To the Editor:
Dr. Arney and colleagues (January 1999)[1] reported their experience with the management of endobronchial blood clots.[1] The authors also reviewed the literature concerned with this subject, including reports of the benefit of topical thrombolytic administration Although examples of the recurrence of bleeding following the use of topical streptokinase were not uncovered within their library search, we indeed reported such a case 10 years ago.[2] The patient had squamous cell carcinoma of the lung and required mechanical ventilation for massive hemoptysis associated with refractory hypoxemia. Following the use of a Swan-Ganz catheter to tamponade the left mainstem bronchus for hemorrhage, an endotracheal (ET) tube blood clot developed, resulting in life-threatening ventilatory failure. Although 100,000 IU of streptokinase was topically applied down the ET tube, thereby relieving the obstruction, later (4.5 h) the patient died of exsanguinating hemorrhage. Three hours after the patient's death, the blood in the ventilator tubing remained unclotted.
It appears that streptokinase in a bolus of 100,000 U can be absorbed from the airway mucosa and result in a systemic lytic state. It is possible that a lower dose, diluted with saline solution and administered in small aliquots, can be safer, as mentioned by the authors. Time may not be on the patient's side, however, if the airway clot is in the trachea or in the ET tube. We agree with Dr. Arney that extreme caution must be used when thrombolytic agents are instilled into the airway, and management needs should be considered, including cryoprecipitates in advance of administering these agents.
Arvind Bansal, MD Robert D. Brandstetter, MD, FCCP Sound Shore Medical Center New Rochelle, NY
Correspondence to: Robert D. Brandstetter, MD, FCCP, Sound Shore Medical Center, 16 Guion Place, New Rochelle, NY 10802
REFERENCES
[1] Arney KL, Judson MA, Sahn SA. Airway obstruction arising from blood clot: three reports and a review of the literature. Chest 1999; 115:293-300
[2] Brandstetter RD. The use of Swan-Ganz catheter and streptokinase in the management of massive hemoptysis. NY State J Med 1990; 1:33-35
COPYRIGHT 1999 American College of Chest Physicians
COPYRIGHT 2000 Gale Group
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