According to the American Thoracic Society (ATS) guidelines, how should aspergilloma be managed in asymptomatic patients versus those with frequent or massive hemoptysis, including recommendations for surgical resection, bronchial artery embolization, systemic antifungal therapy, and follow‑up imaging?

ATS Guidelines for Aspergilloma Management

Asymptomatic Patients: Observation Without Treatment

For asymptomatic aspergilloma patients without hemoptysis, observation without antifungal therapy is recommended, with follow-up imaging and clinical assessment every 3-6 months. 1

• The majority of aspergillomas do not cause life-threatening hemoptysis, so the morbidity and cost of treatment must be weighed against clinical benefit in asymptomatic cases 2
• Serial monitoring allows detection of progression before life-threatening complications develop 1
• Aspergillus-specific IgG titers should be monitored during observation, as increasing titers may indicate need for intervention even in asymptomatic patients 2

Symptomatic Patients or Those With Hemoptysis: Immediate Medical Therapy

Patients with hemoptysis or symptoms require immediate oral itraconazole 200 mg twice daily or voriconazole 200 mg every 12 hours for a minimum of 6 months, though many require prolonged or lifelong therapy. 1

• Therapeutic drug monitoring is mandatory for azole antifungals to ensure adequate levels 1
• Oral itraconazole or endobronchial/intracavitary instillation of antifungals may be useful for this condition 2
• Amphotericin B should not be used as first-line therapy due to poor penetration into cavities and should only be considered if oral agents fail or resistance develops 1

Stepwise Algorithm for Hemoptysis Management

Mild-to-Moderate Hemoptysis

• Start oral tranexamic acid for acute bleeding episodes as first-line hemostatic therapy 1
• Continue or initiate oral azole antifungal therapy, as this helps prevent recurrence of hemoptysis 3

Persistent or Massive Hemoptysis Despite Medical Management

• Bronchial artery embolization is the next step if medical management fails, with 84% immediate success rate. 4
• Embolization rarely produces permanent success but serves as an effective temporizing procedure in patients with life-threatening hemoptysis 2
• Multiple arterial sources may require embolization, including bronchial arteries (53%), intercostal arteries (22%), internal thoracic arteries (16%), inferior phrenic arteries (7%), and pulmonary arterial branches (4%) 4

Recurrent Severe Hemoptysis After Embolization

• Surgical resection should be reserved for high-risk patients with episodes of life-threatening hemoptysis who have adequate pulmonary function to undergo the operation. 2
• Surgery is definitive treatment with no recurrence of hemoptysis in follow-up, but carries significant morbidity (incomplete lung reexpansion in 71% of cases) and mortality (5.7%) 5
• Lobectomy is the most frequent operation performed, though cavernostomy is effective in high-risk patients with severe respiratory insufficiency 6, 5

Special Surgical Considerations

Surgery should be considered for specific high-risk subgroups even before life-threatening hemoptysis occurs:

• Patients with underlying sarcoidosis 2
• Immunocompromised patients 2
• Those with increasing Aspergillus-specific IgG titers 2
• Asymptomatic patients have no mortality or major complications from surgery, making early resection reasonable in low-risk surgical candidates 5

Critical Pitfalls to Avoid

• Never observe patients with hemoptysis without treatment—this is an absolute indication for immediate antifungal therapy. 1, 3
• Do not delay antifungal therapy while awaiting additional microbiological confirmation if clinical and radiographic findings are consistent with aspergilloma 1
• Do not perform routine surgical resection on all aspergillomas, as most do not cause life-threatening complications and surgery carries significant risks 2
• Do not use amphotericin B as first-line therapy given its poor cavity penetration 1
• Do not assume adequate pulmonary function for surgery without formal assessment, as 34% of patients in surgical series had severe respiratory insufficiency limiting surgical options 5

Monitoring During Treatment

• Repeat chest imaging and clinical assessment every 3-6 months to monitor treatment response 1
• Aspergillus IgG titers fall slowly with successful therapy but rarely become undetectable unless continuous therapy is given for years 1
• A sharply rising antibody titer indicates therapeutic failure or relapse and should prompt repeat testing before changing therapy to exclude laboratory error 1