Hemoptysis is an important and sometime alarming symptom which requires thorough investigation.

Hemoptysis is an important and sometime alarming symptom which requires thorough investigation. still in up to 50 percent of cases, no etiology is base Several studies have demonstrated that high-resolution comput tomography (HRCT) can be helpful in the assessment of patients with hemoptysis. It is undoubtedly the modality of choice for the diagnosis of bronchiectasis having, in principally centers, totally replaced bronchography. High-resolution comput tomography may also demonstrate peripheral tumors or focal lesions not apparent bronchoscopically. notwithstanding the role of HRCT in the assessment of patients with hemoptysis is controversial.

In this issue of Chest (see page 1155) McGuinness and coworkers approve that HRCT be performed routinely prior to bronchoscopy in all patients with hemoptysis. While HRCT and bronchoscopy are complementary rather than

competitive, in these days of costliness containment, performing HRCT routinely looks to be, at first glance, extravagant. still the data of the thought by McGuinness and colleagues provide a sinewy argument in favor of HRCT In their prospective reflection the overall diagnostic yield of HRCT was 61 percent compared to 43 percent for bronchoscopy A specific diagnosis was made based forward the CT findings in 50 percent of cases with nondiagnostic bronchoscopy These outcomes are similar to those of Millar et al[1] who, also in a prospective application of mind showed that CT allowed diagnosis in 50 percent of patients with hemoptysis who had normal radiograph and bronchoscopy

The principally common argument for using bronchoscopy rather than CT in the evaluation of patients with hemoptysis is that focal bronchial abnormalities, particularly bronchogenic carcinoma, may be missed in succession CT. However, several studies have demonstrated that the oftenness of bronchogenic carcinoma is cheap ([ or -] 5 percent) in patients with hemoptysis and normal radiograph. In the subject of attention by McGuinness and coworkers, all six bronchogenic carcinomas presenting as endobronchial lesions were lay opened prospectively on CT. Furthermore, all of these patients had abnormal and localizing chest radiographs. Therefore, it appear to bes reasonable to use CT as the primary diagnostic conduct in patients with hemoptysis and normal chest radiographs.

The justification for the use of CT as the primary imaging modality in patients with localizing abnormalities upon the radiograph is more difficult. united of the main diagnostic considerations in these patients is the possibility of lung cancer. Although CT may demonstrate the abnormality, bronchoscopy is required, it may be argued, to make a histologic diagnosis. This argument, however, ignores the fact that the cause of the abnormality may be bronchiectasis, aspergilloma, or a peripheral tumor not accessible to bronchoscopy In as it is cases, bronchoscopy may not be indicated. Furthermore, in in the greatest degree centers, CT is used routinely in the staging of patients with lung cancer. It would appear reasonable that CT be performed prior to bronchoscopy and advance as a road map. It would help in selecting those patients in whom transbronchial biopsy with a Wang needle may be considered and those patients with enlarged mediastinal nodes in whom a mediastinoscopy, anterior mediastinotomy, or CT-guided biopsy should be performed.

Based in succession the data by McGuinness and colleagues, it would be seen that CT should be used prior to bronchoscopy in greatest in number patients with hemoptysis. High-resolution CT may allow specific diagnosis and thus obviate bronchoscopy in a number of patients, and aid as a guide to bronchoscopy in the remaining cases. The main and possibly and nothing else exception would be patients who are actively bleeding. In these cases, bronchoscopy should be done as shortly as possible to accurately identify the bleeding site. It should be noted, however, that the meditation by McGuinness and coworkers included solitary 57 cases, and bronchiectasis accounted for 25 percent of the cases, tuberculosis for 16 percent lung cancer for 12 percent intracavitary aspergillomas for 12 percent and bronchitis for 5 percent Nineteen percent of cases were cryptogenic. The diagnostic yield of HRCT compared to bronchoscopy might be considerably different in a population with a higher prevalence of lung cancer or bronchitis. The authors did not determine the clinical impact of HRCT or bronchoscopy in patient management. This is obviously an important consideration. It is ultimately this potential impact that will determine whether CT or bronchoscopy or the couple are indicated in the assessment of any given patient with hemoptysis.

REFERENCE

[1] Millar AB, Boothroyd AE, Edwards D Hetzel MR The part of computed tomography (CT) in the investigation of unexplained haemoptysis. Respir M 1992; 86:39-44

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