Massive haemoptysis: the definition should be revised.

We thank L. Mascitelli and colleagues for their interesting comments about the role of the renin–angiotensin system in severe chronic obstructive pulmonary disease. Our review [1] was intended to provide guidance on current established therapies rather than consider potential future treatment options and hence we did not include a comment relevant to this interesting but, as yet, unproven treatment approach. The only data we are aware of that directly addresses this were published recently in the European Respiratory Journal and did not find improvements in pre-specified outcomes after blockade of the renin–angiotensin system [2]. This does not preclude a role for this system in some settings in chronic obstructive pulmonary disease; however, it did make us cautious about commenting specifically on the role of these drugs in a review of current disease management. Massive haemoptysis represents one of the most challenging conditions in clinical practice. The condition is potentially lethal and, therefore, warrants clear understanding and precise definition. The definition of massive haemoptysis has not been completely agreed upon and varies widely in the literature. It is unfortunate that almost all previous definitions of massive haemoptysis relied only on the volume of expectorated blood. The use of expectorated blood volume alone to define massive haemoptysis is often misleading and confusing for three main reasons. First, no cutoff volume has been agreed upon in the literature. While AMIRANA et al. [1] proposed an amount of 100 mL of expectorated blood in 24 h to define massive haemoptysis, COREY and HLA [2] defined massive haemoptysis as expectoration of o1,000 mL of blood over 24 h. In the middle of the spectrum we find other studies that use 200 mL [3], 240 mL [4], 500 mL [5] or 600 mL [6] as a cutoff volume for the definition of massive haemoptysis. Secondly, in real practice, the quantification of haemoptysis is often difficult and, from a clinical point of view, such criteria are not useful [7]. In many instances the amount of expectorated blood may be exaggerated by patients. Furthermore, in a majority of patients, quantifica-tion of expectorated blood volume may underestimate the overall amount of blood loss because the volume of blood engulfing the involved lobes or lungs is not quantified and may be significant [8]. Thirdly, morbidity and mortality in patients with haemoptysis depend on not only the volume of expecto-rated blood but also the rate of bleeding, the ability of the …