Hemoptysis is one of the common emergencies in respiratory medicine, with only blood in the sputum if the bleeding is small, or hundreds of milliliters of blood at a time if the bleeding is large. Hemoptysis can be an important manifestation of various serious diseases and should be taken seriously even if the amount of hemoptysis is small. Sometimes, blood in the sputum at the beginning may be a precursor of fatal hemoptysis, which can lead to death by asphyxiation if not rescued in time. Therefore, it is of great importance to master the diagnosis and treatment of hemoptysis.
I. Definition of hemoptysis
Hemorrhage from the larynx and any part of the respiratory system below is called hemoptysis when coughed up through the mouth. There is no universally accepted standard for the definition of hemoptysis. It is generally considered that a 24-h hemoptysis of less than 100 ml is a small hemoptysis, 100-500 ml is a medium hemoptysis, and 500 ml or more is a large hemoptysis; a hemoptysis of 300-500 ml is also a large hemoptysis. Fatal hemoptysis can occur so suddenly that it is too late to take effective resuscitation measures, and no prior chest radiograph or clinical signs can predict the imminent occurrence of hemoptysis. Therefore, in recent years, some people consider a hemoptysis of more than 100 ml to be a hemoptysis.
II. Causes of hemoptysis
There are many causes of hemoptysis, and according to statistics, there are 100 diseases that can cause hemoptysis, including many systemic diseases. Some of the causes are easily identified, however, 5%-15% of patients with hemoptysis are unable to identify the cause despite comprehensive examination. In recent years, hemoptysis has been reported in China mainly due to five diseases, including tuberculosis, bronchiectasis, lung cancer, pneumonia, and cardiovascular disease.
III. Diagnosis of hemoptysis
(A) Medical history
1. Age
Hemoptysis caused by bronchiectasis and mitral stenosis mostly occurs in young patients under 40 years old, while bronchopulmonary cancer is a common cause of hemoptysis in patients over 40 years old.
2. History of respiratory tract disease
Care should be taken to differentiate from a history of gastrointestinal disease. Gastrointestinal bleeding is often accompanied by nausea and vomiting, and patients often have history and signs of ulcer disease or liver cirrhosis. If necessary, laryngoscopy or endoscopy can be done to identify respiratory or gastrointestinal bleeding.
3.Abnormal chest sensation
Abnormal chest sensations such as burning, heaviness and inaccurate chest pain may be limited to the site of bleeding, or to a specific lobe or even one lung.
4.History of hematuria
In patients with hematuria, if hemoptysis is also present, consideration should be given to the possibility of Wechsler’s granulomatosis, pulmonary hemorrhage-nephritis syndrome and polyarteritis nodosa.
5. Appearance of sputum
The presence of white gritty sputum mixed with bloody sputum suggests that the patient may have bronchiectasis. Pink foamy sputum is common in patients with pulmonary edema due to left heart failure. Rust-colored, brown or dark purplish-red sputum is common in bacterial pneumonia. Pus sputum mixed with blood occurs in patients with acute or subacute lung disease and is most likely due to lung abscess or pneumonia; in patients with chronic lung disease, bronchiectasis is the most likely cause.
(ii) Physical signs
Pestle finger is mostly seen in lung cancer, bronchiectasis and chronic lung abscess. Diastolic tremor and open claudication sounds suggest mitral stenosis. Enlarged lymph nodes in the neck, oblique muscles and supraclavicular lymph nodes should be considered for lung cancer. Upper airway midline ulcers are often a sign of midline sarcoidosis.
(C) Laboratory and special tests
1.Sputum examination
Bacteriological examination of sputum should be performed, and cytological examination should be performed for suspected tumor.
2.Blood examination
The increase of total white blood cell count and left shift of neutrophil nucleus can help the diagnosis of septic infection. The test of coagulation analysis can clarify the presence of bleeding disorders.
3.Chest X-ray examination
Chest X-ray is routinely performed to understand the presence of inflammation, tumor or vascular abnormalities in both lungs.
4.Computerized tomography
Computed tomography (CT) examination of the chest can detect anatomical abnormalities that cannot be revealed by ordinary X-ray examination, and can better reveal cavities, isolated masses, and lesions such as enlarged mediastinal and hilar lymph nodes.
5.Fiber bronchoscopy
To determine the cause of hemoptysis and the site of bleeding, fiberoptic bronchoscopy (FB) should be considered as a routine examination.
6.Bronchography
Bronchography is commonly used in patients with proposed bronchiectasis to determine the presence and extent of the lesion. Bronchography can also detect areas of obstruction in the bronchi, thus providing possible evidence of bronchopulmonary cancer.
7.Selective bronchial arteriography
Arteriography is often performed after bronchoscopy and chest X-ray to localize the hemorrhage. When bronchoscopy cannot localize the hemorrhage, systemic arteriography of bronchial and non-bronchial concomitant arteries and pulmonary artery beds can be used to look for signs of bleeding-prone vessels.
8.Pulmonary ventilation and perfusion scan
In patients with suspected pulmonary embolic disease and pulmonary arterial and venous traffic, the choice of pulmonary ventilation and perfusion scan has important diagnostic value.
9.Other diagnostic tests
For some special causes of hemoptysis, corresponding special tests can be selected, such as echocardiography for the proposed diagnosis of mitral stenosis.
IV. Treatment of hemoptysis
(A) Drug treatment
1.General drug treatment
2.Posterior pituitary hormone
3.Procaine
4.Vasodilators
5.Fisetin injection
6.Glucocorticoid
7.Litosterin (Bactrim)
8.Uterine constrictor
9.Other drugs
Cimetidine, metronidazole, etc.
(II) Treatment by fiberoptic bronchoscopy
In case of persistent hemoptysis or hemoptysis, if medical treatment is ineffective, fiberoptic bronchoscopy should be considered to find the site of bleeding and to stop the bleeding.
1.Cold saline bronchial lavage
2.Local medication
3.Endotracheobronchial laser treatment
4.Endotracheobronchial cryotherapy
5.Bronchial artery embolization to stop hemorrhage
(C) Surgical treatment
Patients with massive hemoptysis who are not treated by internal medicine and have a certain reserve of respiratory function can be treated surgically after the site of bleeding is clarified. Practice has proved that surgical treatment can reduce the death rate of patients with hemoptysis.
(iv) Other treatment
Patients with massive hemoptysis should rest in bed absolutely. Care should be taken to keep the affected side facing downward to avoid choking of blood into the healthy side. For those who are irritable or anxious, a small amount of sedative may be given, but only to the extent that it does not inhibit coughing and breathing. For severe coughing, a small amount of codeine can be given temporarily. For excessive blood loss, blood transfusion may be given. Complications such as atelectasis, aspiration pneumonia, asphyxia and hemorrhagic shock should also be prevented and actively managed.