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Care of cystic fibrosis patients with hemoptysis or pneumothorax: recommendations

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – When should cystic fibrosis patients with hemoptysis or pneumothorax be hospitalized? When should they receive antibiotics? When should a chest tube be placed for pneumothorax?

New recommendations from the Cystic Fibrosis Foundation Pulmonary Therapies Committee address these and other issues in the management of hemoptysis and pneumothorax in patients with cystic fibrosis.

“Optimal management of the pulmonary complications of cystic fibrosis can lengthen and improve the lives of individual with this disease,” lead author Dr. Patrick A. Flume of the Medical University of South Carolina in Charleston and co-authors write in their March 18 online paper in the American Journal of Respiratory and Critical Care Medicine.

There are no controlled trials to guide treatment, so the committee sought expert consensus opinion from a panel of clinicians with broad experience treating cystic fibrosis. Here is an abbreviated look at some of the topics covered and recommendations made by the panel.

HEMOPTYSIS

-Topic: When should patients with hemoptysis contact their health care provider?
-Recommendation: Patients with at least mild hemoptysis (5 mL or more) should contact their health care provider. Patients with scant hemoptysis (< 5 mL) should contact their health care provider if it is the first-ever episode or if it is persistent.

-Topic: When should the patient be admitted to the hospital?
-Recommendation: The patient with scant hemoptysis may not require admission. The patient with massive hemoptysis should always be admitted.

-Topic: When should the patient with hemoptysis be treated with antibiotics?
-Recommendation: The patient with at least mild hemoptysis should be treated with antibiotics.

-Topic: Should the patient with hemoptysis stop NSAIDs?
-Recommendation: The patient with at least mild hemoptysis should stop NSAIDs.

-Topic: Which patients should undergo bronchial artery embolization (BAE) and which studies should be performed prior to BAE?
-Recommendation: The patient with massive hemoptysis who is clinically unstable should be treated with BAE, but should not undergo bronchoscopy prior to BAE.

-Topic: Should bi-level positive airway pressure (BiPAP) be continued in patients with hemoptysis?
-Recommendation: BiPAP should not be withheld from patients with scant hemoptysis but should be withheld from patients with massive hemoptysis.

-Topic: Should the patient with hemoptysis stop airway clearance therapies?
-Recommendations: The patient with scant hemoptysis should not stop airway clearance therapies but the patient with massive hemoptysis should.

PNEUMOTHORAX

-Topic: When should the patient with pneumothorax be admitted to the hospital?
-Recommendation: The patient with a large pneumothorax should always be admitted. The patient with a small pneumothorax who is otherwise clinically stable may be closely observed in the outpatient setting.

-Topic: When should a chest tube be placed in a CF patient with pneumothorax?
-Recommendation: Patients with a large chest pneumothorax should have a chest tube placed. Patients should have a chest tube placed for a small pneumothorax if they are clinically unstable.

-Topic: When should pleurodesis be performed to prevent recurrent pneumothorax, and what is the preferred method?
-Recommendation: Pleurodesis should not be done after a first pneumothorax. The patient with a recurrent large pneumothorax should undergo pleurodesis to prevent recurrence. Surgical pleurodesis is the preferred method.

-Topic: Should patients with pneumothorax be treated with antibiotics?
-Recommendation: No recommendation could be made due to the broad range of responses.

-Topic: Should BiPAP be continued in patients with pneumothorax?
-Recommendation: BiPAP should be withheld from patients with pneumothorax as long as the pneumothorax is present.

-Topic: Should the patient with pneumothorax stop airway clearance therapies?
-Recommendation: Some airway clearance therapies, specifically positive expiratory pressure and intrapulmonary percussive ventilation, should not be used in patients with pneumothorax.

While the recommendations are designed for general use in most cystic fibrosis patients with hemoptysis and pneumothorax, they “should be adapted to meet specific needs as determined by the individuals, their families, and their health care providers,” Dr. Flume and colleagues emphasize.

They hope “that the guidelines will facilitate the appropriate application of these treatments to improve and extend the lives of all individuals with cystic fibrosis.”

Reference:
Am J Resp Crit Care Med 2010.