

The upper end of the catheter was cut and the catheter withdrawn from the lens-end of the bronchoscope.

Bronchoscope was cleaned with acetone if there was any spillage of the glue over it or into the channel of the bronchoscope.

The amount of glue used in majority of cases was 0.5 ml.

Repeat bronchoscopy was done immediately after securing the bronchoscope and removing the catheter from the bronchoscope to confirm the proper placement of the glue [Figure 3].

Figure 3

Video bronchoscopic view of the dried glue immediately after instillation

Once confirmed the procedure was labeled successful.

CONTRAINDICATIONS

Patients with serious co-morbidities like CHF, CRF, poor cardiorespiratory reserve, advanced age with neurological deficit, and poorly controlled DM or hypertension are excluded. Also, those cases are excluded who have massive hemoptysis (>200 ml/day) or bleeding from more than two segments or where localization is not possible (as assessed upon bronchoscopy) or with diffuse bleeding.

APPLICATIONS IN OTHER SYSTEMS

Cyanoacrylate glue is a known biocompatible drug used to seal defects/breaches and occlude vessels in various medical specialties. It has been used in the management of recurrent retinal detachment caused by macular hole, lateral tarsorrhaphy, embolization of aneurysms, namely, multiple pulmonary artery aneurysms and renal artery aneurysm in Behcet's syndrome, peripheral pulmonary artery pseudoaneurysm, intratumoral embolization of intracranial and extracranial tumors, sclerotherapy in gastric ulcers, and rectal ulcers. Intrabronchial glue therapy is also effectively used for managing hemoptysis.[23]

CONCLUSION

Glue therapy is found to be a highly safe, effective, and rapid method of controlling hemoptysis[23] and no major side effects are reported by its use.[4] To conclude, endobronchial gluing is a relatively new technique for controlling hemoptysis which can be an effective, economic, and alternative therapy.