Hemoptysis: Clinicians’ Perspectives DISCUSSION

18 Apr

The format of this interactive session provided previously unreported insights about physicians’ per­spectives of the diagnosis and management of patients with hemoptysis. Using this computerized system, a survey of clinical opinions could be combined with the educational objectives of the session, resulting in a unique opportunity to compare principles and recommendations described in medical literature with realities encountered in practice.

Hemoptysis in the Outpatient Setting

Responses to questions about case presentations and selection factors for fiberoptic bronchoscopy sug­gest that criteria which have developed during the past decade for evaluation of patients with unex­plained hemoptysis are useful. Analyses of the clinical characteristics of such patients have helped to improve identification of those likely to have diagnostic bron­choscopy. Moreover, combinations of negative clinical findings (eg, patient age <40 years, bleeding duration <1 week, <40 pack-years’ smoking history, <30 ml of blood expectorated daily) have a high negative predic­tive value. Although 60 percent of the clinicians favored bronchoscopy during the initial 24 hours after presentation with nonmassive hemoptysis, 40 percent deferred it to later in the course. This distribution might reflect agreement with recent observations that patient outcome is similar whether bronchoscopy is performed early in the course of bleeding or on a delayed basis.

Views about the relative clinical values of typical bronchoscopy findings in patients with normal or nonlocalizing chest roentgenograms have important implications. Retrospective studies have shown that lung cancer, the primary diagnostic concern, is found in from 3 to 11 percent of patients with unexplained hemoptysis. It has been suggested that the rela­tively low frequency of lung cancer in this setting contributes to an overuse of bronchoscopy. How­ever, decisions based solely upon the low likelihood of a diagnosis of lung cancer do not take into account other potential impacts of bronchoscopy upon man­agement and might underestimate its utility. Such pragmatic concerns seem clear from the current survey. Although the high relative value (Fig 1) as­signed to bronchoscope detection of lung cancer or other definitive diagnoses is obvious, the nonspecific findings of a localized, albeit otherwise uncharacteri- zed bleeding site, objective bronchitis, or a normal tracheobronchial tree all had a tangible value to over 90 percent of these clinicians. Recent studies have confirmed that such “negative” results have a high negative predictive value: with the possible exception of the elderly, most patients with unexplained he­moptysis, normal or nonlocalizing chest x-ray films, and nondiagnostic fiberoptic bronchoscopy appear to have a good prognosis, and uncommonly develop lung cancer. It seems most likely that the high relative values assigned by participants to nonspecific bron­choscope findings in this clinical situation reflect an added benefit that is not measured by traditional estimates of specific yield alone. In the absence of other measures, clinicians’ estimates such as those provided in this survey can be coupled with the relative frequencies of each result to help determine the utility of bronchoscopy. This information might assist in structuring of decision trees, potentially contributing to decisions about whether to perform the procedure. More information about the impact of “negative bronchoscopy” on clinical decision-making is needed. kamagra tablets

The acknowledgment that factors other than tradi­tional selection criteria might influence the use of fiberoptic bronchoscopy was informative, and repre­sents the first time this issue has been documented (Table 2). Even if all who chose not to answer this question did not believe such factors to be relevant, approximately three fourths of the audience has this view. Concerns about possible litigation and the need to fulfill service obligations were major factors cited. Many respondents noted that within their medical communities, they served as a consultation resource for primary care physicians who regarded broncho­scopy as an essential, definitive part of management planning for patients with hemoptysis. More commu­nity-based physicians were concerned about the risks of litigation than were academicians, perhaps reflecting some degree of insulation of the latter group from this pressure. Elucidation of the importance of such factors in the delivery of care is necessary in order to better understand and optimize use of bronchoscopy.

The current survey also suggests that the roles of special diagnostic studies in patients with hemoptysis need clarification (Table 3). Not surprisingly, computed chest tomography was favored, probably replacing bronchography in detection of bronchiectasis at many institutions. However, 40 percent found chest CT to be either less helpful than other tests or not useful at all, consistent with recent observations that a low impact upon management does not support routine use of CT. Despite experience with radionuclide scanning and bronchography in patients with unexplained hemoptysis, these were the most useful procedures to a minority of individuals. Such studies appear to have a more limited application to only selected patients, perhaps further underscoring the central role of fiberoptic bronchoscopy. Clinical inves­tigations to characterize those persons with unexplain­ed hemoptysis who are most likely to benefit from supplemental diagnostic procedures remain necessary.