Bronchoscopy is the initial procedure of choice for localizing the source of bleeding and enables the physician to choose between the various therapeutic options available. The timing of this procedure in massive hemoptysis has been somewhat controversial, but it is generally accepted that bronchoscopy during active bleeding significantly enhances the likelihood of diagnostic localization ( SierDbach and Varon 1995). Because blood is distributed throughout the tracheobronchial tree, visualization of active bleeding, rather than clot, is essential for definite identification.

In the past, rigid bronchoscopy was advocated as the procedure of choice. Its advantages include improved suctioning capability, continuous airway control, and a larger lumen to clear the airway of large clots and debris as well as to introduce packing materials. However, the rigid instrument has a reduced visual range compared with the flexible bronchoscope; it also requires general anesthesia and so the procedure must be performed in the operation room. Generally, however, the patient needs immediate securing of the airways and cannot wait for the operation room to be prepared. Furthermore, widespread use of the rigid bronchoscope is declining, as fewer institutions currently provide training in this technique.

The flexible bronchoscope has an extensive visual range and possesses increased ability to visualize the upper-lobe bronchial orifices, a preferential bleeding site in hemoptysis. The flexible bronchoscope is tolerated more readily and for longer periods than the rigid instrument. Moreover, flexible bronchoscopy is a technique that can be performed under local anesthesia at the bedside. The drawbacks of flexible bronchoscopy include limited suctioning capacity and the ease with which the fiber-optic tip can become obscured by blood.

For all these reasons, patients are increasingly being investigated by flexible bronchoscopy, with or without intubation. On occasion, the two procedures can be used in combination, with passage of the flexible bronchoscope through the rigid instrument.

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