Hemoptysis is defined as bleeding from the respiratory organs below the larynx, which is expelled from the mouth by coughing action. Hemoptysis must first be differentiated from oral, pharyngeal, and nasal bleeding. Bleeding from the oral cavity and pharynx are easily observed as localized foci of hemorrhage. Nasal bleeding mostly flows from the anterior nostrils, and the foci of bleeding are often found below the anterior nasal septum, which makes the diagnosis easier. Sometimes the posterior nasal bleeding is large and can be misdiagnosed as hemoptysis. Massive hemoptysis must also be distinguished from hematemesis (upper gastrointestinal bleeding). The former often has a history of tuberculosis, bronchiectasis, lung cancer, heart disease, etc. Before bleeding, there is a cough, throat itching, chest tightness, hemoptysis of blood is bright red, mixed with foamy sputum, usually no tar-like stool; the latter often has a history of peptic ulcer, cirrhosis, etc. Before bleeding, there is epigastric discomfort, nausea, vomiting and other symptoms, vomiting blood is brown-black or dark red, sometimes bright red, mixed with food residues, gastric juice, with tarry stools, which may persist for several days after the vomiting stops.
Hemoptysis is a bright red bleeding through the mouth, containing foam or mixed with sputum, and can be pure blood at the beginning, or dark red blood clots at the end. Hemoptysis should be distinguished from vomiting, which is bleeding from the upper gastrointestinal tract, vomiting through the mouth, mostly caused by diseases of the esophagus, stomach, duodenum, liver, gallbladder and pancreas. In addition, oral and nasal bleeding also flows from the oral cavity, and sometimes the bleeding from the posterior part of the nose is more easily misdiagnosed as hemoptysis, so attention should be paid to differentiation.
Hemoptysis often has a history of respiratory disease and heart disease, and is bright red, foamy, mixed with sputum, accompanied by a tickling sensation in the throat, coughing, and difficulty in breathing. Blood in the sputum appears several days after hemoptysis.
Vomiting blood often has a history of stomach or liver disease, with dark red or coffee-colored blood, mixed with food, nausea, vomiting, abdominal discomfort, and black stools.
I. Etiology of hemoptysis
1. Bronchial disorders: chronic bronchitis, bronchiectasis, bronchial endotracheal tuberculosis, primary bronchial lung cancer.
2. Pulmonary disorders: tuberculosis, pneumonia, lung abscess, pulmonary fungal disease, pulmonary parasitic disease, pulmonary cysts, pneumoconiosis.
3, cardiovascular disease: rheumatic heart disease (mitral stenosis), pulmonary stasis, pulmonary edema, pulmonary hypertension, pulmonary infarction.
4.Lung metastasis of malignant tumors: the main malignant tumors causing lung metastasis are: nasopharyngeal cancer, breast cancer, esophageal cancer, gastric cancer, liver cancer, colon cancer, prostate cancer, testicular teratoma, seminoma, chorioepithelial cancer, malignant staphyloma and carcinoid tumor.
5. Systemic diseases and other causes: epidemic hemorrhagic fever, hematological diseases (leukemia, aplastic anemia, hemophilia, thrombocytopenia), rheumatic diseases (leukoaraiosis, systemic lupus erythematosus), nodular disease, pulmonary hemorrhage-nephritis syndrome, alternative menstruation, trauma (violence, sharp instruments, instrumentation, surgery and other injuries)
II. Characteristics of hemoptysis
1. Age and gender: chronic cough and small amount of hemoptysis with anemia in children should be noted for idiopathic iron-containing hemoptysis; hemoptysis in young adults is mostly seen in tuberculosis, bronchiectasis and other diseases; hemoptysis in middle age and above should be alerted to the possibility of lung cancer; if hemoptysis in women is closely related to the menstrual period and occurs several days before menstruation, it may be alternative menstruation.
2. Number of hemoptysis: the first hemoptysis is usually seen in lung infections such as pneumonia and lung abscess; repeated hemoptysis is seen in chronic bronchitis, tuberculosis, bronchiectasis, bronchopulmonary cancer, chronic pulmonary stasis (chronic cardiac insufficiency), etc.
3, hemoptysis volume: daily hemoptysis volume below 100 ml (50 ml is 1 tael) is small hemoptysis, 100-500 ml is medium hemoptysis, and above 500 ml is large hemoptysis. Small amount of hemoptysis or blood in sputum is seen in tuberculosis, pneumoconiosis, pneumonia; large amount of hemoptysis is seen in severe tuberculosis, bronchiectasis, bronchopulmonary cancer, pulmonary hypertension.
4.Concomitant symptoms: fever and chest pain are seen in pneumonia and pulmonary infarction; large amount of pus sputum is seen in lung abscess and bronchial dilation; choking cough is seen in bronchial cancer; paroxysmal severe cough, wheezing and paroxysmal dyspnea are seen in endobronchial tuberculosis; low fever, night sweats, weight loss and fatigue are seen in tuberculosis; anemia and bleeding from other parts are seen in hematological disease; multiple organ damage (especially The presence of multiple organ damage (especially those with arthritic manifestations and nephritis) is considered to be rheumatic diseases (systemic lupus erythematosus, nodular arteritis). With irregular vaginal bleeding and discharge of blister-like fetal mass, consider staphylococcal lung metastasis.
5. Other: If hemoptysis occurs in a person with previous history of bronchiectasis, tuberculosis or heart disease, consideration should be given to whether the original disease is aggravated. If you have a smoking habit, you should consider whether years of smoking is related to the development of lung cancer; if you have a history of raw crabs and mayflies, you should consider whether it is related to the development of pulmonary parasitosis (pulmonary schistosomiasis); female patients should pay attention to their menstrual history and whether it is related to alternative menstruation.
Third, choose the registered department
1.Pulmonary infarction is considered when a patient has previous history of thrombophlebitis, venous thrombosis or persistent atrial fibrillation, and sudden onset of dyspnea, chest pain, cyanosis, fever, cough and hemoptysis. Emergency call “120” or emergency respiratory medicine department should be called.
2. Chronic cough, purulent sputum, large amount of sputum, repeated hemoptysis, sometimes large amount of hemoptysis. If you are prone to recurrent infections and have a long course of illness, consider bronchiectasis. In case of bronchiectasis haemoptysis, call “120” or the emergency respiratory medicine department.
3.Long-term chronic cough, sputum or wheezing with small amount of hemoptysis or blood in the sputum, which is more frequent in autumn and winter every year, consider chronic bronchitis.
4. Paroxysmal violent cough, croup, with paroxysmal dyspnea, recurrent small amount of hemoptysis or blood sputum, often with weight loss, consider endobronchial tuberculosis.
5.A history of long-term smoking, irritating cough, hemoptysis (small amount of hemoptysis or large amount of hemoptysis), chest tightness, shortness of breath, irregular fever, wasting, recurrent episodes of pneumonia at the same – site or the appearance of hoarseness – some symptoms, consider bronchial lung cancer (primary lung cancer).
6, chronic onset, long duration, low fever, fatigue, weight loss, night sweats, cough, hemoptysis (the amount of hemoptysis can be more or less), consider tuberculosis.
7.If the disease starts rapidly, with high fever, chills, cough, chest pain, coughing rust-colored sputum or small amount of hemoptysis, pneumonia is considered.
8.Chills, high fever, cough, chest pain, depression, weakness, gradually increasing sputum, mucopurulent sputum with odor, accompanied by different degrees of hemoptysis, consider lung abscess. (All of the above are respiratory diseases, just hang up the number of respiratory medicine when visiting the clinic).
9. If you have previous history of malignant tumors (such as nasopharyngeal cancer, breast cancer, esophageal cancer, stomach cancer, liver cancer, colon cancer, rectal cancer, prostate cancer, testicular teratoma, seminoma, choriocarcinoma, malignant staphyloma and carcinoid tumor, etc.) and have cough and hemoptysis, you should be highly alert to lung metastasis of malignant tumors. The above cases should be registered with the Thoracic Surgery Department. For adult women with unexplained hemoptysis, patients with vaginal discharge of blister-like fetal mass or continuous irregular vaginal bleeding after miscarriage should consider the possibility of malignant staphyloma or chorioepithelial carcinoma. You can register for gynecology.
10. Young and middle-aged people with a history of rheumatic heart disease, dyspnea, cough and hemoptysis should consider rheumatic heart disease, mitral valve stenosis and pulmonary stasis. You can register for cardiology.
11, engaged in mining and other occupations, long-term exposure to dust, chronic cough, shortness of breath, chest pain, sputum gradually increased and accompanied by hemoptysis, while suffering from tuberculosis, consider pneumoconiosis. This is – class occupational disease, can go to the professional occupational disease control or respiratory medicine consultation.
12.History of previous blood diseases (such as leukemia, aplastic anemia, thrombocytopenia, etc.) with pulmonary symptoms, hemoptysis, along with bleeding from other parts of the body, should be considered as a result of the primary disease, and can still be seen in the hematology department.
13.If the onset of the disease is rapid, with high fever, chills, depression, flushing, conjunctival congestion, eyelid edema, with obvious bleeding tendency (skin and mucous membrane bleeding, blood in urine, hemoptysis), accompanied by renal function impairment, while there is a local epidemiological history and in the good season of epidemic hemorrhagic fever (May-June, October-November), epidemic hemorrhagic fever should be considered. It can be seen at an infectious disease hospital and should be reported to the local epidemic prevention department.
14.If it is a female with symptoms of multi-system damage with hemoptysis, after several consultations, symptomatic and antibiotic treatment with poor results, the possibility of hemoptysis due to rheumatic diseases (systemic lupus erythematosus, polyarteritis nodosa) should be considered, and a visit to the immuno-rheumatology department may have unexpected results.
15. In case of young men with intermittent hemoptysis, dyspnea, chest pain, progressive renal damage (proteinuria, hematuria, tubuluria and renal failure), pulmonary hemorrhage and nephritis syndrome should be considered. It can be seen in the department of nephrology.
Four, may need to do auxiliary examination
1. X-ray examination: X-ray examination should be done for every patient with hemoptysis. If X-ray fluoroscopy fails to confirm the diagnosis, a chest plain film should be done. It is not uncommon to find clinical cases of hemoptysis without abnormal x-ray signs, the main reasons for which are as follows.
(1) Nonspecific ulceration of the trachea and main bronchus, usually manifested as a small amount of hemoptysis or hematochezia.
(2) Venous straining of the trachea or bronchi, mostly at the opening of the right upper lobe bronchus, often causing hemoptysis without sputum.
(3) Pulmonary aneurysm, rupture of small bronchial arteriosclerosis, rupture of pulmonary arteriovenous fistula
(4) Small pulmonary infarcts are often not easily detected, usually with a history of heart disease, venous thrombosis, trauma, or puerperium.
(5) Hookworm larvae, Ascaris larvae, and schistosome larvae migrate into the lungs and cause hemoptysis.
(6) Early bronchial tumor, mild bronchiectasis, endobronchial tuberculosis, pulmonary tuberculosis, etc. Therefore, those who are not found to have abnormalities in chest X-ray examination should be further examined in conjunction with clinical examination.
2.Bronchoscopy: Bronchoscopy should be considered for unexplained hemoptysis or bronchial obstruction, which can reveal non-specific ulcers of tracheal and bronchial mucosa, submucosal varices, tuberculosis lesions, tumors and other lesions, and pathological examination can be done under direct vision.
3.CT examination of the chest: For hemoptysis of unknown origin, CT examination should be done when X-ray examination cannot provide a diagnosis.
4.Laboratory examinations.
(1) Sputum: Bacteriological examination of sputum can be done for suspected inflammatory lung diseases, and pneumonia and lung abscess caused by various pathogenic bacteria can be found; antacid bacillus examination can be done for suspected tuberculosis; pathological examination of sputum can be done for suspected lung cancer to find cancer cells; sputum smear can be done for suspected trematode disease to find lung trematode eggs.
(2) Routine blood tests: Hemoglobin measurement can infer the degree of bleeding and determine the cause of hemoptysis. Decreased platelets are seen in primary and secondary thrombocytopenia; eosinophilia can be considered as parasitic disease.
(3) Suspected bleeding disorders: bleeding time, clotting time, platelet count, and prothrombin time can be measured.
(4) Other laboratory tests: immunological tests such as antinuclear antibodies, plasma protein electrophoresis, immunoglobulin determination, etc. can be done for suspected rheumatic diseases.
(5) Other ancillary tests: electrocardiogram, echocardiogram and cardiac catheterization may be performed for hemoptysis suspected to be caused by cardiovascular disease.