Selection of patients with hemoptysis for fiberoptic bronchoscopy

time of resolution is also compatible with the diagnosis of pulmonary edema. In summary, although it is somewhat unusual, the possibility of re-expansion pulmonary edema should be kept in mind even after relatively short episodes of complete pulmonary collapse. In addition, it is important to be aware that pulmonary collapse preceding the event may be secondary either intrinsic bronchial obstruction, as in this case, extrinsic factors such as pneumothorax or pleural effusion. Carl

Duke

thorax.

RL, Berne

Radiology

M.D., F.C.C.P., and S. Dahmash, M.D., Department of Radiology, Medical Center, Durham

Reprint

requests:

University

Dr. Ravin,

ion of Patients

Rberopfic

with

Hemoptysis

disease,

accompanying

more

bronchoscopy

for

patients

phenomenon.

of

nonmalignant

as

underlying

has

do

clinical not

hemoptysis. been

tuberculosis,’

in

indica-

the

walls

association

with

nonspecific

the

so-called

“scar

carcinoma.”

be approached

diagnosis

may

be

to

The

reported

vigorously in a patient

of

undergo

coexistence documented

many of

in

76:1-2).

evidence

need

is a well

in

should

1979;

(Chest

disease

Malignancy

with

liberal

one of the points

with

with “strong disease”

evaluation

and

fairly

by Snider

pulmonary

heinoptysis

sharply

editorial

that those

disease,

encourage

examination.

disagree

nonneoplastic

the

would

for bronchoscopic

We would

and

in

of

Weaver

et in the

bronchoscopy

al

provides

useful

diagnosis

with the symptom the interpretation

guide-

of carcinoma

of hemoptysis. of their data

in

Sevare in

TO THE EDITOR

and

assuming

that

all

of the

28

cancer

patients

have

positive bronchoscopic findings, the odds that a patient with hemoptysis will have a positive finding on broncoscopy are 28:42. In using a factor such as patient age for selecting patients for bronchoscopy, one should evaluate the extent to which the factor will increase the odds beyond 28:42 that the

results

of bronchoscopy

(LR) the

is a measure ratio

of

patient will

with be

will be positive. of this,

the

probability

the

disease

present

determined

and

the

LR

The

to

the

be

will

probability

without

Weaver’s

likelihood

may

a symptom

in a patient

from

the

that

ratio

calculated

be

as

present the

disease.1

in

a

symptom

This

may

be

Table 4 as LR = %. The table below

(100%.-false shows the I have added the symptom of only” to the table. It can be seen

negative %) /false positive results of these calculations. “flecks or streaks of blood that anemia, weight loss and long duration

of hemoptysis

are

the patient factors which most increase the usefulness of this diagnostic procedure. Based upon their data, age does not represent a particularly useful criterion. The authors’ Table 4 suggests that they

years

by

bronchoscope

only

five

old (88% of the 42 non-cancer

patients

less

patients

were

Risk

Factors

than

40

> 40),

To

bronchogenic Significance

granulomatous Hence,

no matter otherwise

of

Individual

new

what felt

to

possibly suggestive of malignancy. In our own practice (in fact, within the last year) we have performed “curative” resections of bronchogenic carcinoma in a patient with pulmonary hemosiderosis, another with pulmonary silicosis, and are following-up two or three patients with positive acid-fast bacilli in their resected bronchogenic carcinoma specimens. In summary, while we would agree with critical evaluation of the need for bronchoscopy, we would suggest that there are other benefits to bronchoscopy besides simply the diag-

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studied

examined

times

be at risk for carcinoma. Obviously, the tenth bout of hemorrhage in a patient with known bronchiectasis does not require a full blown workup, but any new symptoms to us are

710

paper

using

First, analysis should permit determination of those patient characteristics which make a positive finding from bronchoscopy more likely. Overall, based on the 70 patients

nonmalignant

cysts,’

of Thoracic of Tennessee,

order.

1979; 76:7-10) have presented a study; however, we find ourselves in some disagreement with their conclusion that patients with hemoptysis need observation only when older than 40 years, with an abnormal chest film, or prolonged hemoptysis. While the incidence of malignancy might be nearly negligible in this group of patients, hemoptysis is a worrisome symptom which demands a diagnosis. Bronchoscopy is helpful in localizing the bleeding site for future reference and may well reveal a nonmalignant disease requiring specific therapy. In fact the authors’ own figures of specific diagnosis in 69 of their 70 patients who underwent endoscopy, and of the 62 percent diagnostic accuracy in the patients with

conjunction

recent for

patients who present eral points regarding

for

Weaver et al (Chest done retrospective

of carcinoma

and

Jr., M.D. Surgery Memphis

Cole,

1 Gerami 5, Cole FH. Coexisting carcinoma of the lung and pulmonary tuberculosis. Ann Thorac Surg 1969; 7:317321 2 Moersch HJ, Clagett OT. Pulmonary cysts. J Thorac Surg 1947; 16:179-199 3 McFadden RR, Dawson PJ. Adenocarcinoma arising in a Ghon complex and presenting with massive pericardical effusions. Chest 1972; 62:520-522

The

Bronchoscopy

He states

Department

lines

nicely

the

F.C.C.?.,

Hammond

University

Duke

To the Editor:

tions

F.

To the Editor:

Division,

27710

Durham

M.D.,

H. Cole,

Francis

of pneumo-

Imaging

Director,

Center,

Medical

Select

Rapid re-expansion 12, 1970

AS:

96:509-5

noma.

REFERENCES

REFERENCES

1 Humphreys

state that a benign bronchogenic carci-

and would strongly rule out a coexisting

the to or

E. Ravin, Nabil

University

nosis of malignancy diagnosis does not

Age

> 40

Nonnormal

chest

Hemoptysis

> 1 week

Chronic

Smoke HCT Recent Flecks blood

x-ray

cough

> 40 pk-years < 38 weight or

streaks only

loss

film

False Negative

False Positive

%

%

0

88

1.14

0

64

1.56

14

46

1.87

7

74

1.26

12

61

1.44

43

12

4.75

43

29

1.97

32

49

1.38

Likelihood Ratio

of

CHEST, 77: 5, MAY, 1980

conclude that bronchoscopy many more young patients study by Weaver et al.

is unnecessary should have

in young been

Philip Johns

patients,

included

Hai’ber,

Hopkins

in

M.D.,

But surely the Drs. Cole would not have every acutely ill patient with hemoptysis medical service, Such patients often have pneumonia,

pulmonary

cavitary

University,

Baltimore REFEIurrrcE

have blood

To the

to medical

decision

making.

Spring-

1968

Editor:

We appreciate these thoughtful comments on our paper. The indications for bronchoscopy suggested by our analysis should be considered a preliminary answer to the common clinical problem of hemoptysis and should be evaluated in the light of experience at other institutions. The Drs. Cole seem to be advocating more extensive use of bronchoscopy than we favor. Their position is certainly defensible and has many sympathizers; however, our article was an attempt to advance the analysis of this important issue. We are familiar with all the points raised in favor of the Coles’ position, but we do not think that they warrant changing our conclusions. Dr. Harber apparently assumes that likelihood ratios provide the best way to compare various possible indications for bronchoscopy. We believe that other methods may be more useful sometimes. Although likelihood ratios have been employed by several investigators seeking to improve medical decision-making, they are not completely satisfactory. First, the indications for a procedure chosen through use of these ratios may be contrary to the implicit preferences of clinicians. For example, Dr. Harber favors anemia over advanced age as a criterion for performing bronchoscopy; yet, in our

experience, age is mentioned more frequently when physicians are defending their decision to perform this procedure. Second, direct calculation of the likelihood ratios from the data in our paper may be illegitimate because our investigation was not designed to estimate the relevant variables. Forty of the 110 patients with hemoptysis did not undergo bronchoscopy. This occurred sometimes because the attending physician attributed the bleeding to some recognized benign condition. If some of these patients had had bronchoscopy, the likelihood ratios would have been different, and it is conceivable that the differences could have altered the

relative

rankings

decision

of

procedure

in our analysis

age,

hematocrit,

emphasizing

might

false

be less affected Norman

Northwestern

University

etc.

The

negatives

that

two-step was

used

by this problem. Solliday, M.D.,

F.C.C.P.

Medical

Chicago

School,

One of the definitions of perspective is “the interrelation in which a subject or its parts are mentally viewed.” It is apparent that the Drs. Cole, working as they do in a department of thoracic surgery, were not viewing the group of patients to whom I was referring when I stated in my

editorial’ that patients with hemoptysis, who had strong clinical evidence of non-neoplastic lung disease, did not need bronchoscopy. able,

Coles

to exclude

in patients

with

culosis,

other

problem

such

not protect CHEST,

Nor do I think

they

every patient who expectorates after a noctural epistaxis site. These are the patients,

bleeding

would a little from a compris-

of 40 individuals with hemoptysis, who were not by Weaver, et al, These are also the patients referred to in the early but still pertinent report by Moersch and to whom I was referring in my editorial. I suggest that the disagreement between the Drs. Cole and me is more apparent than real-and is all just a matter of perspective! ing a group bronchoscoped

Cordon

Boston Veterans

Snider,

L.

M.D.,

F.C.C.?.

School of Medicine Medical Center Boston

University Administration

REFERENCES 1 Webster’s

New

Collegiate

Dictionary,

Springfield,

Mass,

C.&C. Merriam Co., 1977 2 Snider GL. When not to use

the bronchoscope for heChest 1979; 78:1-2 3 Weaver U, Solliday N, Cugell DW. Selection of patients with hemoptysis for fiberoptic bronchoscopy. Chest 1979; 76 :7-10 4 Moersch HJ. Clinical significance of hemoptysis. JAMA 1952; 14g: 1481-1465 moptysis.

In Defense

of Preoperative

Pulmonary

Function

Tests To the Editor: It is the time of therapeutic nihilism in the name of cost effectiveness bowing to the temple of H.E.W. Let’s see how little we can do for the patient in the name of stopping inflation. The purpose of this letter is not to refute the argument that medical care is too expensive (it is not), but rather the offensive conclusions drawn by Cain et al in the article entitled “Preoperative Pulmonary Function and Complications after Cardiovascular Surgery” (Chest, 1979; 78: 130-135). Whether or not “alarming economic ramifications” occur by disproving the value of obtaining preoperative pulmonary function tests is of no significance. If they are of value, they should be done; if they are of no value, they should be discontinued. Preoperative pulmonary function tests are not ordered for either the profit of this hospital nor for the profit of this medical director. I certainly concur with Cain et al...

To the Editor:

As the

admitted to a bleeding due to lung abscess or

putrid

disease.

us bronchoscope in the morning

demonstrated 1 Lusted L. Introduction field, Charles C Thomas,

infarction,

granulomatous

us bronchoscope

state,

bronchoscopy

will

generally

be

advis-

the development of bronchogenic carcinoma, hemoptysis who have previously had tubergranulomatous disease or some other chronic as pulmonary

against

another.

77: 5, MAY, 1980

cystic

disease.

One

disease

does

“that

maintenance

of the

integrity

requires

function

tests

fore, “proper

that

scientific

The care

are

suggest

Dr. and

arbitrarily as an

way

reflects

the

be

prevented

preoperatively.

scientific

Cain’s

retrospective

intellectual

integrity.”

chosen

unit

proper

validation or reputation. of no value preoperatively.

index very

by The

postoperative

complications postoperative

.“

intellectual

that pulmonary I would, therestudy

lacks

stay

in the complications

of postoperative

pulmonary

and .

that

function

would

testing stay

in

the

be

and

the

intensive in no

expected

to

treatment

intensive

care

unit reflects numerous other complications as well, in addition to the surgeon’s attitude towards the use of the ICU. No description is given of the preoperative and postoperative respiratory therapy other than stating they are “standard

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