Certain Factors Could Predict Severe Episodes of Coughing Up Blood in CF Patients, Study Says

Factors such as diabetes, a specific type of fungal infection, and previous mild to moderate episodes of hemoptysis, or coughing up blood, may help predict the risk of massive hemoptysis in people with cystic fibrosis (CF), a study suggests.

The study, “Predictors of massive haemoptysis after a first episode of mild-to-moderate haemoptysis in patients with cystic fibrosis,” was published in the European Respiratory Journal.

Older age, advanced lung disease, Pseudomonas aeruginosa lung infections, CF-related diabetes, portal hypertension (high blood pressure in the liver’s portal vein), and liver cirrhosis have all been described as risk factors for hemoptysis in CF.

But it is still unclear which factors could predict the development of massive hemoptysis in CF patients who have experienced mild or moderate episodes in the past.

To investigate which factors could lead to massive hemoptysis, a group of researchers in France did a retrospective analysis of the clinical data of all adult CF patients followed at the Lille CF Centre between 2008 and 2018, who had a history of at least one mild to moderate hemoptysis episode.

Massive hemoptysis was defined as a volume of coughed blood greater than 240 mL in 24 hours, or more than 100 mL over two or more days. Coughed blood leading to airway obstruction or changes in blood flow was also considered a symptom of massive hemoptysis.

Mild to moderate hemoptysis was defined as an episode resulting in a volume of coughed blood between 5 and 240 mL.

The team analyzed a total of 85 CF patients, 23 of whom were excluded because of missing follow-up data. The remaining 62 patients were included and followed for a median of 73 months until they experienced massive hemoptysis or until the end of the follow-up period (132 months, or about 11 years).

During follow-up, 15 patients (24.2%) experienced massive hemoptysis. Three of them (20%) died due to this serious event. No deaths were registered among the 47 patients who did not experience massive hemoptysis.

Allergic bronchopulmonary aspergillosis (ABPA), CF-related diabetes, and treatment with triazoles (a group of antifungal medications) were all found to be significantly associated with subsequent massive hemoptysis.

ABPA is caused by a fungus called Aspergillus, which invades the airways of CF patients and causes an allergic reaction. ABPA is a frequent complication in adults with CF, linked to poorer outcomes. Triazole is an antifungal treatment that helps manage ABPA.

Overall, 21 patients had ABPA: nine of the 15 patients who had massive hemoptysis (60%) and 12 of the 47 (25.5%) patients without massive haemoptysis.

Treatment with triazole was prescribed to 15 of the 21 patients with ABPA, of whom six had massive hemoptysis and nine did not, suggesting the therapy had no real impact on preventing massive hemoptysis, according to the team.

Diabetes was more common among patients who experienced massive hemoptysis — 33.3% (five patients), compared with 2.1%, or one patient, without this complication.

Massive hemoptysis occurred in four of five patients with liver cirrhosis and three of four with thrombocytopenia (low platelet levels). However, the small number of patients did not allow statistical analysis to be performed and establish potential correlations.

Recurrence of mild to moderate hemoptysis was more frequent among patients who experienced massive hemoptysis — a recurrence rate of of 16.5 per 100 patient-months — compared with 5.9 per 100 patient-months in those without it.

To manage massive hemoptysis, 11 patients (73.3%) received terlipressin, an anti-hemorrhagic therapy; 11 patients (73.3%) underwent bronchial artery embolization; and nine (60%) received both treatments. Bronchial artery embolization is a minimally invasive procedure that uses a catheter to clot the bronchial artery to stop the bleeding. Bronchial arteries are the major supply vessels of oxygenated blood to the lungs.

These findings suggest that “ABPA, metabolic disorders and recurrent mild-to-moderate haemoptysis may predict MH [massive hemoptysis] occurrence in CF patients with at least one mild-to-moderate haemoptysis episode” in the past, the researchers wrote.

“Whether optimal management of these events would help to reduce the risk of MH remains to be determined,” they added.