Role of fiberoptic bronchoscopy in patients with hemoptysis and a normal chest roentgenogram

We reviewed the charts of 48 consecutive patients who had fiberoptic bronchoscopy performed in the evaluation of hemoptysis with a normal chest roentgenogram. Fiberoptic bronchoscopy provided a diagnosis other than endobronchial inflammation in only four patients--benign fibromuscular polyp in one patient, Mycobacterium tuberculosis in 1 patient, and carcinoma in two others. A literature review revealed an overall 3 percent incidence of bronchogenic carcinoma in patients with hemoptysis and normal findings on chest roentgenogram. Other than abnormal findings on chest roentgenogram, risk factors for carcinoma in patients with hemoptysis include: (1) age greater than 40; (2) significant smoking history; and (3) duration of hemoptysis for longer than one week. We concluded that in patients with hemoptysis and normal chest x-ray film findings, routine fiberoptic bronchoscopy may not always be indicated to rule out malignancy.     

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.     

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.     

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.     

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.     

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.     

纤维支气管镜对胸片正常咯血患者的诊断价值

目的 探讨胸部X线检查正常的咯血患的病因。方法 通过纤维支气管镜检查确定142例胸部X线检查正常的咯血患的病因。结果 142例患中,110例（77.46%）患通过纤支镜检查确定病因,其中炎症88例（61.97%）,肺癌16例（11.27%）,支气管内膜结核6例（4.22%）。结论 纤支镜对确定胸片正常的咯血患的病因有重要作用。     

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.     

Primary small cell bronchogenic carcinoma in a 14-year-old boy

A 14-year-old Korean boy was admitted with cough, hemoptysis, and fever. A chest X-ray showed a solitary pulmonary mass and pneumonitis. Bronchial biopsy by fiberoptic bronchoscopy revealed a poorly differentiated small cell carcinoma. All of the staging information indicated that the patient had limited disease. During the 7 months following diagnosis, he received adjuvant chemotherapy in conjunction with radiotherapy. The size of the lesion was reduced by almost 50%. Small cell bronchogenic carcinoma has not been reported previously in childhood.     

Diagnostic fiberoptic bronchoscopy: Techniques and results of biopsy in 600 patients.

Six hundred patients underwent diagnostic flexible fiberoptic bronchoscopy (FFB). The two diseases most frequently encountered were bronchogenic carcinoma in 330 patients (55 percent) and bacterial infection in 94 (16 percent). A positive cytology on biopsy material was obtained in 279 of 330 patients (85 percent) with primary lung cancer. Fluoroscopy was a valuable aid in diagnosing bronchogenic carcinoma, since 42 percent of the tumors were not visible endoscopically and required fluoroscopic control for placement of the biopsy instrument. Of the 55 patients with hemoptysis and negative chest x-ray films, nine (15 percent) had fiberoptically visible endobronchial carcinomas! In addition, two patients with carcinoma of the larynx and one with carcinoma of the nasopharynx were discovered. Transbronchial biopsy (TBB) in 68 patinets with diffuse and localized disease achieved an overall 69 percent diagnostic success, including a correct diagnosis in each of four patients with Pneumocystis carinii pneumonia. Brush biopsy provided additional valuable laboratory data in bacterial, mycobacterial and cytomegalovirsu infectious but had a poor yield in Pneumocystis infection. Complications as a result of forceps biopsy were minimal, except for brisk bleeding in six patients.     

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.     

Bronchial artery embolization in the management of hemoptysis in cystic fibrosis

Massive hemoptysis and/or recurrent expectoration of measurable amounts of blood are common complications of chronic bronchopulmonary infections in cystic fibrosis (CF). When conservative treatment fails to control bleeding, surgery or bronchial artery embolization (BAE) is frequently considered. We present our experience and long-term follow up of BAE in 14 CF patients (age range 15–39 years) with massive (6 subjects) and/or recurrent (8 subjects) hemoptysis not responsive to medical treatment. Seven had chronic hypercapnic respiratory failure. After angiographic evaluation, polyvinyl alcohol particles (halon) were injected to embolize obviously enlarged bronchial arteries. Seventeen procedures were performed in 14 patients and 36 bronchial arteries were embolized. All the patients stopped bleeding immediately upon BAE. Most of the patients had postembolization fever, dysphagia, and transient chest pain which were managed symptomatically. After median follow-up period of 10.5 months (range 0.5–38 months), no recurrence of hemoptysis was observed in 8 patients who are still alive. In 3 patients hemoptysis recurred and they underwent reembolization after 3,22, and 25 months, respectively. Three subjects died of respiratory failure within 5 months from BAE. Presently, 50% of patients studied had a ≥ 1 year interval free of major hemoptysis after the first BAE. Our experience indicates that massive and/or recurrent hemoptysis in C:F patients can be safety and effectively managed by BAE if the procedure is performed by skilled practitioner. The procedure was well tolerated and resulted in prolonged and satisfactory bleeding control in most patients. © 1995 Wiley-Liss, Inc.     

Cryptogenic hemoptysis: from a benign to a life-threatening pathologic vascular condition

RATIONALE: Data on hemoptysis of unknown origin (i.e., "cryptogenic") are scarce and the outcome of patients affected is controversial. OBJECTIVES: To describe the clinical spectrum and course of patients with cryptogenic hemoptysis, as well as pathologic findings when surgery is performed. METHODS: A cohort of 81 patients referred for cryptogenic hemoptysis after clinical evaluation, chest radiography, fiberoptic bronchoscopy, and computed tomographic scan to a respiratory intermediate care and intensive care unit, from December 1995 to August 2004, with a prospective follow-up by visit or telephone interview. MEASUREMENTS AND MAIN RESULTS: The 81 patients (69 males) had a mean cumulative volume of hemoptysis averaging 190 ml on admission. First-line conservative measures and bronchial artery embolization controlled hemoptysis in 73 patients (90%). Emergency surgery was performed in six patients (7%) because of failure of bronchial artery embolization, and secondary surgery was scheduled in a seventh patient. A total of 73 patients were followed for a mean of 47 (+/- 35) months. No lung cancer developed. Hemoptysis recurred in 10 patients (4 within the first year; 6 between 1 and 8 yr later), 2 of whom underwent surgery. A specific bronchial vascular involvement (Dieulafoy disease) was demonstrated in five of the nine patients who had undergone surgery, especially in those with high amounts of bleeding. CONCLUSIONS: Cryptogenic hemoptysis may be a life-threatening condition. Nonsurgical approaches provide immediate control of bleeding in most patients with cryptogenic hemoptysis, with few recurrences in both short and long terms. Dieulafoy disease of the bronchus, unsuspected after routine imaging investigations, may be involved in a subset of patients yet to be determined.     

Fiberoptic bronchoscopy and pleural effusion of unknown origin

We reviewed our experience with fiberoptic bronchoscopy (FOB) in patients with pleural effusion of unknown origin. Seventy patients underwent FOB for the investigation of pleural effusion between 1978 and 1983. Those with a second reason for FOB, a mass on chest roentgenogram, or lobar atelectasis were excluded. Forty five patients remained: 28 patients with unexplained pleural effusion after pleural fluid analysis and pleural biopsy (UPE), and 17 patients with malignant pleural fluid cytology and/or pleural biopsy but no known primary tumor (MPE). In the UPE group, only one FOB demonstrated malignancy, despite a final diagnosis of tumor in seven. No other specific diagnoses were made by FOB in this group. In the MPE group, FOB demonstrated bronchogenic carcinoma in two; ultimately, five patients were found to have a bronchogenic neoplasm. Although pleural effusion of unknown origin is frequently caused by bronchogenic carcinoma, FOB in the absence of other indications for this procedure is rarely diagnostic and should not be routinely employed.     

Bronchoscopy-guided topical hemostatic tamponade therapy for the management of life-threatening hemoptysis

STUDY OBJECTIVES: Massive hemoptysis is a life-threatening condition. Therapeutic strategies such as interventional angiography, surgery, and/or bronchoscopy have been applied in the clinical setting with variable results. We investigated the efficacy of bronchoscopy-guided topical hemostatic tamponade therapy (THT) using oxidized regenerated cellulose (ORC) mesh in the management of life-threatening hemoptysis. DESIGN: Seventy-six consecutive patients underwent emergency bronchoscopy for massive hemoptysis. Fifty-seven patients (75%) had persistent endobronchial bleeding despite bronchoscopic wedging technique, cold saline solution lavage, and instillation of regional vasoconstrictors. These patients subsequently underwent THT according to the same procedure. SETTING: Teaching hospital, bronchoscopy unit of a 300-bed tertiary pulmonary referral center. RESULTS: THT with ORC was successfully performed on 56 of 57 patients (98%) with an immediate arrest of hemoptysis. All patients successfully treated with THT remained free of hemoptysis for the first 48 h. None required intensive care support or immediate surgery. Mean procedure time (+/- SD) of THT was 11.5 +/- 4.2 min. Recurrence of hemoptysis that was characterized as being mild (< 30 mL) to moderate (30 to 100 mL) developed in six patients (10.5%) 3 to 6 days after THT. Post-obstructive pneumonia developed in five subjects (9%) after endoscopic THT. A subgroup of patients (n = 14) underwent bronchoscopic follow-up 4 weeks after discharge. The ORC mesh was absorbed in all of these patients without signs of foreign body reaction. CONCLUSIONS: Endobronchial THT using ORC is a safe and practicable technique in the management of life-threatening hemoptysis with a high success and a relatively low complication rate.     

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.     

Fiberoptic bronchoscopy in the evaluation of lung abscesses

To define the results of flexible fiberoptic bronchoscopy (FFB) in patients with lung abscess and to characterize those patients most likely to have an underlying carcinoma, we retrospectively studied the records of 52 consecutive patients undergoing FFB at our institution between 1975 and 1982. Nineteen patients (36.5 percent) had an associated bronchogenic carcinoma (group 1); 33 (63.5 percent) had no malignancy (group 2). The FFB aided in diagnosing 73.7 percent of group 1 patients, but added no information in group 2 patients. Group 1 and 2 patients differed significantly with respect to prevalence of systemic symptoms (15.8 percent vs 51.5 percent, p less than 0.01); predisposition to aspiration pneumonia (26.3 percent vs 60.6 percent, p less than 0.01); mean presenting white blood cell count (10.9 vs 14.2, p less than 0.05); mean oral temperature at presentation (37.5 vs 38.3 degrees C, p less than 0.05); and the prevalence of extensive infiltrates on the initial chest roentgenogram (17.0 percent vs 83.6 percent, p less than 0.05). Based on these data, we believe that by carefully considering the available clinical information, it is possible to identify those patients whose lung abscesses are likely to be related to bronchogenic carcinoma. Such individuals should be promptly evaluated. It is not necessary, however, to routinely order bronchoscopy for all patients with lung abscess.     

Managing life-threatening hemoptysis: has anything really changed?

STUDY OBJECTIVES: To delineate current chest clinicians' approaches to the management of patients with life-threatening hemoptysis. DESIGN: Survey during a computer-assisted interactive continuing medical education presentation. SETTING: The 1998 American College of Chest Physicians (ACCP) Annual Scientific Assembly. PARTICIPANTS: Chest clinicians attending the respiratory emergency symposium. RESULTS: Most clinicians (86%) had cared for patients with life-threatening hemoptysis, and 28% had cared for patients with fatal events during the previous year. Those clinicians favored management in the ICU setting (95%) with early endotracheal intubation (85%), and they tended to use a large-bore, single-lumen endotracheal tube (57%). The majority (64%) favored the early performance of diagnostic bronchoscopy during the first 24 h. Most clinicians (79%) used the flexible instrument, a higher frequency than respondents at a similar symposium on hemoptysis at the 1988 ACCP meeting (48%; p < 0.0001). Most current clinicians (77%) had experience with endobronchial measures to control bleeding, but few (14%) found them to be consistently worthwhile. Chest CT scanning was often helpful in diagnosis (55%). In their management of bleeding, half of these clinicians favored the use of interventional angiography, even in operable patients, which is a substantial change from 1988 when 23% had favored this approach (p < 0.0001). CONCLUSIONS: During the past decade, life-threatening hemoptysis has remained an important problem. Flexible bronchoscopy and interventional angiography have become increasingly established, more widely accepted approaches to patient care.     

A prospective analysis of 184 hemoptysis cases: diagnostic impact of chest X-ray, computed tomography, bronchoscopy

BACKGROUND: The clinical presentation of hemoptysis often raises a number of diagnostic possibilities. OBJECTIVES: This study was designed to evaluate the relative frequency of different causes of hemoptysis and the value of chest radiography, computed tomography (CT) scanning and fiber-optic bronchoscopy in the evaluation of a Greek cohort population. METHODS: We prospectively followed a total of 184 consecutive patients (137 males/47 females, 145 smokers/39 nonsmokers) admitted with hemoptysis between January 2001 and December 2003 to the University Hospital of Heraklion. Follow-up data were collected on August 2005. RESULTS: The main causes of hemoptysis were bronchiectasis (26%), chronic bronchitis (23%), acute bronchitis (15%) and lung cancer (13%). Bronchiectasis was significantly more frequent in nonsmokers (p < 0.02). Among nonsmokers, patients with moderate/severe bleeding or a history of tuberculosis were more likely to have bronchiectasis (OR 8.25; 95% CI 1.9-35.9, p = 0.007 and OR 16.5; 95% CI 1.7-159.1, p = 0.007, respectively). Nonsmokers with normal or abnormal X-rays were equally likely to have bronchiectasis (OR 2.5; 95% CI 0.66-9.39, p = 0.2). Lung cancer was only found in smokers. Smokers with normal X-rays were less likely to have lung cancer compared to smokers with abnormal X-ray (OR 5.4; 95% CI 1.54-19.34, p = 0.004). There were no smokers with normal CT and lung cancer. Follow-up data were collected in 91% of patients. Lung cancer did not develop in any patient assumed to have hemoptysis of another origin than lung cancer on initial evaluation. CONCLUSIONS: Bronchiectasis is the main diagnosis in patients admitted with hemoptysis to a Greek University Hospital and it is more frequent among nonsmokers with moderate/severe bleeding and/or previous tuberculosis infection. Nonsmokers with moderate/severe hemoptysis and/or a history of tuberculosis should be evaluated with high-resolution CT. Smokers with hemoptysis are at increased risk for lung cancer and need to be extensively evaluated with chest CT and bronchoscopy.     

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.