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(Chest. 2000;118:1431-1435.)
© 2000 American College of Chest Physicians

Managing Life-Threatening Hemoptysis*

Has Anything Really Changed?

Edward F. Haponik, MD, FCCP; Alan Fein, MD, FCCP and Robert Chin, MD, FCCP

* From the Department of Internal Medicine (Dr. Haponik), Section on Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Wake Forest University School of Medicine (Dr. Chin), Winston-Salem, NC; and North Shore Hospital (Dr. Fein), New York, NY.

Correspondence to: Edward F. Haponik, MD, FCCP, Professor of Medicine, Director of Clinical Operations, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E Monument St, Room 301, Baltimore, MD 21205


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To delineate current chest clinicians’ approaches to the management of patients with life-threatening hemoptysis.

Design: Survey during a computer-assisted interactive continuing medical education presentation.

Setting: The 1998 American College of Chest Physicians (ACCP) Annual Scientific Assembly.

Participants: Chest clinicians attending the respiratory emergency symposium.

Results: Most clinicians (86%) had cared for patients with life-threatening hemoptysis, and 28% had cared for patients with fatal events during the previous year. Those clinicians favored management in the ICU setting (95%) with early endotracheal intubation (85%), and they tended to use a large-bore, single-lumen endotracheal tube (57%). The majority (64%) favored the early performance of diagnostic bronchoscopy during the first 24 h. Most clinicians (79%) used the flexible instrument, a higher frequency than respondents at a similar symposium on hemoptysis at the 1988 ACCP meeting (48%; p < 0.0001). Most current clinicians (77%) had experience with endobronchial measures to control bleeding, but few (14%) found them to be consistently worthwhile. Chest CT scanning was often helpful in diagnosis (55%). In their management of bleeding, half of these clinicians favored the use of interventional angiography, even in operable patients, which is a substantial change from 1988 when 23% had favored this approach (p < 0.0001).

Conclusions: During the past decade, life-threatening hemoptysis has remained an important problem. Flexible bronchoscopy and interventional angiography have become increasingly established, more widely accepted approaches to patient care.

Key Words: massive hemoptysis • respiratory emergencies


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Few respiratory emergencies are more terrifying for both the patient and the health-care professional than life-threatening hemoptysis.1 2 3 4 5 6 The acuity, unpredictability, risk, and relative infrequency of this medical problem have generally precluded its systematic prospective investigation. Accordingly, most management principles have derived from retrospective series and anecdotal reports, with the usual approach dictated by the patient’s characteristics, the clinician’s experience, and the timely availability of supportive resources.4 6 7 There is littleinformation available about the current approaches of chest physicians or about whether major technologic progress has influenced diagnosis and therapy. To appraise their perspectives about life-threatening hemoptysis, we recorded and reviewed the responses of clinicians attending an interactive symposium on respiratory emergencies during the 1998 meeting of the American College of Chest Physicians (ACCP).


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
The 1998 ACCP meeting in Toronto, Canada, included a symposium on respiratory emergencies. An interactive format was used in which the perspectives of the audience could be surveyed by means of a computer keypad with which each participant could enter their responses to questions. During the presentation, the faculty posed questions regarding life-threatening hemoptysis, and the frequency distributions of the audience’s responses could be displayed and were recorded. We reviewed these responses and compared them to the results of a similar survey administered during an interactive symposium on hemoptysis at a previous ACCP annual meeting in 19888 and to published information regarding the management of patients with life-threatening hemoptysis. Because the surveys were not identical, we limited our comparisons to those areas in which both the context and content of the questions and the optional answers were similar. The differences observed in the proportions of the responses in the 1988 and 1998 surveys were appraised using Fisher’s Exact Test, and statistical significance was accepted for p < 0.05.


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The demographic characteristics of this group of clinicians, including the settings of their practices and the relative numbers of pulmonologists, intensivists, thoracic surgeons, and anesthesiologists participating were not obtained. The number of respondents to questions varied from 111 to 230 during the presentation. There were fewer respondents to questions posed earlier in the session. While differences in the number of respondents might have reflected the unclarity of the questions, respondent reservations about the options offered, or other unrecognized factors, it appeared likely that the lower number of responses to these earlier questions reflected a rapid transition from the didactic aspect of the presentation to requests for audience input. On-site observations suggested that the increasing number of responses as the presentation progressed likely reflected adaptation of the participants to the format and pace of the questions and/or an increase in audience size.

Eighty-six percent of respondents (111 of 129 respondents) indicated that they had cared for patients with life-threatening hemoptysis during the previous year, and 28% of respondents (44 of 111 respondents) had had a patient die from pulmonary hemorrhage during the previous year. These clinicians overwhelmingly favored the care of such patients in the ICU setting (211 of 223 respondents [95%]). The approaches to airway management favored by respondents are summarized in Table 1 . In general, early endotracheal intubation was favored, but clinicians varied in their strategies. They more often favored the placement of large-bore, single-lumen tubes rather than a double-lumen tube, and they expressed reservations about their own proficiency in consistently placing the latter airways.


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  		Table 1.. Approaches to Airway Management in Life-Threatening Hemoptysis

 
Approaches to bronchoscopy in patients with life-threatening hemoptysis are summarized in Table 2 . The vast majority of respondents (79%) used the fiberoptic instrument, and they tended to perform bronchoscopy during the first 24 h of the patient’s presentation with life-threatening bleeding. The current use of flexible bronchoscopy cited was higher than that cited in 1988, when 56 of 108 respondents (52% overall) used this approach (p < 0.0001). While most of the current survey respondents (ie, those from the 1998 survey) indicated that they had used endobronchial therapy (eg, instillation of epinephrine or cold saline solution and use of balloon catheters) during efforts to control massive bleeding, relatively few found this approach to be consistently worthwhile. In considering other diagnostic modalities, 119 of 217 respondents (55%) had found chest CT scanning helpful in their appraisal of patients with life-threatening hemoptysis. Details regarding the specific effects of CT-derived information or the impact of new developments in CT technology on management were not obtained.


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  		Table 2.. Approaches to Bronchoscopy in Life-Threatening Hemoptysis

 
The general approach of these clinicians to the management of patients with life-threatening pulmonary hemorrhage is shown in Figure 1 . Half of the respondents favored an initial attempt at interventional angiographic techniques to control bleeding. This proportion differed from 1988, when 23 of 99 clinicians (23%) favored this approach (p < 0.0001). Equal proportions of the remaining current respondents (25%) preferred either to proceed directly to surgical resection of the bleeding site or to engage in a "watch and wait" strategy in hopes that the bleeding would abate spontaneously.



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  		Figure 1.. A higher proportion of chest clinicians favored interventional angiography over either surgery or observation in their approaches to life-threatening hemoptysis.

 

   Discussion
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
As manifested by the interest and feedback provided during this interactive symposium, life-threatening hemoptysis remains an important clinical concern of chest physicians. Most of these clinicians had cared for patients with life-threatening hemoptysis during the previous year, and many acknowledged that some of their patients had died as a result of this problem. That nearly all of these physicians cared for patients with massive bleeding in the ICU setting is not surprising and is consistent with the immediacy of supportive management priorities and the need for careful monitoring. The prioritization of airway maintenance, with early endotracheal intubation favored by 85% of respondents, is also consistent with established approaches to the care of these patients. A slight majority of these clinicians favored the use of large-bore, single-lumen tubes, rather than double-lumen tubes. Of the 1988 clinicians who responded during a similar interactive conference, 23% either inserted a double-lumen tube (7%) or consulted an anesthesiologist (16%).8 Interestingly, a majority of the current clinicians (71%) acknowledged a lack of proficiency with the double-lumen tube. We believe that this finding reflects the fact that, at most institutions, anesthesiologists rather than pulmonary/critical care physicians have the most experience inserting these tubes and that these tubes are seldom used outside of the operating room. A higher proportion of current clinicians favored double-lumen tubes, but this difference may reflect variations in the format of questions relating to airway support, with more options having been offered in the 1998 survey.

The early timing of the bronchoscopic evaluation favored by most of these clinicians appears to be consistent with the presumed importance of the localization of the bleeding site in order to isolate and protect the nonbleeding lung and/or to facilitate specific therapy. Whether this strategy realizes these goals consistently in patients with life-threatening hemorrhage remains undefined. Although rigid bronchoscopy is the time-honored approach that is recommended for airway evaluation in this setting, generally because the open tube instrument secures the airway and may facilitate a broader array of interventional options, most of these clinicians (79%) reported the use of the flexible instrument. They favored this approach more often than their 1988 counterparts (48%).8 While this strategy undoubtedly reflects familiarity with the current fiberoptic technology (as well as selection bias by this group), it also might suggest that prohibitively high morbidity has not been encountered when the flexible instrument is used via an already secured airway. While there has been particular emphasis placed on a variety of endobronchial therapies purported to help control massive bleeding, the majority of these respondents who had used such treatments did not find them to be consistently worthwhile. The survey did not address the emerging applications of cryotherapy or laser photocoagulation in the treatment of major airway hemorrhage.

Interestingly, approximately half of the 1998 respondents found chest CT scanning to be helpful in appraising patients with life-threatening bleeding, a frequency similar to that reported in 1988 (60%). Although the frequencies of CT use were similar, we believe that the influence of this modality on the care of these patients may increase in the future because of important technologic developments. A previous review of the use of CT scanning in the general evaluation of patients with hemoptysis showed that such imaging more often identified the bleeding site than the conventional posteroanterior and lateral chest radiograph but that the information obtained by the CT scan seldom influenced patient management.9 More recently, CT scanning performed with a newer generation of scanners has had a high diagnostic yield and impact on decision making in such patients.10 Well-suited for delineating bronchiectasis, neoplastic disease, tuberculosis, necrotizing infection, vascular abnormalities, and other major causes of life-threatening hemoptysis, CT scan findings also may clarify radiologic details that would otherwise be obscured by atelectasis and/or aspirated blood. While the practical use of CT scanning in critically ill patients has been limited by scanning duration and other factors, newly available helical ("spiral") scanners allow rapid scanning, making timely examination feasible. Additional options including CT angiography, multiplanar reconstructions, and endobronchial simulations also may enhance the appraisal of life-threatening hemoptysis. In preliminary experiences, "virtual bronchoscopy" derived from helical CT scan data sets has helped to characterize more completely airway disease.11 Few patients with life-threatening bleeding have been included in such reports, however, and the role of CT scanning and its impact on outcomes in this acute setting require further study.

The views of these clinicians about approaches to early treatment were particularly informative. In 1988, only 21% of survey respondents advocated interventional angiography for most patients with massive hemoptysis, and only 2% favored this modality in all patients.8 Nearly one third of respondents were undecided about the role of this therapy, and 45% reserved it for inoperable patients only. By contrast, half of the present respondents favored interventional angiography as an early approach to therapy. We believe this changing viewpoint reflects the further validation of interventional angiography for this indication during the past decade, together with the more widespread availability of this modality.11 12 13 14 Newer microcatheters that allow superselective catheterization, better selection of embolic materials, and enhanced training in interventional radiology, and the perception of a relatively low frequency of complications also may have helped to popularize the procedure.15 The rates of initial control of bleeding have ranged from 77 to 95%, enhancing the acceptance of early angiographic intervention despite the fact that it is rarely curative, complications are not rare, and recurrence rates are relatively high. It is not clear whether the watchful waiting approach favored by one quarter of the current respondents reflects the spontaneous resolution of even massive bleeding in some patients and/or its association with extensive chronic parenchymal disease that often precludes meaningful intervention.

Because of time constraints, the current survey was necessarily abbreviated and did not include important demographic data about respondents. Such factors as the relative proportions of thoracic surgeons, anesthesiologists, pulmonologists, and full-time intensivists, their levels of experience, and the settings of their practices might be expected to influence the approaches to patients with life-threatening hemoptysis. In addition, comparisons with the survey administered 10 years previously were limited to those areas in which both the context and the content of the questions and the optional answers were similar. It is likely that a more comprehensive survey that includes more details relating to patient evaluation and management as well as characterization of respondents and their practices would be even more informative about current approaches. We anticipate that such an expanded instrument would refine observations about differences in practice style and would be strongly influenced by regional variations in the epidemiology of hemoptysis and by the availability of institutional resources for diagnosis and therapy.

Other important limitations include selection bias due to sampling highly motivated physicians attending the ACCP international conference, and inaccuracies related to incomplete survey options or respondents’ imprecise recollections about experiences. Nevertheless, these observations present interesting insights into current approaches to a classic dilemma in respiratory medicine. Life-threatening hemoptysis remains an important problem to be managed by chest clinicians and generally requires ICU management. Although many aspects of acute care continue to be highly individualized and have not changed substantially over time, during the past decade early flexible bronchoscopy and interventional angiography appear to have become increasingly established, more widely accepted approaches. Whether these modalities, other nuances of care, or future technologic innovations contribute to improved patient outcomes in this high-risk setting requires future investigation.


   Acknowledgements
 
The authors thank all of the staff of the ACCP for their contributions toward data collection during CHEST 1998, and Ms. Debbie Belcastro for her secretarial assistance in preparation of this report.


   Footnotes
 
Abbreviation: ACCP = American College of Chest Physicians

Received for publication October 13, 1999. Accepted for publication May 23, 2000.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Crocco, JA, Rooney, JJ, Fankushen, DS, et al (1968) Massive hemoptysis. Arch Intern Med 121,495-498[CrossRef][ISI][Medline]
  2. Garzon, AA, Gourin, A (1977) Surgical management of massive hemoptysis. Ann Surg 137,267-271
  3. Bobrowitz, ID, Ramakrisna, S, Shim, Y-S (1983) Comparison of medical vs surgical treatment of major hemoptysis. Arch Intern Med 143,1342-1346
  4. Conlan, AA (1985) Massive hemoptysis: diagnostic and therapeutic implications. Surg Annu 17,337-354[Medline]
  5. Corey, R, Hla, MK (1987) Major and massive hemoptysis: reassessment of conservative management. Am J Med Sci 294,301-309[ISI][Medline]
  6. Winter, SM, Ingbar, DH (1988) Massive hemoptysis: pathogenesis and management. J Intensive Care Med 3,171-188
  7. Cahill, BC, Ingbar, DH (1994) Massive hemoptysis: assessment and management. Clin Chest Med 15,147-167[ISI][Medline]
  8. Haponik, EF, Chin, R (1990) Hemoptysis: clinicians’ perspectives. Chest 97,469-475[Abstract/Free Full Text]
  9. Haponik, EF, Britt, EJ, Smith, PL, et al (1987) Computed chest tomography in the evaluation of hemoptysis: impact on diagnosis and treatment. Chest 91,80-85[Abstract/Free Full Text]
  10. McGuinness, G, Beacher, JR, Harkin, TJ, et al (1994) Hemoptysis: prospective high resolution CT/bronchoscopic correlation. Chest 105,1155-1162[Abstract/Free Full Text]
  11. Haponik, EF, Aquino, SL, Vining, DJ (1999) Virtual bronchoscopy. Clin Chest Med 20,201-217[CrossRef][ISI][Medline]
  12. Remy, J, Arnaud, A, Fardou, H, et al (1977) Treatment of hemoptysis by embolization of bronchial arteries. Radiology 122,33-37[Abstract]
  13. Uflacker, R, Kaemmerer, A, Picon, PD, et al (1985) Bronchial artery embolization in the management of hemoptysis: technical aspects and long-term results. Radiology 157,637-644[Abstract/Free Full Text]
  14. Rabkin, JE, Astafjer, VI, Gothman, LN, et al (1987) Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 163,361-365[Abstract/Free Full Text]
  15. White, RI (1999) Bronchial artery embolotherapy for control of acute hemoptysis. Chest 115,912-915[Free Full Text]
  16. Mal, H, Rullon, I, Mellot, F, et al (1999) Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 115,996-1001[Abstract/Free Full Text]



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