Aetiology, diagnosis and treatment of moderate-to-severe haemoptysis in a North American academic centre.

Significant haemoptysis is a frightening event for patients and clinicians alike. There is a paucity of contemporary literature on the subject. A retrospective analysis of hospitalisations for haemoptysis of more than 50 mL·day-1 in a tertiary referral centre during a 5-year period was performed. Patient's characteristics, haemoptysis aetiology, management and outcome were individually recorded. The aim of this study was to detail the causes of moderate (50-200 mL·day-1) to severe (>200 mL·day-1) haemoptysis along with the diagnostic measures and treatment options used in their management in a 21st century, tertiary-care North American centre. A total of 165 hospitalisations for moderate-to-severe haemoptysis were included in the analysis. Lung cancer (30.3%) and bronchiectasis (27.9%) proved to be most frequent aetiologies. Computed tomography (CT) imaging and bronchoscopy were complementary in identifying the source of bleeding. Bronchial artery embolisation (BAE) was the most common treatment approach (61.8%) and resulted in initial bleeding control in 73.5% of cases. In-hospital mortality was 13.9%, varying from 3.3% in the moderate group to 24.7% in the severe group. Despite being the favoured approach in patients with more severe bleeding, initial BAE therapy was associated with a trend towards lower mortality compared to initial non-BAE therapy. In summary, lung cancer and bronchiectasis were the main causes of moderate-to-severe haemoptysis in our population, CT and bronchoscopy are complementary in identifying the source of bleeding, bleeding volume is associated with outcomes and BAE is a key management tool.

Pulmonary Rehabilitation.

Pulmonary rehabilitation (PR) is an essential intervention in the management of patients with chronic obstructive pulmonary disease. To guide health care professionals in the implementation and evaluation of a PR program, this article discusses the current key concepts regarding exercise testing, prescription, and training, as well as self-management intervention as essential parts of PR and post-rehabilitation maintenance. Moreover, new approaches (alternative forms of organization and delivery, tele-rehabilitation, exercise adjuncts) and unique and challenging situations (patients experiencing acute exacerbations, advanced disease) are thoroughly reviewed. Finally, validated point-of-care resources and online tools are provided.

Approach to Hemoptysis in the Modern Era.

Hemoptysis is a frequent manifestation of a wide variety of diseases, with mild to life-threatening presentations. The diagnostic workup and the management of severe hemoptysis are often challenging. Advances in endoscopic techniques have led to different new therapeutic approaches. Cold saline, vasoconstrictive and antifibrinolytic agents, oxidized regenerated cellulose, biocompatible glue, laser photocoagulation, argon plasma coagulation, and endobronchial stents and valves are amongst the tools available to the bronchoscopist. In this article, we review the evidence regarding the definition, etiology, diagnostic modalities, and treatment of severe hemoptysis in the modern era with emphasis on bronchoscopic techniques.

Modalities and Complications Associated With the Use of High-Flow Nasal Cannula: Experience in a Pediatric ICU.

BACKGROUND: High-flow nasal cannula (HFNC) therapy is increasingly used in pediatric ICUs as an intermediate level of support between conventional oxygen delivery and noninvasive ventilation (NIV). The safety of HFNC has seldom been studied, and some cases of barotrauma have been reported. This retrospective study aims to describe HFNC use in a tertiary care pediatric ICU, with a focus on the complications associated with this therapy. METHODS: Between January 2013 and January 2014, all children <18 y old treated with HFNC in the pediatric ICU were included. Demographic data, HFNC settings, chest radiograph reports, and blood gas values were gathered from the electronic medical records. Episodes of pneumothorax, pneumomediastinum, and significant epistaxis were noted. Pneumothorax was distinguished from chest tube-related air leak (frequent after cardiac surgery), which was defined as a small pneumothorax with no clinical impact that resolved spontaneously after chest tube removal. RESULTS: During the 1-y study period, there were 177 HFNC episodes, involving 145 subjects with a median (interquartile range) age of 8 (2-28) months. HFNC was used as primary support in 31% of episodes, after extubation in 36% and after NIV in 18%. HFNC was administered exclusively for nitric oxide delivery in 16% of episodes. Two children (1%) developed new pneumothoraces that required chest tube insertion, whereas 5 (3%) chest tube-related air leaks were noted. One (0.6%) episode of significant epistaxis was noted. Among 6 preexisting pneumothoraces, none worsened under HFNC. Failure of HFNC occurred in 32 episodes, requiring transition to NIV in 28 cases and endotracheal intubation in 5 cases. CONCLUSIONS: Support with HFNC following a clinical protocol in pediatric ICUs was associated with a relatively low rate of complications. Since HFNC use is increasing, further evidence is needed to confirm its efficacy and safety.