Role of Fiberoptic Bronchoscopy in Patients with Hemoptysis and a Normal Chest Roentgenogram

In the investigation of lung cancer, current practice in many healthcare systems would support bronchoscopy regardless of CT findings in patients with hemoptysis. We sought to identify the cause, the diagnostic yield of CT and bronchoscopy and the requirement for bronchoscopy in at risk patients with hemoptysis with a normal CT scan through our rapid access lung cancer clinic (RALC).

Initially, a chart review was performed on all patients with hemoptysis (2011–2012) and thereafter a prospective analysis was performed (2013–2016).

Our analysis represents the largest study to date in outpatients with hemoptysis. In our retrospective study, 155 patients reported hemoptysis. Causes were lower respiratory tract infections (RTIs) (47%) and lung cancer (16%). Our prospective study included 182 patients. The causes of hemoptysis were RTIs (50%) and lung cancer (18%). There were no false negative CT-scans for lung cancer. 47/57 present with lung cancer underwent bronchoscopy and 43/47 were positive for lung cancer (92%). Patients with hemoptysis and lung cancer have a higher stage of malignancy with a predominance of squamous cell lung carcinoma. Smoking status, the duration of hemoptysis or description of hemoptysis were not predictive of lung cancer however lung cancer was not identified in patients age <50.

One sixth of patients presenting with hemoptysis to our lung cancer clinic had lung cancer. No patient identified with cancer related haemoptysis had a CT negative for lung cancer and a combination of bronchoscopy plus endobronchial ultrasound trans-bronchial needle aspiration (EBUS-TBNA) in those patients with a CT suspicious of lung cancer is 92% sensitive for lung cancer causing hemoptysis.

Bronchoscopy, computed tomography (CT) and surgical staging procedures are complimentary methods of investigating patients with lung cancer. CT has been shown to be of value prior to bronchoscopy in the investigation of haemoptysis and malignancy, with excellent correlation between the detection of disease within the large airways on CT and direct visualisation at bronchoscopy. The utility of CT has been further increased by the development of multislice scanners with the generation of volumetric data enabling multiplanar image acquisition. Additionally the advent of CT co-registered with positron emission tomography will play an important role in guiding the choice of surgical staging procedures The increasing use of multidisciplinary medical care requires radiologists to have a greater understanding of the abilities and limitations of both bronchoscopy and surgical staging procedures in evaluating disease demonstrated on imaging.

To provide current data on the long-term outcome and incidence of lung cancer in a large cohort of patients with hemoptysis of unknown origin.

A retrospective chart review followed by a telephone interview for follow-up.

A university-affiliated tertiary referral center for pulmonary diseases.

Seven hundred twenty-two patients who presented with hemoptysis from January 1990 to December 1993. One hundred thirty-five patients were identified as having hemoptysis of unknown origin.

One hundred thirty-five patients (19%) had hemoptysis of unknown origin; follow-up data were obtained in 115 patients, of whom 100 were still alive. The mean time of observation was 6.6 years after initial presentation. Lung cancer developed in 7 of 115 patients (6%) and was unresectable once detected; all of these patients were smokers > 40 years old, and malignancy developed within 3 years after first presentation.

Hemoptysis of unknown origin is present in a minority of patients presenting with hemoptysis if evaluated at a referral center for pulmonary diseases. Lung cancer seems to be increasing in these patients compared to previous studies, and closer follow-up or additional testing may be indicated in the defined population at risk.

Haemoptysis is an alarming symptom, and the management depends upon the aetiology. Emergency management depends upon localization of the site of bleeding by roentgenogram, computerized chest tompgraphy and bronchoscopy.

We prospectively evaluated 52 patients with haemoptysis admitted to the Chest Hospital, Kuwait for 1 year (January 1998 to December 1998) and followed them up for 1 year (January 1999 to December 1999). There were 42 males (80·8%) and 10 (19·2%) females, with a mean age of 42·2 (16–86) years. Of these, 26·9% were Kuwaiti nationals, 36·5% were Arab non-Kuwaiti nationals, 34·6% were Asians and 1·9% were other nationals.

The aetiologies of haemoptysis were bronchiectasis (21·2%), old pulmonary tuberculosis with bronchiectasis (17·3%), active pulmonary tuberculosis (15·4%), bronchitis (5·8%), aspergilloma, rheumatic heart disease and carcinoid (1·9%). Aetiology could not be identified in 25% of patients. The site of bleeding in haemoptysis could not be localized by the consultants in 18 (32%) by roentgenogram, 16 patients (37%) by CT scan and 23 patients (50%) by Fibreoptic bronchoscopy. Sequential estimation of hemoglobin showed a mean of 13·56 (SD 1·9) and 13·31 (SD 1·8) after 24 h. The difference in mean was statistically significant (p<0·036).

Conservative management was given in 80·8%, and embolotherapy or surgical intervention in 19·2% of patients. Only 12% of patients had recurrent haemoptysis at 1-year follow up.

In conclusion, bronchiectasis and pulmonary tuberculosis were the major causes of haemoptysis in this study. Roentgenogram, CT scan and fibreoptic bronchoscopy are useful for localizing the site of bleeding. Sequential estimation of haemoglobin may be helpful in assessing the severity of haemoptysis, but larger studies are required to address this observation. The outcome of haemoptysis is generally good, with a low mortality and recurrence rate.