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 our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT SC 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 firstname.lastname@example.org RI PT Rebuttal from Drs. Cardenas-Garcia and Feller-Kopman TE D M AN U 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 email@example.com Correspondence to: Dr. José Cárdenas-García, M.D. firstname.lastname@example.org EP Conflicts of Interest AC C 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 RI PT 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, SC 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 M AN U 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 TE D 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 EP 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 AC C be treated bronchoscopically, 3,4 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 ACCEPTED MANUSCRIPT 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 RI PT 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 SC be performed in all patients who are smokers and 40 years of age or older and who M AN U 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, TE D 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 EP experience hands, and as outlined in our ‘pro’ side, we remain confident that in the large AC C majority of patients the benefits of bronchoscopy outweigh the risks. ACCEPTED MANUSCRIPT Bibliography: 6. RI PT SC 5. M AN U 4. TE D 3. EP 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. AC C 1.