Bronchoscopy as a supplement to computed tomography in patients with haemoptysis may be unnecessary

Abstract

BackgroundHaemoptysis is a common symptom and can be an early sign of lung cancer. Careful investigation of patients with haemoptysis may lead to early diagnosis. The strategy for investigation of these patients, however, is still being debated.ObjectivesWe studied whether the combination of computed tomography (CT) and bronchoscopy had a higher sensitivity for malignant and non-malignant causes of haemoptysis than CT alone.MethodsThe study was a retrospective, non-randomised, two-centre study and included patients who were referred from primary care for the investigation of haemoptysis.ResultsA total of 326 patients were included in the study (mean age 60.5 [SD 15.3] years, 63.3% male). The most common aetiologies of haemoptysis were cryptogenic (52.5%), pneumonia (16.3%), emphysema (8.0%), bronchiectasis (5.8%) and lung cancer (4.0%). In patients diagnosed with lung cancer, bronchoscopy, CT and the combination of bronchoscopy and CT had a sensitivity of 0.61, 0.92 (p<0.05) and 0.97 (p=0.58), respectively. In patients with non-malignant causes of haemoptysis, most aetiologies were diagnosed by CT and comprised mainly pneumonia, emphysema and bronchiectasis. Bronchoscopy did not reveal these conditions and the sensitivity to these conditions was not increased by combining CT and bronchoscopy.ConclusionsCT can stand alone as a diagnostic workup for patients with haemoptysis referred to an outpatient clinic. Bronchoscopy does not identify any malignant aetiologies not already diagnosed by CT. Combining the two test modalities does not result in a significant increase in sensitivity for malignant or non-malignant causes of haemoptysis.

Does this lung nodule need urgent review? A discrete choice experiment of Australian general practitioners

“…The haemoptysis Diagnostic Imaging Pathway that is endorsed by the Western Australian Department of Health only suggests CT chest in selected high risk patients and bronchoscopy only when CT does not identify a cause for symptoms [20]. This conservative approach to haemoptysis management is based on several studies that have shown the additional diagnostic yield for lung cancer from bronchoscopy is very low when thoracic imaging has not already demonstrated concerning findings [21][22][23]. The appropriate management of mediastinal and hilar lymphadenopathy without a parenchymal lung lesion is less clear.…”

Life-Threatening Hemoptysis

“…Its sensitivity for isolating the source of the bleeding is as high as 92%. 10 CT can help differentiate between a parenchymal versus vascular cause of bleeding if used in conjunction with intravenous contrast 10 (►Fig. 4).…”

POINT: Should All Initial Episodes of Hemoptysis Be Evaluated by Bronchoscopy? Yes

“…5 Chest CT scanning plays a crucial and complementary role to bronchoscopy in cases of hemoptysis, with an ability to identify the site, side, and cause of bleeding of up to 92%. 6 The superiority of chest CT scanning over bronchoscopy is explained by the fact that a CT scan can identify lesions in the lung parenchyma, as well as vascular abnormalities that cannot be visualized bronchoscopically. Recently, it has been suggested that chest CT scans could stand alone as the diagnostic workup in cases of nonmassive hemoptysis in the outpatient setting.…”

“…Recently, it has been suggested that chest CT scans could stand alone as the diagnostic workup in cases of nonmassive hemoptysis in the outpatient setting. 6 Bronchoscopy, however, is superior in diagnosing mucosal abnormalities in the central airways, is equivalent to a CT scan of the chest in localizing the site of bleeding, and perhaps most importantly, can provide a tissue-based diagnosis to guide further therapy. 7 Clearly, it is inadvisable to transport an unstable and actively bleeding patient to the CT suite unless a secure airway is in place.…”