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j.chest.2017.09.037

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Accepted Manuscript
Rebuttal from Drs. Cardenas-Garcia and Feller-Kopman
José L. Cárdenas-García, MD, David Feller-Kopman, MD, FCCP
PII:
S0012-3692(17)32875-1
DOI:
10.1016/j.chest.2017.09.037
Reference:
CHEST 1367
To appear in:
CHEST
Received Date: 20 September 2017
Accepted Date: 20 September 2017
Please cite this article as: Cárdenas-García JL, Feller-Kopman D, Rebuttal from Drs. Cardenas-Garcia
and Feller-Kopman, CHEST (2017), doi: 10.1016/j.chest.2017.09.037.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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ACCEPTED MANUSCRIPT
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José L. Cárdenas-García, MD
Interventional Pulmonology Attending
Assistant Professor of Medicine and Surgery
Penn State Milton S. Hershey Medical Center
500 University Drive, C5800, H041
Hershey, PA 17033
jdecardenasg@gmail.com
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Rebuttal from Drs. Cardenas-Garcia and Feller-Kopman
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David Feller-Kopman MD, FCCP
Director, Bronchoscopy and Interventional Pulmonology
Professor of Medicine, Anesthesiology, Otolaryngology – Head and Neck Surgery
Johns Hopkins Hospital
1800 Orleans St., Suite 7125
Baltimore, MD 21287
dfk@jhmi.edu
Correspondence to:
Dr. José Cárdenas-García, M.D.
jdecardenasg@gmail.com
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Conflicts of Interest
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This work in original and all authors meet the criteria for authorship, including
acceptance of responsibility for the scientific content of the manuscript. This paper is not
under consideration in any other Journal and all the authors have read and approved the
content of the manuscript.
No potential conflict of interest exists with any companies or organizations whose
products or services may be discussed in this article. This paper has not been funded by
the National Institutes of Health (NIH), the Wellcome Trust or their agencies.
Dr. Cardenas-Garcia has no conflict of interest.
Dr. Feller-Kopman has received consulting fees from Fujifilm, USA.
ACCEPTED MANUSCRIPT
We agree in full with Drs. Koenig and Lakticova,1 that there is no place for dogma in
Medicine. We agree that all patients may not require bronchoscopy (i.e. in the case of
bronchitis), and chest CT may identify the underlying source of the bleed (i.e. a lung
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mass). Drs. Koenig and Lakticova reference the recent study by Nielsen and colleagues
suggesting that bronchoscopy does not add to the sensitivity of chest CT for diagnosing
either malignant or non-malignant causes of hemoptysis. 2 The reader should note,
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however, that this study has many flaws including its retrospective design, outpatient
setting, exclusion of massive hemoptysis cases, and the lack of description of the time
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between the bronchoscopy and the last episode of hemoptysis. Perhaps most importantly,
chest CT did not make the diagnosis, but rather just identified the underlying source. In
2017, “tissue is the issue”, and one should not make a diagnosis of cancer based on chest
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imaging.
Likewise, we agree that in the right clinical setting of non-massive hemoptysis with chest
imaging suggesting a diagnosis of pneumonia, or in the patient with cystic fibrosis and
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recurrent non-massive hemoptysis, bronchoscopy may have little value. That being said,
if the pneumonia fails to resolve, or there is the possibility of a superficial vessel that can
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be treated bronchoscopically,
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the benefits of bronchoscopy outweigh the risks.
Regarding the controversy over the role of bronchoscopy in patients at risk of lung cancer
and normal chest radiography (CXR), Tsoumakidou's prospective study included 184
non-massive and massive hemoptysis patients with high risk of lung cancer, who
underwent chest imaging (CT chest and CXR) and bronchoscopy. The author found that
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41% of patients with negative CXR had positive CT findings, and that 21% of patients
with both negative CXR and CT chest had positive bronchoscopic findings. These results
highlight the importance of extensive work-up of hemoptysis in patients with high risk of
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lung cancer, and the complementary role of CT chest and bronchoscopy. 5 Another study,
in the same type of population supported these findings. 6 More recently, the Danish
Lung Cancer Group (DLCG) guidelines recommended that CT and bronchoscopy should
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be performed in all patients who are smokers and 40 years of age or older and who
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present with non-massive hemoptysis even if the CXR is normal. 2
We all agree that there is a lack of literature to support routine bronchoscopy in all cases
of hemoptysis, however, as part of our human nature, we are poor at predicting whether
and when a patient with non-massive hemoptysis will progress to fatal bleeding. As such,
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it is prudent to approach each case on an individual basis, weighing the relative risks and
benefits of observation / empiric therapy with that of bronchoscopy. Though all patients
may not receive a diagnosis from bronchoscopy, it remains a safe procedure in
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experience hands, and as outlined in our ‘pro’ side, we remain confident that in the large
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majority of patients the benefits of bronchoscopy outweigh the risks.
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Bibliography:
6.
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5.
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4.
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3.
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2.
Koenig SJ, Lakticova V. Counterpoint: Should all initial episodes of
hemoptysis be evaluated by bronchoscopy? No. Chest. 2017;XX(XX):XX.
Nielsen K, Gottlieb M, Colella S, Saghir Z, Larsen KR, Clementsen PF.
Bronchoscopy as a supplement to computed tomography in patients with
haemoptysis may be unnecessary. Eur Clin Respir J. 2016;3:31802.
Kolb T, Gilbert C, Fishman EK, et al. Dieulafoy's disease of the bronchus.
American journal of respiratory and critical care medicine.
2012;186(11):1191.
Medrek SK, Kular HS, Lazarus DR, Bujarski S, Patel K, Bandi V. Use of
Sclerotherapy for the Treatment of Massive Hemoptysis due to a Bleeding
Bronchial Varix. Annals of the American Thoracic Society. 2017;14(7):12211223.
Tsoumakidou M, Chrysofakis G, Tsiligianni I, Maltezakis G, Siafakas NM,
Tzanakis N. A prospective analysis of 184 hemoptysis cases: diagnostic
impact of chest X-ray, computed tomography, bronchoscopy. Respiration;
international review of thoracic diseases. 2006;73(6):808-814.
Thirumaran M, Sundar R, Sutcliffe IM, Currie DC. Is investigation of patients
with haemoptysis and normal chest radiograph justified? Thorax.
2009;64(10):854-856.
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