Cryptogenic hemoptysis. Clinical features, bronchoscopic findings, and natural history in 67 patients

We reviewed the clinical outcome of 67 patients with hemoptysis and a normal or nonlocalizing chest roentgenogram and nondiagnostic fiberoptic bronchoscopic examination. During a 38 +/- 22 (SD) month period after bronchoscopy, 57 (85%) patients remained well without evidence of active tuberculosis or overlooked bronchogenic carcinoma, and 9 patients died of nonpulmonary conditions. One patient developed bronchogenic carcinoma 20 months after bronchoscopy and resolution of symptoms. Hemoptysis had resolved completely before hospital discharge in 38 (57%) patients, within 6 months in 60 (90%), and recurred in only 3. Five patients (7.5%) had intermittent episodes of bleeding for more than 1 year. Fiberoptic bronchoscopy effectively excludes specific underlying causes of hemoptysis in the setting of a normal chest roentgenogram. The prognosis for patients with cryptogenic hemoptysis is generally good, usually with resolution of bleeding within 6 months of evaluation.     

Bronchoscopy to evaluate hemoptysis in older men with nonsuspicious chest roentgenograms

Six of 106 older men with hemoptysis and a nonsuspicious chest roentgenogram who underwent fiberoptic bronchoscopy were found to have cancer. Four of the five bronchogenic carcinomas appeared to be surgically resectable. Cancer patients were significantly older, had smoked within the last five years, and had a significantly higher frequency of central abnormalities on chest roentgenogram. Six additional bronchogenic carcinomas were diagnosed at follow-up. Two of these were probably present but not detected at the time of bronchoscopy. We conclude that (1) hemoptysis with a nonsuspicious chest roentgenogram carries an appreciable risk of cancer in older men with substantial smoking histories, (2) these cancers are often resectable, (3) a chest roentgenogram in which the central lung fields are obscured in any way should not be considered negative in patients with hemoptysis, and (4) a negative bronchoscopic examination does not exclude the possibility of cancer in these patients.     

Hemoptysis. Indications for bronchoscopy

Indications for bronchoscopy in patients with hemoptysis and a normal or nonlocalizing chest roentgenogram continue to be controversial. We reviewed the records for 119 bronchoscopies performed for hemoptysis in patients with a normal (n = 75) or nonlocalizing (n = 44) chest roentgenogram. Bronchogenic carcinoma was identified in 2.5% of the bronchoscopies. Additional neoplasms were found in another 2.5%. The presence of nonlocalizing abnormalities was not associated with an increase in either the rate of bronchogenic carcinoma or in the diagnostic yield (specific anatomic diagnosis or bleeding site identified) at bronchoscopy when compared with patients with normal chest roentgenograms. The factors of male sex, age more than 40 years, and a more than 40 pack-year smoking history appear useful in identifying patients in whom the yield of bronchoscopy is likely to be high.     

Fiberoptic bronchoscopy in patients with haemoptysis and normal chest roentgenograms.

Over the last 10 years, 53 patients with hemoptysis, but with a normal chest radiograph underwent diagnostic fiberoptic bronchoscopy. Forty-three patients did not show any abnormal findings, the site of bleeding could be localised in five and non-specific mucosal changes were seen in the remaining five patients. Thirty-two patients were followed up clinically for a 3-18 months period. One patient on follow-up developed tubercular pleural effusion. Bronchogenic carcinoma was not detected in any of these patients during the procedure or at follow up. A review of literature revealed a 3 per cent incidence of bronchogenic carcinoma and the risk factors associated with higher incidence were age above 40 years, cigarette smoking and a longer duration of hemoptysis. We conclude that fiberoptic bronchoscopy has little role in this relatively benign condition (hemoptysis) especially when the risk factors are absent.     

Computed chest tomography in the evaluation of hemoptysis. Impact on diagnosis and treatment

The results of computed chest tomograms (CT) and chest roentgenograms (CR) were compared in 32 patients who presented with hemoptysis. The CT demonstrated roentgenographic abnormalities more often than CR (p less than 0.01), providing new diagnostic information in 15 patients (46.9 percent), and clarifying CR abnormalities in five (15.6 percent) others. In addition, CT correctly localized sources of bleeding in 23 (88.5 percent) of the 26 patients in whom a site was identified at bronchoscopy, while CR localization was correct in 17 (65.4 percent) (p less than 0.05). Despite this augmentation of roentgenographic yield, information derived from CT scans influenced the management of only six patients, did not obviate the need for bronchoscopy, and supplemented the combined diagnostic yield of CR and bronchoscopy in only two. Outcome was changed in one patient in whom CT had demonstrated an otherwise unrecognized malignant solitary pulmonary nodule. The chest roentgenogram and fiberoptic bronchoscopy provided all the information essential for diagnosis and therapeutic recommendations in 93.7 percent of these patients. Although the CT provided additional information in over one half of our patients, its overall impact on clinical management was small and does not support routine use of this imaging procedure in evaluation of hemoptysis. The possible role of chest CT in evaluating carefully selected patients with hemoptysis requires further study.     

The role of fiberoptic bronchoscopy in evaluating the causes of pleural effusions

To evaluate the diagnostic merit of fiberoptic bronchoscopy in pleural effusions, we performed fiberoptic bronchoscopy in addition to thoracocentesis and closed pleural biopsy in 140 patients who were admitted for diagnostic investigation of the causes of pleural effusions. The patients were divided into subgroups based on clinical features and roentgenographic findings of chest x-ray films. In 39 patients, the pleural effusions were due to various nonneoplastic disorders and in 95 patients it was caused by malignancy. In six patients, the causes of the pleural effusions remained undetermined. A final diagnosis was made by pleural examination in 68 patients, by fiberoptic bronchoscopy in 58 patients, and by either one or both in 100 patients. In 82 patients who had no hemoptysis, a final diagnosis was made by pleural examination in 57 cases and by fiberoptic bronchoscopy in 11 cases only. The diagnostic yield of fiberoptic bronchoscopy (47/58) was superior to that of pleural examination (11/58) in 58 patients presenting with hemoptysis. In 74 patients who had pleural effusions as the sole roentgenographic abnormality, the final entity was established by pleural examination in 45 and by fiberoptic bronchoscopy in 12. The diagnostic merit of fiberoptic bronchoscopy was significantly higher in 59 patients who had concurrent pulmonary abnormalities on their chest roentgenograms. A final diagnosis was made in 43 cases by fiberoptic bronchoscopy in comparison with 21 cases by pleural examination. For patients with unknown pleural effusions, fiberoptic bronchoscopy was more likely to yield a diagnosis than thoracocentesis with closed pleural biopsy in those who had hemoptysis or pulmonary abnormality on chest x-ray films, whereas the reverse applied when these features were absent.     

经纤维支气管镜微导管治疗肺大咯血几种不同置人方法安全性的评价

目的探讨经纤维支气管镜微导管治疗肺大咯血几种不同置入方法的安全性。方法总结我科2010年10月至2011年12月大咯血患者10例,均为男性,通过对比观察手术过程难易程度、耗费时间、并发症等指标及治疗效果判定,对导丝引导法（方法A）、并行法（方法B）、体外留置支气管镜法（方法C）三种经纤支镜置入微导管治疗肺大咯血的安全性进行评价。结果在10例患者中,方法A完成3例,方法B完成2例,方法C完成5例,三种不同方法经纤维支气管镜下置入微导管操作均顺利,操作时间3—30min不等。方法A、B中均有病例出现鼻腔出血、声音嘶哑,方法C则无。三种方法中均无明显胸痛、肺不张、阻塞性肺炎、导管滑脱及局部支气管黏膜坏死的发生。结论对于微导管置人方法的选择,应选择术者较熟练、简便、费时短的方法,以充分保证患者的安全。体外留置纤支镜法置入微导管值得在肺大咯血中进一步推广应用。     

Changing spectrum of hemoptysis. Underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy

A retrospective study to examine the underlying causes of hemoptysis in patients undergoing diagnostic bronchoscopy was conducted. We found hemoptysis to be caused by bronchitis in 55 (37%) of 148, bronchogenic carcinoma in 28 (19%) of 148, tuberculosis in 10 (7%) of 148, and bronchiectasis in 1 (1%) of 148 patients. Compared with previous studies, it appears that hemoptysis is less likely to be caused by bronchiectasis or tuberculosis while hemoptysis caused by bronchitis has increased proportionately. The rate of occurrence of hemoptysis caused by bronchogenic carcinoma has not changed significantly. All patients with underlying bronchogenic carcinoma had a positive smoking history and abnormal chest roentgenogram. The rate of hemoptysis was not a good indicator of the underlying disease.     

Bronchial adenoma--an eleven-year experience.

Thirteen patients with bronchial adenoma were investigated. Most of these were young males and had recurrent hemoptysis and chest infection. Radiographs of the chest were abnormal in 11 patients. The tumor was visualized by fiberoptic bronchoscopy in all but one patient. The procedure was safe and none of the patients had massive hemoptysis following bronchoscopic biopsy. Limited follow-up revealed good results following surgery.     

Fiberoptic bronchoscopy in patients with hemoptysis and nonlocalizing chest roentgenograms

We reviewed retrospectively the records of 45 patients undergoing fiberoptic bronchoscopy for hemoptysis in whom chest roentgenograms either were normal or showed only nonlocalizing findings. Follow-up was available for up to three years. In none of the patients was evidence of malignant neoplasms found either at the time of the initial evaluation or at the time of follow-up. This was true for all age groups and for smokers as well as nonsmokers. We conclude that routine fiberoptic bronchoscopy for hemoptysis is not necessarily indicated in patients like ours. Indications for this procedure in this type of case should be carefully weighed.     

Safety of the transbronchial biopsy in outpatients

The objective of our study was to determine the safety of transbronchial biopsy (TBB) in nonhospitalized patients. The design was a prospective study of the consecutive cases from July 1987 until September 1988 in the setting of a university hospital of the third level with 1,800 beds. The patients were a consecutive sample of 169 patients who had 184 procedures of fiberoptic bronchoscopy (FOB) with TBB performed. They suffered from different diseases: lung nodules or masses, diffuse interstitial disease, alveolar condensation, etc. An FOB with TBB was performed in immunocompetent outpatients, who were kept under observation for four hours and then had a chest roentgenogram taken afterwards. We contacted them again after 72 hours to rule out delayed complications. In three cases, more than 100 ml of blood were obtained during the FOB, without significant hemoptysis being recorded in those patients during the observation period; chest pain occurred in 15 patients during the TBB; pneumothorax occurred in two patients (1 percent), one of whom required admission to the hospital, without requiring chest tube drainage. Other complications are reported (bronchospasm, parenchymal hemorrhage, and pneumonia). In conclusion, we consider the TBB to be a technique with a low incidence of complications for outpatients, so therefore we do not believe that admission to the hospital is mandatory for this type of patient, although we do recommend a longer observation period.     

Endobronchial tuberculosis revisited

Analysis was made of 20 patients with endobronchial tuberculosis proven by fiberoptic bronchoscopy and bronchial biopsy. Unlike prechemotherapy reports, the disease affects the older age group and more men. Only one half of the patients had fever, and the characteristic localized wheeze was found in 15 percent of cases. Chest roentgenogram showed typical collapse-consolidation in most cases; however, it was clear in 20 percent of patients. Sputum/smear was negative for AFB in 85 percent of patients. When the gelatinous granulation tissue was not found during bronchoscopy, a diagnosis of bronchogenic carcinoma was made incorrectly in 30 percent of patients. At a mean period of 27 months postchemotherapy, all 12 patients recalled for study developed bronchostenosis proven by bronchoscopy/bronchography except one. Noninvasive methods such as chest roentgenogram and flow-volume loops were insensitive for detection of stenosis. Steroid therapy probably did not influence outcome of tuberculous endobronchitis.     

Immediate chest roentgenography following fiberoptic bronchoscopy

It is a common practice for some clinicians to obtain a chest roentgenogram immediately following FOB in an attempt to detect complications of the procedure, particularly pneumothorax; however, the roentgenogram adds substantially to the cost of FOB. It was our clinical impression that the diagnostic and therapeutic value of immediate chest roentgenography was minimal. Therefore, we reviewed 130 chest roentgenograms taken immediately after bronchoscopy that were obtained over 36 months. One hundred fourteen (88 percent) were unchanged from the most recent roentgenogram before bronchoscopy. Ten (8 percent) showed an increase in alveolar infiltrate due to bronchoalveolar lavage or hemorrhage. Five (4 percent) had changes presumably unrelated to the procedure. Only one patient had a pneumothorax on the roentgenogram taken immediately after bronchoscopy; however, the patient was symptomatic, and the pneumothorax was detected by fluoroscopy prior to the chest roentgenogram. Management of the patient's condition was not altered in a single case based upon findings on the chest roentgenogram. We conclude that the immediately postbronchoscopic chest roentgenogram rarely provides clinically useful information or detects a complication that is not suspected clinically; furthermore, it appears to have minimal impact, if any, on the management of a patient's condition.     

Analysis of patients with hemoptysis in a reference hospital for chest diseases

Chest physicians frequently come across with the symptom hemoptysis, an alerting symptom which may result from a wide variety of disorders. In this study, we aimed to determine the main causes of hemoptysis in a reference hospital for chest diseases. All the patients who admitted to our emergency clinic with hemoptysis during three months of study period were included in the study. The mean age of 143 patients (106 males, 37 females) who were included in this study was 48 +/- 17 years. Medical history, physical examination and chest radiography were performed for each patient. Sputum examination for acid fast bacilli, computed tomography of thorax, fiberoptic bronchoscopy, ventilation-perfusion scintigraphy, echocardiography, ear-nose-throat examination and upper gastrointestinal system endoscopy were the further diagnostic investigations for selected patients. Bronchiectasis was the most common cause of hemoptysis (22.4%), followed by lung cancer (18.9%), active tuberculosis (11.2%), and inactive tuberculosis (10.5%). Sputum smear for acid fast bacilli was performed in 102 patients and were positive in 15.6% of them. Computed tomography of thorax was performed in 102 patients and was pathologic in 81.3% of them. Fiberoptic bronchoscopy was performed in 46 patients and localized the bleeding site in 67.4% of them. In conclusion, the most common causes of hemoptysis were bronchiectasis, lung cancer and tuberculosis in our hospital. Based on this finding, we suggest that, the diagnostic approach to the patients presenting with hemoptysis should include first a detailed medical history, physical examination, and chest radiography; second sputum smear for acid fast bacilli; third computed tomography of thorax and lastly fiberoptic bronchoscopy.     

A resected case of endobronchial metastasis from breast carcinoma

A 54-year-old woman, who had received left radical mastectomy 12 years previously, was admitted with persistent cough and hemoptysis. Plain chest X-ray film showed no abnormality but fiberoptic bronchoscopy revealed that a polypoid lesion occluded the right truncus and the surrounding bronchial mucosa was firm and edematous. Biopsy specimen demonstrated adenocarcinoma. Right middle and lower sleeve bilobectomy was performed. The tumor occupied mainly the outer and submucosal layer of the bronchial wall. Histologically, this tumor showed scirrhous adenocarcinoma with the same pathologic appearance as the primary breast lesion. It is considered that endobronchial metastasis from breast carcinoma is not particularly uncommon, therefore any patient with a past history of breast cancer and respiratory symptoms should undergo fiberoptic bronchoscopy, particularly when the chest X-ray is normal or shows non-specific changes.     

A reappraisal of the causes of hemoptysis.

We reviewed the records of 264 patients who underwent fiberoptic bronchoscopy for unexplained hemoptysis to determine the various causes of hemoptysis. Bronchogenic carcinoma (29%), bronchitis (23%), and idiopathic hemoptysis (22%) accounted for the majority of causes of hemoptysis. In contrast to older studies, the incidence of hemoptysis secondary to tuberculosis and bronchiectasis has decreased. Although our patient population is predominantly male and elderly, our data may well be representative of more recent epidemiologic trends in causes of hemoptysis.     

Bronchoscopy in patients with haemoptysis and normal chest roentgenograms

We reviewed the records of 58 patients with haemoptysis and normal chest roentgenograms who underwent fibreoptic bronchoscopy. A diagnosis of malignancy was made in six patients at bronchoscopy. Three patients had bronchogenic squamous cell carcinoma, one a carcinoid tumour and two laryngeal carcinoma. Sputum for cytology was negative for malignant cells in all six patients. Follow-up data were available for the other 52 patients for an average period of 55.7 +/- 29.6 (SD) months. Two patients had a subsequent diagnosis of bronchogenic carcinoma at 2 and 6 years after initial evaluation. Three patients died from conditions not related to pulmonary malignancy and the remaining patients followed a benign course. Our patients come from a predominantly male, elderly population of cigarette smokers. Among such patients, we conclude that bronchoscopy is indicated in the evaluation of those with haemoptysis and a normal chest roentgenogram.     

Bronchoscopy and transbronchial biopsy in evaluation of patients with suspected active tuberculosis

To assess the value of fiberoptic bronchoscopy and transbronchial biopsy for evaluating patients suspected of having tuberculosis, we reviewed the records of 56 patients (1974–1980). All patients (1) were clinically suspected of having active tuberculosis; (2) had an abnormality on chest roentgenogram consistent with tuberculosis; (3) had an absence of acid-fast bacilli on three sputum smears or an inability to produce sputum; (4) had undergone fiberoptic bronchoscopy and transbronchial biopsy. The evaluations included fiberoptic bronchoscopy with collection of bronchial washings and brushings, and transbronchial biopsy and postbronchoscopy sputum specimens. Thirteen patients subsequently underwent percutaneous needle aspiration and one underwent thoracotomy.

Evaluations were diagnostic in 29 of the 56 patients (52 percent). Diagnoses were mycobacterial infection in 22 (39 percent) and other disease processes in seven (13 percent). Fiberoptic bronchoscopy and transbronchial biopsy provided a diagnosis when sputum cultures obtained before bronchoscopy were negative for Mycobacteria in 11 (20 percent) patients. Immediate diagnoses were made from microscopic specimens obtained from 11 of 23 (48 percent) fiberoptic bronchoscopy and transbronchial biopsy procedures on patients with previously undiagnosed mycobacterial infection. Transbronchial biopsy had the best yield for a microscopic diagnosis. On culture, bronchoscopy specimens had a lower yield (10 of 23 or 44 percent) than sputum specimens obtained before bronchoscopy (14 of 21 or 67 percent) probably due to the inhibition of mycobacterial growth by tetracaine. Of the patients in whom evaluation proved nondiagnostic, 17 of 27 were lost to follow-up; therefore, a definitive statement regarding the number of false negative evaluations is not possible.

Fiberoptic bronchoscopy and transbronchial biopsy (FFB/TBB) is a useful procedure in evaluating patients with negative smears who are clinically suspected of having tuberculosis. It can improve the ability to document active tuberculosis, provide a sensitive means of making an immediate diagnosis, and uncover other disease processes presenting like tuberculosis.     

对胸部CT未确诊的咯血行支气管镜检查的价值探讨

目的评价纤维支气管镜检查(FOB)在胸部CT未能确诊病因的咯血诊断中的价值。方法回顾近5年来我科收治的82例胸部CT未确诊病因的咯血病人临床资料,所有病人在胸部CT检查后1周内行FOB检查,并选择性使用了冲洗,剧检,活检,支气管肺泡灌洗(BAL),CT定位下经支气管镜肺活检(TBLB),经支气管镜针吸活检(TBNA)。获取的标本进行细菌学、细胞学或病理学检查。结果71例(87%)咯血病因确诊,其中肺结核25例,肺癌18例,支气管炎9例,肺炎10例,其他9例。11例(13%)仍未确诊。确诊方法:恻检18例(阳性率54%),冲洗21例(46%),BAL12例(63%),活检22例(71%),TBLB7例(54%),TBNA4例(40%)。采用两种以上支气管镜检查技术的阳性率(85.5%)高于单一技术(53.3%)。结论对于胸部CT未确诊病因的咯血病人,FOB检查是明确病因的有效手段。联合使用两种或以上FOB检查技术可以提高确诊率。     

Bronchoscopic evaluation of 390 cases of hemoptysis without definite abnormality on the chest roentgenogram

From Jan 1981 through Oct. 1988, fiberoptic bronchoscopic examination was undertaken in 390 patients with hemoptysis and basically normal chest roentgenogram or prominent pulmonary markings. A diagnosis of malignancy was made in sixteen cases (4.1 percent). The positive rates in was higher in those were heavy smokers or in patients of age greater than 40 years, whose bloody sputum rate were significantly higher than non-smoking patients whose age were less than 40 years, and patients coughed up cupfull of blood intermittently, (P less than 0.005). The absolute indication of bronchoscopic examination in patients with hemopstysis and a basically normal chest X-ray film are those who are greater than 40 years old, heavy smokers, coughing up bloody sputum and no improvement by active treatment for two weeks.