Which Is the Best Way to Treat Massive Hemoptysis? A Systematic Review and Meta-Analysis of Observational Studies

Abstract

Introduction: Hemoptysis is one of the most common symptoms of respiratory system diseases. Common causes include bronchiectasis, tumors, tuberculosis, aspergilloma, and cystic fibrosis. The severity of hemoptysis varies from mild to moderate to massive hemoptysis and can easily lead to hemodynamic instability and death from suffocation or shock. Nevertheless, the most threatening hemoptysis that is presented to the emergency department and requires hospitalization is the massive one. In these cases, today, the most common way to manage hemoptysis is bronchial artery embolization (BAE).

Methods: A systematic literature search was conducted in PubMed and Scopus from January 2017 (with the aim of selecting the newest possible reports in the literature) until May 2023 for studies reporting massive hemoptysis. All studies that included technical and clinical success rates of hemoptysis management, as well as rebleeding and mortality rates, were included. A proportional meta-analysis was conducted using a random-effects model.

Results: Of the 30 studies included in this systematic review, 26 used bronchial artery embolization as a means of treating hemoptysis, with very high levels of both technical and clinical success (greater than 73.7% and 84.2%, respectively). However, in cases where it was not possible to use bronchial artery embolization, alternative methods were used, such as dual-vessel intervention (80% technical success rate and 66.7% clinical success rate), customized endobronchial silicone blockers (92.3% technical success rate and 92.3% clinical success rate), antifibrinolytic agents (50% clinical success rate), and percutaneous transthoracic embolization (93.1% technical success rate and 88.9% clinical success rate), which all had high success rates apart from antifibrinolytic agents. Of the 2467 patients included in these studies, 341 experienced rebleeding during the follow-up period, while 354 other complications occurred, including chest discomfort, fever, dysphagia, and paresis. A total of 89 patients died after an episode of massive hemoptysis or during the follow-up period. The results of the meta-analysis showed a pooled technical success of bronchial artery embolization equal to 97.22% and a pooled clinical success equal to 92.46%. The pooled recurrence was calculated to be 21.46%, while the mortality was 3.5%. These results confirm the ability of bronchial artery embolization in the treatment of massive hemoptysis but also emphasize the high rate of recurrence following the intervention, as well as the risk of death.

Conclusion: In conclusion, massive hemoptysis can be treated with great clinical and technical success using bronchial artery embolization, reducing mortality. Mortality has now been reduced to a small percentage of cases.

Keywords: bronchial artery embolization; management; massive hemoptysis; meta-analysis; systematic review.

Figure 1

PRISMA 2020 flow chart. This diagram illustrates the process followed for the collection and selection of studies used in our systematic review.

Figure 2

Etiology of massive hemoptysis.

Figure 3

Forest plot for technical success [45,47,49,50,53,54,56,57,59,60,61,62,63,64,66,67,68,70,72,74].

Figure 4

Funnel plot for technical success.

Figure 5

Forest plot for clinical success [45,46,47,48,49,50,51,53,54,56,57,59,60,61,62,63,66,67,68,69,71,72,74].

Figure 6

Funnel plot for clinical success.

Figure 7

Forest plot for recurrence [46,47,48,49,50,51,52,54,56,59,60,62,63,64,66,67,68,69,70,71,72,74].

Figure 8

Regression test for funnel plot asymmetry. Significant asymmetry was observed (p = 0.0246).

Figure 9

Forest plot for mortality [45,47,49,50,51,52,54,56,59,60,61,62,63,64,66,68,69,70,71,72,74].

Figure 10

Funnel plot for mortality.