What is the next step to confirm diagnosis in a 20-year-old male presenting with significant hemoptysis (expectoration of 700 milliliters of blood) and a chest radiograph showing a cavitary lesion in the upper lung?

From the Guidelines

The best approach to confirm the diagnosis in this case is bronchoscopy under general anesthesia with adrenaline injection (option C), as it allows both diagnostic evaluation and immediate therapeutic intervention to control the bleeding. For a 20-year-old patient with massive hemoptysis (700 ml) and a cavitary lesion in the upper lung, bronchoscopy with therapeutic intervention is indicated 1. This procedure enables direct visualization of the bleeding source, collection of samples for microbiological and pathological examination, and immediate hemostasis through adrenaline injection. The cavitary lesion in a young adult suggests possibilities like tuberculosis, fungal infection, malignancy, or vasculitis, which can be better characterized through bronchoscopic sampling. While CT would provide detailed imaging, it doesn't offer therapeutic options for active bleeding, although it can be useful in identifying the cause of bleeding in a high percentage of cases 1. Thoracotomy is too invasive as an initial diagnostic approach and should be reserved for cases where less invasive methods fail or are contraindicated. Some studies have shown that CT with IV contrast is the primary modality to determine hemoptysis etiology, especially in nonmassive hemoptysis 1, but in this case, with active bleeding, bronchoscopy is the preferred initial approach. The utility of CT in determining the cause for hemoptysis has been established, but it is not the best initial choice for a patient with massive hemoptysis and active bleeding 1. In terms of morbidity, mortality, and quality of life, the priority is to control the bleeding and diagnose the underlying cause, making bronchoscopy under general anesthesia with adrenaline injection the most appropriate initial approach. Key points to consider include:

• The patient's age and presentation suggest a possible infectious or inflammatory cause for the hemoptysis
• The cavitary lesion in the upper lung requires further characterization through bronchoscopic sampling
• The need for immediate therapeutic intervention to control the bleeding makes bronchoscopy the preferred initial approach
• CT with IV contrast can be useful in identifying the cause of bleeding, but it is not the best initial choice for a patient with massive hemoptysis and active bleeding.

From the Research

Diagnostic Approach

To confirm the diagnosis of a 20-year-old boy presenting with hemoptysis and a cavitary lesion in the upper lung, the following steps can be considered:

• The patient has already undergone a chest radiograph, which showed a cavitary lesion in the upper lung, but the side is not specified.
• Given the severity of the hemoptysis (700 ml of blood), further diagnostic testing is necessary to determine the etiology of the bleeding.

Recommended Diagnostic Tests

The following diagnostic tests can be considered:

• Computed Tomography (CT) scan: CT and CT angiography of the chest with intravenous contrast are the preferred modalities to determine the etiology of bleeding, as stated in the study by 2.
• Bronchoscopy: Bronchoscopy may be needed to identify the source of bleeding and to protect the airway, as mentioned in the study by 2. However, the use of bronchoscopy under general anesthesia (GA) or with adrenaline injection is not explicitly recommended in the provided studies for initial diagnosis.

Rationale for Test Selection

The selection of diagnostic tests is based on the following rationale:

• CT scan is preferred due to its high sensitivity in determining the site and etiology of bleeding, as stated in the study by 2.
• Bronchoscopy may be necessary in some cases, but its use should be guided by the patient's clinical condition and the results of other diagnostic tests.

Other Considerations

Other considerations in the diagnosis and management of hemoptysis include:

• Dual-vessel intervention: In cases of massive hemoptysis caused by cavitary lung lesions, dual-vessel intervention, including bronchial or pulmonary arterial embolization, may be effective, as reported in the study by 3.
• Underlying causes: The management of hemoptysis should include treatment of the underlying etiology, as stated in the study by 2. The underlying causes of cavitary lesions can vary, including infections such as Streptococcus pyogenes, as reported in the study by 4.