[ Editorials Point and Counterpoint ]

POINT: (3) nonmassive hemoptysis with risk factors for lung

cancer with normal chest radiograph, and (4) cases of
Should All Initial Episodes of self-limited nonmassive hemoptysis with both normal
Hemoptysis Be Evaluated by chest radiograph and without risk factors for lung cancer.
Bronchoscopy? Yes We propose that all, aside from the last group, would
benefit from bronchoscopy. In the first group,
Jose Cardenas-Garcia, MD bronchoscopy can be life-saving, providing isolation of
Hershey, PA the “good lung.” As chest imaging in this scenario often
David Feller-Kopman, MD, FCCP shows diffuse airspace disease due to aspirated blood,
Baltimore, MD
bronchoscopy can identify the source of bleeding and
serve as a temporizing measure prior to more definitive
ABBREVIATIONS: APC = argon plasma coagulation
therapy.2 In the second and third groups, bronchoscopy
is valuable in both identifying the source of bleeding and
Hemoptysis is one of the leading causes for pulmonary providing a tissue-based diagnosis. In patients with
admissions and consultations,1 and can be both hemoptysis with normal chest radiograph and risk factors
frightening (for the patient and provider) and for lung cancer, the incidence of underlying malignancy
life-threatening (for the patient). One of the first is approximately 10%. Thus, further workup including a
questions the physician will encounter is “should CT scan of the chest followed by early bronchoscopic
bronchoscopy be performed for all initial episodes?” and evaluation is recommended.3 In this setting, the CT scan
if so, when, by whom, and where? Bronchoscopy is a can serve as a “road map” for the bronchoscopist and
safe and relatively inexpensive procedure that allows the should be performed prior to the bronchoscopy.
rapid identification and control of the source of
bleeding, and can help guide a more definitive treatment Bronchoscopy vs CT Chest Scan
if necessary. As such, bronchoscopy has a role in the
The diagnostic role of bronchoscopy vs various
evaluation of the large majority, if not all, patients
imaging modalities has been evaluated extensively in the
presenting with hemoptysis.
literature. Chest radiographs can identify the side of
bleeding in 33% to 82% of patients with hemoptysis.4
Defining Hemoptysis
The reason for this low yield may be explained by the
Excluding the cases in which hemoptysis is a debatable presence of subtle endobronchial or parenchymal
diagnosis (ie, epistaxis, hematemesis) and for which abnormalities that might be missed with this modality,
bronchoscopy can be used to rule out the airways as a or aspiration of blood into a nonbleeding segment,
source of bleeding, the physician will encounter four including the contralateral lung.5 Chest CT scanning
distinct clinical scenarios: (1) massive hemoptysis, (2) plays a crucial and complementary role to bronchoscopy
nonmassive hemoptysis with abnormal imaging studies, in cases of hemoptysis, with an ability to identify the site,
side, and cause of bleeding of up to 92%.6 The
AFFILIATIONS: From the Division of Pulmonary, Allergy and Critical
superiority of chest CT scanning over bronchoscopy is
Care Medicine (Dr Cardenas-Garcia), Interventional Pulmonology
Section, Pennsylvania State University; and the Division of Pulmonary explained by the fact that a CT scan can identify lesions
and Critical Care Medicine (Dr Feller-Kopman), Interventional in the lung parenchyma, as well as vascular
Pulmonology Service, Johns Hopkins University.
FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have
abnormalities that cannot be visualized
reported to CHEST the following: D. F.-K. has received consulting fees bronchoscopically. Recently, it has been suggested that
from Fujifilm, USA. None declared (J. C. G.). chest CT scans could stand alone as the diagnostic
CORRESPONDENCE TO: Jose Cardenas-Garcia, MD, Interventional
Pulmonology, Penn State Health Milton S. Hershey Medical Center, workup in cases of nonmassive hemoptysis in the
500 University Drive, C5800, H041, Hershey, PA 17033; e-mail: outpatient setting.6 Bronchoscopy, however, is superior
jdecardenasg@gmail.com
in diagnosing mucosal abnormalities in the central
Copyright Ó 2017 American College of Chest Physicians. Published by
Elsevier Inc. All rights reserved. airways, is equivalent to a CT scan of the chest in
DOI: https://doi.org/10.1016/j.chest.2017.09.036 localizing the site of bleeding, and perhaps most

302 Point and Counterpoint [ 153#2 CHEST FEBRUARY 2018 ]

importantly, can provide a tissue-based diagnosis to TABLE 1 ] Major Causes of Hemoptysis
guide further therapy.7 Clearly, it is inadvisable to
Tumors
transport an unstable and actively bleeding patient to the B Malignant: Lung cancer, bronchial adenomas, and
CT suite unless a secure airway is in place. We believe metastatic disease to the lungs/airways (including lung
that CT scanning and bronchoscopy should be cancer, thyroid, breast, renal, colon, melanoma, etc.)

considered complementary techniques, both offering B Benign: Carcinoid tumor (typical and atypical)

valuable information.
Bronchiectasis

Infections
B Mycobacterial (especially tuberculosis)
Benefits of Performing Bronchoscopy in B Aspergillosis
Patients With Hemoptysis B Necrotizing bacterial pneumonias and lung abscesses
The clinical reasoning supporting the bronchoscopic

Vascular
evaluation of a patient with hemoptysis includes B Pulmonary arterial aneurysm
allowing the physician to: B Pulmonary sequestration

Identify the anatomic site and side of the bleeding8 B Tracheovascular fistulas

Assess the nature of the bleeding source (endobron- B Arteriovenous malformation
chial lesion, central vascular fistulas [ie, Dieulafoy’s B Iatrogenic
disease of the bronchus], vs parenchymal)8 (Table 1)
Vasculitis

Assess the severity of bleeding8 B Granulomatosis with polyangiitis

Evaluate the feasibility of therapeutic bronchoscopic B Behçet’s disease and Hughes-Stovin syndrome
intervention if required8 B Takayasu’s arteritis

Collect samples for cytologic, pathologic, and micro- B Systemic lupus erythematosus
biologic purposes, which will impact the treatment
B Diffuse alveolar hemorrhage (due to infection/
and prognosis capillaritis)
From the therapeutic perspective, if the source of bleeding
Trauma
is endoscopically visible, the bronchoscopist can achieve B Post-transbronchial biopsies and trans-tracheal
hemostasis (using laser, argon plasma coagulation [APC], aspirates

electrocautery, or cryotherapy). In those cases in which B Post-traumatic hematoma

the source of bleeding is a peripheral airway, the operator B Pulmonary erosion from a rib fragment

can both identify the segmental bronchus and isolate the
Cardiovascular abnormalities
airway if needed.8 It should be noted that the data for B Eisenmenger’s syndrome
using instilled epinephrine, iced saline, thrombin with or B Mitral stenosis
without fibrinogen, and cyanoacrylate or tranexamic acid
Bronchial circulation abnormality
to stop parenchymal bleeding come from very small case B Dieulafoy’s lesion
series,9-14 and as such, in the setting of moderate to B Bronchial artery hemangioma
massive hemoptysis, we typically recommend using a
Coagulopathy
bronchial blocker to achieve lung isolation until definitive B von Willebrand’s disease, hemophilia
therapy (embolization/surgery) can be performed. B Anticoagulant therapy

The treatment of massive hemoptysis should be done B Thrombocytopenia, platelet dysfunction

via a multidisciplinary team including the B Disseminated intravascular coagulation

pulmonologist, interventional radiologist, and thoracic
Others: Foreign body, broncholith, catamenial
endometriosis
surgeon (Fig 1). If the patient is stable enough and the

Cryptogenic
source is known, bronchial artery embolization can
occur prior to bronchoscopy; however, we stress that Bronchiectasis, tumors, tuberculosis (acute and late complications), and
airway isolation be considered prior to sending the cryptogenic causes account for more than 80% of the causes of hemop-
tysis. (Modified with permission from Khalil et al.1)
patient to the interventional radiology suite as these
patients can become unstable quickly. In addition to
providing lung isolation, bronchoscopy can help guide procedure. Likewise, bronchoscopy can be beneficial
embolization by directing the radiologist to the prior to surgical resection by identifying endobronchial
appropriate segment, minimizing the duration of the sites of disease that may impact resection. It should also

chestjournal.org 303
 Hemoptysis

A. Assess airway/try to identify source of bleeding

B. Breathing (if known, place bleeding side down)
C Circulation – Obtain intravenous access, hemoglobin,
platelets, coagulation profile
D. Directed history and physical
E. Evaluation by pulmonary/IP, Thoracic Surgery and IR

Airway not secure Airway secure

Secure the airway with rigid CT chest

bronchoscope or large-diameter ETT Flexible/rigid bronchoscopy
followed by flexible bronchoscopy
Bleeding localized
Lung isolation with available tools
CT chest

Yes No

Endobronchial therapy possible? Conservative management with

protection of the ‘good lung’,
reassessment as needed for source
Successful Unsuccessful/not localization
possible (ie, distal
parenchymal
source) Bronchial artery embolization

Successful Unsuccessful

Definitive therapy Further therapy with Emergency surgery

surgery/radiation as
needed

Figure 1 – Algorithm for treatment of hemoptysis. (Modified from Yendamuri.2) ETT ¼ endotracheal tube; IP ¼ interventional pulmonology;
IR ¼ interventional radiology.

be noted that embolization is associated with 60% to obstruction), this procedure has a good safety profile
90% short-term success, an up to 40% incidence of with a low rate of complications (< 4%). There are no
rebleeding, as well as a 1.4% to 6.5% risk of transverse specific data regarding the safety of bronchoscopy in
myelitis due to the anterior medullary artery arising patients with hemoptysis. As such, the location of
from the right (or left) intercostal bronchial trunk.15,16 bronchoscopy (ICU vs operating room vs endoscopy
Likewise, although surgery can be life-saving, it is often suite) should be dependent on local resources/expertise.
used for cases that are refractory to bronchoscopy/
The timing of bronchoscopy after an episode of
embolization and is associated with a mortality rate of
hemoptysis should also be considered, as the diagnostic
15% to 38%.17,18
yield of bronchoscopy will be lower the longer the time
Where, When, and Who Should Do the since the last event. This highlights the importance of
early bronchoscopic evaluation, even in the setting of
Bronchoscopy?
nonmassive hemoptysis.
Bronchoscopy is underutilized in the vast majority of
cases of hemoptysis because of the common The creation and training standardization of several
misconception that it is a risky procedure to be dedicated interventional pulmonology fellowship
performed only in a high-risk patient. Ost et al19 have programs, across the United States, has led to the
shown that when an experienced team performs increased availability of interventional pulmonologists in
bronchoscopy in high-risk patients (with central airway many large academic and private hospitals in the

304 Point and Counterpoint [ 153#2 CHEST FEBRUARY 2018 ]

country.20 The training emphasizes rigid bronchoscopy 3rd ed: American College of Chest Physicians evidence-based
clinical practice guidelines. Chest. 2013;143(5 suppl):e455S-e497S.
and other therapeutic interventions to control
9. Conlan AA, Hurwitz SS. Management of massive haemoptysis with
life-threatening airway emergencies such as massive the rigid bronchoscope and cold saline lavage. Thorax. 1980;35(12):
hemoptysis. The benefits of rigid bronchoscopy include 901-904.
10. Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R. Massive
obtaining an airway to allow for oxygenation and hemoptysis: review of 123 cases. J Thorac Cardiovasc Surg.
ventilation, as well as the use of large-bore suction and 1983;85(1):120-124.
ability to apply the techniques listed above (ie, laser, 11. Bhattacharyya P, Dutta A, Samanta AN, Chowdhury SR. New
procedure: bronchoscopic endobronchial sealing; a new mode of
APC) that can be used with the flexible bronchoscope as managing hemoptysis. Chest. 2002;121(6):2066-2069.
well. Whether rigid or flexible, bronchoscopy should be 12. Dupree HJ, Lewejohann JC, Gleiss J, Muhl E, Bruch HP. Fiberoptic
performed by an experienced endoscopic team. bronchoscopy of intubated patients with life-threatening
hemoptysis. World J Surg. 2001;25(1):104-107.
Although having advanced modalities such as APC can 13. Tsukamoto T, Sasaki H, Nakamura H. Treatment of hemoptysis
be helpful, bronchial blockers should be available in all patients by thrombin and fibrinogen-thrombin infusion therapy
using a fiberoptic bronchoscope. Chest. 1989;96(3):473-476.
bronchoscopy suites, operating rooms, and ICUs.
14. Marquez-Martin E, Vergara DG, Martin-Juan J, Flacon AR, Lopez-
Likewise, we encourage all bronchoscopy units to Campos JL, Rodriguez-Panadero F. Endobronchial administration of
occasionally drill/practice what they would do in the tranexamic acid for controlling pulmonary bleeding: a pilot study.
J Bronchology Interv Pulmonol. 2010;17(2):122-125.
setting of massive hemoptysis. This includes knowing
15. Andersen PE. Imaging and interventional radiological treatment of
one’s specific roles, such as where to rapidly find hemoptysis. Acta Radiol. 2006;47(8):780-792.
necessary equipment. 16. Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. Bronchial and
nonbronchial systemic artery embolization for life-threatening
In conclusion, in experienced hands, bronchoscopy is a hemoptysis: a comprehensive review. Radiographics. 2002;22(6):
1395-1409.
safe, readily available tool that plays a key role for both
17. Hirshberg B, Biran I, Glazer M, Kramer MR. Hemoptysis: etiology,
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therapeutic bronchoscopy for malignant central airway obstruction:
being said, as the eighteenth century British philosopher results of the AQuIRE Registry. Chest. 2015;148(2):450-471.
William Hazlitt said, “Never say ‘never’ and always 20. Mullon JJ, Burkart KM, Silvestri G, et al. Interventional
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bronchoscopy in the detection of the site and cause of bleeding in CORRESPONDENCE TO: Seth J. Koenig, MD, FCCP, 410 Lakeville Rd,
patients with large or massive hemoptysis? AJR Am J Roentgenol. Ste #107, New Hyde Park, NY 11042; e-mail: skoenig@northwell.edu
2002;179(5):1217-1224. Copyright Ó 2017 American College of Chest Physicians. Published by
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