A bleeding problem in lung cancer patients.

“Death has a hundred hands and walks by a thousand ways”, stated T.S. Eliot [1]. In lung cancer patients, severe haemoptysis is arguably the most terrifying of these [2]. Although definitions of severe haemoptysis are somewhat variable, all refer to an amount and rate of bleeding from the respiratory tract that overwhelm the patient’s capacity to clear the airways of blood and sustain respiratory and haemodynamic stability, thus directly jeopardising survival [3]. The expectoration of quantities of blood exceeding 100–200 mL, which is a traumatic experience in itself, may lead to asphyxiation in the absence of prompt interventions to maintain a free airway, support ventilation and halt further bleeding. Towards these aims, a coordinated and streamlined effort by pulmonologists, emergency and critical care physicians, (interventional) radiologists, and thoracic surgeons is needed. However, when severe haemoptysis occurs in the context of a known pulmonary malignancy, it is usually seen as the harbinger of a grim prognosis [4, 5]. As such, physicians may doubt whether an aggressive pursuit of stabilisation, including airway intubation, mechanical ventilation, and a series of diagnostic and therapeutic interventions, is to be preferred instead of a mere relief of anxiety and distress by urgent sedation. Traditionally, lung cancer patients have been considered poor candidates for intensive care unit (ICU) admission in cases of life-threatening emergencies because of a perceived dismal outcome. However, with advances in oncological and supportive therapies in lung cancer patients, including those with nonresectable non-small cell lung cancer (NSCLC), increasing numbers of them are being referred to the ICU, and their survival has been improving [7, 8]. In a large, multinational study conducted in 2011, lung cancer patients accounted for 3.5% of all ICU admissions and their hospital survival was 61% [8]. As lung cancer patients are a relatively new category of ICU patients, treatment algorithms for guidance of diagnostics and empirical therapy are in the process of development [9]. No recent studies have provided details on cancer patients with haemoptysis as a reason for ICU referral. The report by RAZAZI et al. [10] on the characteristics and outcome of 125 NSCLC patients with severe haemoptysis treated in their tertiary referral centre in Paris, France, in this issue of European Respiratory Journal is, therefore, a significant addition to the literature.