Hemoptysis in the Outpatient Setting
Most (72 percent) respondents held chronic bronchitis to be the major cause of mild hemoptysis; other selections included lung cancer (11 percent), idiopathic causes (“essential” or “cryptogenic”) (7 percent), tuberculosis (5 percent), and bronchiectasis (5 percent). Most (91 percent) advocated fiberoptic bronchoscopy of a 55-year-old, 80 pack-year cigarette smoker with a one-week history of hemoptysis, nondiagnostic sputum, and a nonlocalizing chest roentgenogram. Nearly all (98 percent) would perform bronchoscopy on a similar patient whose duration of bleeding was ten days and bleeding rate exceeded 30 to 60 ml daily. In patients with mild hemoptysis, the best predictor of a specific bronchoscope diagnosis was thought to be abnormal findings on chest x-ray film (54 percent); fewer noted that a bleeding duration > one week (26 percent), anemia and weight loss (12 percent), and patient age >40 years (8 percent) were the best predictors.
Following discussion of the common results of diagnostic bronchoscopy in patients with hemoptysis and normal or nonlocalizing chest roentgenograms, clinicians were asked to grade the clinical worth of each of these potential findings, and in particular, their impact upon patient management. Findings were graded from zero (no usefulness) to five (maximum value) (Fig 1). Not surprisingly, specific bronchoscopic diagnoses (either lung cancer or another precise etiology of bleeding), with scores of 4.4±1.45 (mean±SD) and 4.44 ±1.03, respectively, were viewed as the most valuable results, while nonspecific information—objective bronchitis, (3.2 ± 1.59), normal airways, (2.71 ± 1.91), and either localized (3.41 ± 1.48) or diffuse (2.13 ±1.69) tracheobronchial blood—had significantly less value (all p<0.01). There was, however, considerable overlap in these scores. Of 447 responses about nonspecific bronchoscopic findings, only 34 (7.5 percent) assigned a value of 0 to this result; fewer than 20 percent of respondents viewed the nondiagnostic findings of a normal tracheobronchial tree as worthless. Moreover, over one fourth perceived nonspecific findings of localized bleeding, objective bronchitis, or normal airways to have a maximum value for management. canada pharmacy mall
FIGURE 1. Bronchoscopic findings in patients with hemoptysis and a normal or nonlocalizing chest roent¬genogram vary in their clinical worth. Specific diag¬noses (lung cancer or other conditions) were perceived to be more useful than nonspecific results (p<0.01). All findings, however, were thought to have at least some value, (x — SD indicated; n = number of respondents.)
Opinions varied about the optimum timing for fiberoptic bronchoscopy in patients with mild hemoptysis. Eighteen percent favored the procedure immediately upon the patients presentation, and another 42 percent indicated it should be performed during the first day. Others (21 percent) favored bronchoscopy either during the initial 48 hours after presentation, or deferred it until active bleeding had abated (19 percent).
Table 2—Potential External Factors Influencing Patient Selection for Bronchoscopy (n=75)
Loss of income
None of the
All but one respondent indicated that external factors, in addition to conventionally recognized criteria, influenced patient selection for diagnostic bronchoscopy (Table 2). Fears of litigation related to unrecognized lung cancer or other treatable disease detectable by bronchoscopy, and obligations to provide service to their respective institutions, were the most important of these factors, but potential loss of income was also a concern. Loss of referrals was much less often cited as an issue; pressures to satisfy DRG requirements were not held to be most important. Some individuals chose not to answer this question: although 100 or more persons responded to 19 of the 22 questions, only 75 chose to address this issue. A larger number of responses to the immediately preceding (113) and following (106) questions also suggested a reluctance to comment on this area. Clinicians’ views differed according to the settings of their practices: although only 4.8 percent of academicians recorded concerns about litigation, 38.7 percent of community-based practitioners believed this factor to influence patient selection for bronchoscopy (p<0.02).
Table 3—Hemoptysis Unexplained by Bronchoscopy: Roles of Special Diagnostic Studies (n=106)
Most useful to
None of the
Of the ancillary diagnostic techniques which, in addition to the chest roentgenogram and fiberoptic bronchoscopy, are used to evaluate patients with unexplained hemoptysis, computed chest tomography was found to be most helpful (60 percent) (Table 3). Bronchography and radionuclide scanning with technetium sulfur colloid or tagged erythrocytes were most helpful to a minority, and one fifth of respondents noted that none of the procedures offered was especially valuable.