I. Hemoptysis Overview There are nearly 100 known diseases that cause hemoptysis, and bronchial lung cancer is one of the most common causes. Hemoptysis is defined as a hemoptysis of more than 100 ml at one time or more than 600 ml in 24 h. Patients mainly present with hypovolemia and airway obstruction: pale face, rapid pulse, low urine output, profuse sweating, irritability, dyspnea, and asphyxia. Chen Enguo, Department of Respiratory Medicine, Run Run Shaw Hospital, Zhejiang University School of Medicine Treatment plan and principles: 1. Pre-hospital emergency (1) Comfort the patient, reduce his fear and anxiety, keep the patient quiet and actively cooperate with treatment. (2) Let the patient take a lateral position with the affected side down and the healthy side up to prevent misaspiration and airway obstruction caused by blood entering the healthy side of the bronchus and keep the airway of one lung open. For patients with bilateral hemorrhage or those who cannot determine the site of hemorrhage, adopt a prone position with the head low and feet high, or place the head in a drooping position on the side of the bed to facilitate the discharge of blood. (3) For patients with sudden cessation of hemoptysis, irritability, throat rattling, inability to pronounce, hands clutching, eyes staring, mouth open, sweating, horrible and dull expression, general cyanosis, incontinence of stool and respiratory arrest, immediately invert the patient or let the patient’s torso hang upside down from the bed while another person taps on the back to remove the asphyxiated blood clot. You can also pry open the teeth, put in the dental pad, reach into the fingers, take the blood clots in the mouth, throat and larynx cavity, and then do artificial respiration. (4) According to the local situation at that time, give hemostatic drugs, establish intravenous access, oxygen, tracheal intubation and tracheotomy for sputum, and remove blood clots, etc. Units without treatment conditions should transfer the patient to the nearest hospital with conditions for treatment as soon as possible. En route, the patient should be kept stable and prevented from violent shocks and bumps. 2. Treatment after admission (1) Give the patient oxygen, sedation, cough, establish intravenous access, and give rehydration and hemostatic drugs. Commonly used hemostatic drugs are: posterior pituitary gland: 5-10U + 25% glucose solution 20-40ml, 10-15min intravenous injection finished Hua. Or posterior pituitary 10-20U + 5% glucose 250-500ml static point; repeat after 6-8h. The purpose is to make the small pulmonary arteries contract, intrapulmonary blood flow decreases, and pulmonary circulation pressure decreases. However, it should be used with caution or not for patients with hypertension, coronary artery disease, atherosclerosis, pulmonary heart disease, heart failure and pregnancy. Pay attention to the patient’s reaction during administration. Slow down the drip rate or discontinue it if the patient has headache, sweating, palpitation, abdominal pain, constipation or sudden rise in blood pressure. General hemostatic drugs: 6 amino acetic acid (EACA): 6g+5％ glucose solution 250ml, IV. Hemostatic aromatic acid (PAMBA): 0.1~0.2g+5％ glucose solution 250ml, intravenous. Hemostatic: 0.25g~0.75g+5％ glucose solution 500ml, static. Lipitor (Reptilase) 1 to 2KU, intramuscular injection, etc. (2) Perform intensive care. At the time of admission, the patient was hemoptysis, life was in a critical state, and even asphyxia and respiratory arrest had occurred. At this point, we must race against time to immediately relieve asphyxia and stop the bleeding, otherwise the patient will die quickly. Emergency tracheal intubation and rapid removal of intra-tracheal clots with a thick suction tube. The uncooperative patient should be given appropriate sedation and anesthesia, and if necessary, general anesthesia. Emergency tracheotomy or cricothyrotomy can be done if necessary. Aspiration of the clot with a suction device through a subsonic tracheostomy. For unilateral lung and unilateral bronchial hemorrhage, a right-type double-lumen bronchial cannula can be used to separate the left and right sides, although one lung and bronchus may be flooded with blood and cause misaspiration; however, the other lung and bronchus remain open, so that time can be bought to stop the hemorrhage by surgery or bronchial artery embolization, etc., and then the clot in the affected bronchus can be removed. (3) Hemoptysis triggered by excessive anticoagulation therapy, such as prolonged coagulation time caused by heparin, can be neutralized by intravenous drip fisetin; prolonged prothrombin time caused by bicoumarin, vitamin K 120 mg/dose intravenously should be given immediately, and fresh blood should be transfused if necessary. (4) Bronchoscopy and treatment. If the patient’s vital signs are stable and hemoptysis is under control at the time of admission, fiberoptic bronchoscopy is feasible, and the bleeding site can be cauterized with laser or APC if available. (5) Selective Bronchial Angiography (SBA) and Bronchial Artery Embolization (BAE) Selective Bronchial Angiography (SBA) and Bronchial Artery Embolization (BAE) can not only accurately verify the site of bleeding in the bronchial arteries, but are also effective non-surgical treatments for hemoptysis. (6) Surgical treatment: advanced malignant tumors, where surgery cannot cure the tumor and cannot prolong the patient’s life. More than 70% of bronchial lung cancers have “centripetal” growth, and symptoms can appear when the lumen is blocked by more than 75%. It can be caused by the pressure of external tumor on airway, complications of tumor radiotherapy, lung metastasis and malignant pleural effusion. Clinical manifestations are gradually worsening or sudden onset of dyspnea, shortness of breath, wheezing, hoarseness, or with cough and hemoptysis. Treatment plan and principles: At the time of diagnosis of lung cancer, 20%-30% of patients have airway obstruction, the symptoms of which depend on the tumor growth site and the degree of obstruction, and are obvious for tumors in the trachea and bullae; inflammatory swelling, secretion retention and bleeding can aggravate the degree of obstruction and hypoxia. Usually, transbronchoscopic route is used to treat airway obstruction, such as mechanical resection, stent placement, brachytherapy, laser, electrocautery, freezing, intratumoral injection, etc. Balloon dilation is indicated for lesions with short stenoses. Electrocautery is simple, has a remission rate of 88%, and can be performed on an outpatient basis, under local anesthesia. Cryotherapy has few complications and can result in symptomatic improvement in most patients, with an effective range of 1.5-2 cm. The disadvantage is that multiple treatments are required and is not applicable to large airway obstruction. Internal radiation can be applied alone or in combination with external radiation, airway tumor removal or stenting. It has been reported in the literature that external radiation combined with internal radiation can relieve dyspnea in 80% of patients and cough in 43% of patients, and the complications are mainly bronchial and esophageal fistulas, with an incidence of 8 percent. The complication is mainly bronchial and esophageal fistula, with an incidence of 8%. In recent years, endobronchial stents have been developed rapidly, both with and without membranes. Wilson et al. reported the efficacy of Gianturco stent in 56 cases of inoperable malignant tumors with airway stenosis, and the rates of symptom relief and improvement of lung function were 77% and 67%, respectively; the average survival time was 77 d. Tumors can grow into the lumen of the stent without membrane through the metal hole. Therefore, stents with membranes are preferred for intraluminal tumors. Laser treatment provides immediate relief of obstruction in more than 90% of patients. Laser therapy is mainly indicated for patients with lesions that have failed other therapeutic measures, invasion of the bronchial wall (up to the extent of cartilage), and length of intraluminal tumor.