Korean Clinical Imaging Guideline for Hemoptysis

Mi-Jin Kang; Jin Hwan Kim; Yoon Kyung Kim; Hyun Joo Lee; Kyung Min Shin; Jung Im Kim; Hyun Ju Lee; Kyung Hyun Do; Hwan Seok Yong; Sol Ji Choi; Miyoung Choi; Jung Im Jung

doi:10.3348/jksr.2018.78.2.81

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This article has been corrected. See "Korean Clinical Imaging Guideline for Hemoptysis" in Volume 78 on page 299.

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Kang, Kim, Kim, Lee, Shin, Kim, Lee, Do, Yong, Choi, Choi, and Jung: Korean Clinical Imaging Guideline for Hemoptysis

Review Article

J Korean Soc Radiol 2018;78(2):81-87.

Published online: 4 February 2018

DOI: https://doi.org/10.3348/jksr.2018.78.2.81

Korean Clinical Imaging Guideline for Hemoptysis

Mi-Jin Kang, MD¹, Jin Hwan Kim, MD², Yoon Kyung Kim, MD³, Hyun Joo Lee, MD⁴, Kyung Min Shin, MD⁵, Jung Im Kim, MD⁶, Hyun Ju Lee, MD⁷, Kyung Hyun Do, MD⁴, Hwan Seok Yong, MD⁸, Sol Ji Choi, MPH⁹, Miyoung Choi, RN⁹, Jung Im Jung, MD^10,^*

¹Department of Radiolgoy, InJe University Sanggye Paik Hospital, Seoul, Korea

²Department of Radiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea

³Department of Radiology, Gachon University Gil Medical Center, Incheon, Korea

⁴Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

⁵Department of Radiology, Kyungpook National University Chilgok Hospital, Daegu, Korea

⁶Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea

⁷Department of Radiology, Seoul National University Hospital, Seoul, Korea

⁸Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea

⁹Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea

¹⁰Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

^*Corresponding author: Jung Im Jung, MD Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Bandpo-daero, Seocho-gu, Seoul 06591, Korea. Tel. 82-2-2258-1435 Fax. 82-2-599-6771 E-mail: jijung@catholic.ac.kr

Received 29 June 2017 Revised 4 August 2017 Accepted 7 August 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

In 2014, the American College of Radiology announced a guideline for appropriate diagnostic approach and treatment in patients with hemoptysis, according to severity of hemoptysis and risk of lung cancer. However, in Korea many patients have pulmonary fibrosis due to previous tuberculosis or have active tuberculosis. Therefore, application of this guideline is not appropriate. The Korean Society of Radiology and Korean Society of Thoracic Radiology proposed a guideline more closely matching the real state of diagnostic approach and treatment of patients with hemoptysis in Korea. The guideline was prepared in consensus by a development committee, working party, and an advisory committee. The process of the guideline proposal was based on methodology for developing evidence-based clinical imaging guidelines: joint recommendations by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency. The clinical imaging guideline for adult patients with hemoptysis is as follows. Chest radiography is an initial imaging modality to evaluate hemoptysis. Contrast enhanced chest CT is recommended in patients with two lung cancer risks (> 40 years old and > 30 packs per year smoking history), moderate hemoptysis (> 30 cc/24 hours) or recurrent hemoptysis. Contrast enhanced chest CT is also recommended for patients with massive hemoptysis (> 400 mL/24 hours) without cardiopulmonary compromise.

Keywords: Index terms, Guideline, Hemoptysis, Radiography, Thoracic, Tomography, X-ray Computed, Evidence-Based Practice, Republic of Korea

References

1. ACR Appropriateness Criteria® hemoptysis. Available at:. https://acsearch.acr.org/docs/69449/Narrative/. Published. Aug, 2010. Accessed Jan 31, 2017.

2. Choi SJ, Jeong WK, Jo AJ, Choi JA, Kim MJ, Lee M, et al. Methodology for developing evidence-based clinical imaging guidelines: joint recommendations by Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency. Korean J Radiol. 2017; 18:208–216.

3. 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. 2006; 73:808–814.

4. Fidan A, Ozdog˘an S, Oruç O, Salepçi B, Ocal Z, Cag˘layan B. Hemoptysis: a retrospective analysis of 108 cases. Respir Med. 2002; 96:677–680.

5. Bruzzi JF, Rémy-Jardin M, Delhaye D, Teisseire A, Khalil C, Rémy J. Multi-detector row CT of hemoptysis. Radiographics. 2006; 26:3–22.

6. Lee SJ, Rho JY, Yoo SM, Kim MD, Lee JH, Kim EK, et al. Usefulness of multi-detector computed tomography before bronchoscopy and/or bronchial arterial embolization for hemoptysis. Tuberc Respir Dis. 2010; 68:80–86.

7. Revel MP, Fournier LS, Hennebicque AS, Cuenod CA, Meyer G, Reynaud P, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? AJR Am J Roentgenol. 2002; 179:1217–1224.

8. Delage A, Tillie-Leblond I, Cavestri B, Wallaert B, Marquette CH. Cryptogenic hemoptysis in chronic obstructive pulmonary disease: characteristics and outcome. Respiration. 2010; 80:387–392.

9. Menchini L, Remy-Jardin M, Faivre JB, Copin MC, Ramon P, Matran R, et al. Cryptogenic haemoptysis in smokers: angiography and results of embolisation in 35 patients. Eur Respir J. 2009; 34:1031–1039.

10. Poe RH, Israel RH, Marin MG, Ortiz CR, Dale RC, Wahl GW, et al. Utility of fiberoptic bronchoscopy in patients with hemoptysis and a nonlocalizing chest roentgenogram. Chest. 1988; 93:70–75.

11. Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin. Chest. 2001; 120:1592–1594.

12. Thirumaran M, Sundar R, Sutcliffe IM, Currie DC. Is investigation of patients with haemoptysis and normal chest radiograph justified? Thorax. 2009; 64:854–856.

13. McGuinness G, Beacher JR, Harkin TJ, Garay SM, Rom WN, Naidich DP. Hemoptysis: prospective high-resolution CT/bronchoscopic correlation. Chest. 1994; 105:1155–1162.

14. Kim HB. Bronchial artery embolization. Korean Society of Interventional Radiology. ed.Interventional radiology. 2nd ed.Seoul: Ilchokak;2014. p. 321–325.

15. Millar AB, Boothroyd AE, Edwards D, Hetzel MR. The role of computed tomography (CT) in the investigation of unexplained haemoptysis. Respir Med. 1992; 86:39–44.

16. Khalil A, Fartoukh M, Parrot A, Bazelly B, Marsault C, Carette MF. Impact of MDCT angiography on the management of patients with hemoptysis. AJR Am J Roentgenol. 2010; 195:772–778.

17. Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB. Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis. AJR Am J Roentgenol. 2001; 177:861–867.

Fig. 1.

Flow chart for literature selection. GIN = Guideline International Network, I = intervention/index test, KCIG = Korean Clinical Imaging Guidelines, NGC = National Guideline Clearinghouse, O = outcome, P = population/patient

Table 1.

AGREE II

Source of Recommendation	AGREE II Score	Proposal of Develomental Committee
ACR Appropriateness Criteria® hemoptysis.	66	Recommended

Not recommended: AGREE score < 50.

ACR = American College of Radiology, AGREE = Appraisal of Guidelines for Research & Evaluation

Table 2.

Criteria for Evidence Level of Each Evidence Literatures

Level	Content
1	Research satisfying all of criteria following three
	1) Good reference standard
	2) Consecutive patients study
	3) Blind interpretation
	Systematic review of level 1
	Randomized controlled trial or cross-sectional cohort study that compares index test to comparators
2	Research satisfying all of criteria following two
	1) Good reference standard
	2) Consecutive patients study or blind interpretation
	Systematic review of level 2
	Observational studies that compares index test to comparators
3	Without consistently applied reference standards
4	Case-control study
	Poor or non-independent reference standard
5	Expert opinion

Adated from Choi SJ et al. Korean J Radiol 2017;18:208–216 (2)

Table 3.

Grades of Korean Clinical Imaging Guidelines Recommendation

Grading	Content	Meaning
A	Recommended	This intervention (examination) has enough evidence to support desired effect, and therefore, is recommended
B	(Conditional) recommended	This intervention (examination) has intermediate to enough level of evidence to support desired effect
		Provide intervention (examination) selectively, or for specific individuals based on expert's judgment
C	Not recommended	This intervention (examination) has enough evidence to support non-desired effect, and therefore,
		is not recommended (use of this examination is not recommended)
D	No recommendation	This intervention (examination) does not have enough evidence to either support or reject effectiveness, and
		needs further research
		This intervention (examination) has very low level of certainty for desired effect, and decision based on recommendation grading has no meaning

Adated from Choi SJ et al. Korean J Radiol 2017;18:208–216 (2)

Table 4.

Korean Relative Radiation Level

Supplementary Table 1

Evidence Table

Literatures	Research Type	Number of Enrolled Patients	Evidence Level
Tsoumakidou M, Chrysofakis G, Tsiligianni I, Maltezakis G, Siafakas NM, Tzanakis N.	Observational (retrospective)_Dx	184	2
A prospective analysis of 184 hemoptysis cases: diagnostic impact of chest X-ray,
computed tomography, bronchoscopy. Respiration 2006;73(6):808–814.
Fidan A, Ozdog˘an S, Oruç O, Salepçi B, Ocal Z, Cag˘layan B. Hemoptysis:	Observational (prospective)_Dx	108	2
a retrospective analysis of 108 cases. Respir Med 2002;96(9):677–680.
Bruzzi JF, Rémy-Jardin M, Delhaye D, Teisseire A, Khalil C, Rémy J.	Review/other-Dx	N/A	2
Multi-detector row CT of hemoptysis. Radiographics 2006;26(1):3–22.
Ketai LH, Mohammed TL, Kirsch J, et al. ACR appropriateness criteria® hemoptysis.	Review/other-Dx	N/A	2
J Thorac Imaging 2014;29(3):W19-W22.
Lee SJ, Rho JY, Yoo SM, et al. Usefulness of multi-detector computed tomography	Observational (prospective)_Dx	125	2
before bronchoscopy and/or bronchial arterial embolization for hemoptysis.
Tuberc Respir Dis 2010;68(2):80–86.
Revel MP, Fournier LS, Hennebicque AS, et al. Can CT replace bronchoscopy in the	Observational-Dx	80	3
detection of the site and cause of bleeding in patients with large or massive
hemoptysis? AJR Am J Roentgenol 2002;179(5):1217–1224.
Delage A, Tillie-Leblond I, Cavestri B, Wallaert B, Marquette CH. Cryptogenic	Observational-Dx	39	3
hemoptysis in chronic obstructive pulmonary disease: characteristics
and outcome. Respiration 2010;80(5):387–392.
Menchini L, Remy-Jardin M, Faivre JB, et al. Cryptogenic haemoptysis in smokers:	Observational-Dx	35	3
angiography and results of embolisation in 35 patients. Eur Respir J 2009;34(5):
1031–1039.
Poe RH, Israel RH, Marin MG, et al. Utility of fiberoptic bronchoscopy in patients	Observational-Dx	196	4
with hemoptysis and a nonlocalizing chest roentgenogram. Chest 1988;93(1):
70–75.
Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence	Review/other-Dx	722	4
in patients with hemoptysis of unknown origin. Chest 2001;120(5):1592–1594.
Thirumaran M, Sundar R, Sutcliffe IM, Currie DC. Is investigation of patients with	Observational-Dx	270	2
haemoptysis and normal chest radiograph justified? Thorax 2009;64(10):854–856.
McGuinness G, Beacher JR, Harkin TJ, Garay SM, Rom WN, Naidich DP.	Observational-Dx	57	2
Hemoptysis: prospective high-resolution CT/bronchoscopic correlation.
Chest 1994;105(4):1155–1162.
Millar AB, Boothroyd AE, Edwards D, Hetzel MR. The role of computed	Review/other-Dx	40	4
tomography (CT) in the investigation of unexplained haemoptysis. Respir Med
1992;86(1):39–44.
Khalil A, Fartoukh M, Parrot A, Bazelly B, Marsault C, Carette MF. Impact of MDCT	Observational-Dx	400	3
angiography on the management of patients with hemoptysis. AJR Am J
Roentgenol 2010;195(3):772–778.
Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB.	Review/other-Dx	28	3
Utility of fiberoptic bronchoscopy before bronchial artery embolization for
massive hemoptysis. AJR Am J Roentgenol 2001;177(4):861–867.

Dx = diagnosis

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