Hemoptysis is defined as bleeding from the respiratory tract or lung tissue below the vocal cords, and is called “hemoptysis” when it is expelled through the mouth. The manifestation can be blood in the sputum or a large amount of hemoptysis. Therefore, clinically, patients are often classified into small, moderate and large hemoptysis according to the amount of hemoptysis. Usually, hemoptysis is defined as a hemoptysis of more than 100 ml or more than 600 ml in 24 hours.
It is important to emphasize that the judgment of the severity of hemoptysis should not be overly bound to the amount of hemoptysis, but should be combined with the general condition of the patient, including nutritional status, facial color, pulse, respiration, blood pressure and the presence of cyanosis. For those who have been ill for a long time or have a weak cough, even a small amount of hemoptysis can cause death by asphyxiation, so these patients should also be treated according to the principles of treatment for hemoptysis.
What causes it
(A) Causes
The lungs have two groups of vessels, namely the pulmonary circulation and the bronchial circulation. The pulmonary artery and its branches, which originate from the cone of the right ventricular artery, are the low-pressure system and provide about 95% of the blood supply to the lungs. The bronchial arteries, which originate from the aorta, are the high-pressure system and generally supply about 5% of the blood to the lungs, mainly to the airways and supporting structures. Statistically, 90% of the bleeding in patients with hemoptysis comes from the bronchial circulation, while only about 10% of the bleeding comes from the pulmonary circulation.
There are nearly 100 known diseases that can cause hemoptysis. According to their anatomical locations, they can be divided into 4 major categories, namely: (1) tracheal and bronchial disorders; (2) pulmonary disorders; (3) cardiovascular disorders; and (4) systemic disorders.
According to a recent comprehensive study of medical and surgical series, among the above common causes, the common causes of hemoptysis are, in order: ① bronchial dilatation (about 30%); ② lung cancer (about 20%); ③ pulmonary tuberculosis (about 15%-20%).
(II) Pathogenesis
Hemoptysis is due to destruction of the bronchial wall and lumen expansion and deformation caused by inflammation and bronchial obstruction of the bronchi and surrounding tissues, often accompanied by capillary dilation or anastomosis such as expansion of the bronchial artery and the terminal branch of the pulmonary artery complex, forming a ruptured aneurysm, so a large amount of hemoptysis can be repeated.
What are the manifestations and how to diagnose
Recurrent hemoptysis can last for years or decades, with varying degrees of severity, ranging from a small amount of bloody sputum to a large amount of hemoptysis. Some patients have no cough, sputum, or other respiratory symptoms and have recurrent hemoptysis as the main manifestation.
Generally, after taking a medical history and physical examination as well as the above-mentioned tests, a correct diagnosis of the cause of hemoptysis can be made. Hemoptysis is often part of the clinical manifestations of systemic diseases, and a thorough and detailed physical examination will help to diagnose the etiology of hemoptysis.
What tests should be done
1. Hematological examination The total number of leukocytes often increases in inflammation, and there is a leftward nuclear shift. If infantile leukocytes are found, the possibility of leukemia should be considered. Eosinophilia often indicates the possibility of parasitic disease. In case of bleeding disorders, clotting time, prothrombin time and platelet count should be measured, and bone marrow examination should be performed if necessary.
2.Sputum examination Through sputum smear and culture, look for general pathogenic bacteria, tuberculosis bacteria, fungi, parasite eggs and tumor cells, etc.
Chest X-ray examination Chest X-ray is of great significance for the diagnosis of hemoptysis, so it should be a routine examination item. Multiple positions are required, and if necessary, anterior arch, point film and tomogram should be added. The presence of curly shadows along the bronchial distribution on chest radiographs is mostly suggestive of bronchial dilatation; liquid flat is mostly seen in lung abscesses; substantial lesions are mostly considered as lung tumors. It is worth noting that blood can be aspirated into the adjacent airways during massive bleeding from the lesion, and such aspiration can lead to alveolar filling and the formation of blood aspiration pneumonia. In the early stage, it is easily confused with a substantial lung lesion, but blood aspiration pneumonia is often absorbed within 1 week, so re-taking the film will help to differentiate the two.
2. CT chest is a non-invasive examination and is safe for people with pulmonary dysfunction. However, in patients with active hemoptysis, it should generally be performed after the hemoptysis has stopped. Compared with plain X-ray chest radiography, CT examination has unique advantages in detecting lesions overlapping with heart and hilar vessels and small local lesions. Chest CT has largely replaced bronchography in the evaluation of patients with stable bronchiectasis. A foreign study reported that the sensitivity of CT for cystic bronchiectasis was 100% and for columnar bronchiectasis was 94%; the specificity of both was 100%. Due to the price factor, CT of the chest is still only used as a second-line examination item for patients with hemoptysis.
3.Bronchoscopy For those with unclear diagnosis of the cause of hemoptysis, or those with poor hemostatic effect by conservative medical treatment, early bronchoscopy during hemoptysis is currently advocated. The basis for this is.
(1) early bronchoscopy can identify the site of bleeding more accurately.
(2) It can significantly improve the correct diagnosis of the cause of hemoptysis.
(3) It provides a basis for the selection and implementation of treatment methods (e.g., surgery, bronchial artery embolization, etc.).
(4) Local hemostasis can be performed directly on the bleeding site.
The types of bronchoscopes can be divided into rigid bronchoscopes and flexable bronchoscopes (i.e. fiberoptic bronchoscopes). Usually surgeons prefer rigid bronchoscopes, while pulmonologists prefer fiberoptic bronchoscopes. In comparison, fiberoptic bronchoscopy has been widely adopted because it is easy to perform, does not require general anesthesia, and has a wide area of visibility with minimal damage. However, once the amount of bleeding exceeds the suction capacity of the fiberoptic bronchoscope, or if there are repeated cases of blood clots staining and blocking the fiberoptic bronchoscope, rigid bronchoscopy should be used instead. Or tracheal intubation should be given to prevent choking due to excessive bleeding and to facilitate withdrawal for cleaning and reentry after the lumen or endings of the fiberoptic bronchoscope suction tube are blocked by blood clots. It should be emphasized that bronchoscopy during hemoptysis has certain risks. Therefore, necessary resuscitation preparations, especially for asphyxia, should be made before the examination. Attention should also be paid to the administration of oxygen and monitoring of ECG, blood pressure, oxygen saturation, etc. during the examination to reduce the occurrence of adverse consequences.
4.Bronchography With the widespread use of chest CT and fiberoptic bronchoscopy, it is now possible to observe the airway with a diameter of only a few millimeters under direct vision. In addition, the procedure of bronchography has the potential risk of causing hypoxia and bronchospasm, which is often difficult to tolerate in patients with massive hemoptysis. Therefore, its diagnostic value is quite limited in patients with recent or active hemoptysis. Currently, bronchography is mainly used: (i) to confirm the presence of limited bronchiectasis (including isolated lung lobes); and (ii) to exclude the presence of more extensive lesions in patients with limited bronchiectasis who are to be treated surgically.
5.Angiography
(1) Selective bronchial arteriography: In recent years, a group of data showed that among 306 patients with hemoptysis, 280 cases (91.5%) had bleeding from the bronchial arteries and 26 cases (only 8.5%) from the pulmonary arteries. In another study of 72 patients with hemoptysis, only 8.4% of the bleeding came from the pulmonary artery. It can be seen that the vast majority of bleeding in patients with hemoptysis comes from the bronchial artery system. Selective bronchial arteriography can not only clarify the exact site of hemorrhage, but also detect abnormal dilatation, distortion, aneurysm formation, and the presence of body-pulmonary circulation traffic branches in bronchial arteries, thus providing a basis for bronchial artery embolization treatment.
(2) Pulmonary arteriogram: For recalcitrant hemoptysis caused by cavitary pulmonary tuberculosis, pulmonary abscess and other diseases; as well as those suspected of having erosive pseudoaneurysm and pulmonary artery malformation, pulmonary arteriogram should be added along with selective bronchial arteriogram.
6.Isotope scan A ventilation/perfusion scan after the hemorrhage has stopped can help clarify the diagnosis of pulmonary embolism.
How to treat
(A) Treatment
1.General treatment Absolute bed rest is required for patients with hemoptysis. Health care personnel should instruct the patient to take the affected side and do a good job of explaining to eliminate the patient’s tension and fear. During hemoptysis, some unnecessary moving should be reduced as much as possible to avoid aggravating bleeding and death by asphyxiation due to bumps on the way. At the same time, the patient should be encouraged to cough up the stagnant blood in the respiratory tract so as not to cause respiratory obstruction and pulmonary atelectasis. If the patient is overly nervous, use a small dose of sedative, such as diazepam 2 or 5 mg orally, 2 times/d, or diazepam injection 10 mg intramuscularly. For frequent or severe coughing, cough suppressants such as pentoxifylline 25mg, orally, 3 times/d; or epradone 40mg, orally, 3 times/d. If necessary, codeine 15-30mg, orally, 3 times/d. However, cough suppressants should not be given to elderly and frail patients. For those with pulmonary insufficiency, morphine and pethidine are prohibited to avoid inhibiting the cough reflex and causing asphyxia.
2.Hemostatic treatment
(1) Drug hemostasis.
① Posterior pituitary hormone: can act directly on vascular smooth muscle, with a strong vasoconstrictor effect. Due to the contraction of small pulmonary arteries, the blood flow in the lungs is sharply reduced and the pressure of pulmonary circulation is lowered, thus facilitating the formation of blood clots at the ruptured pulmonary vessels and achieving hemostasis. Specific use: posterior pituitary 5-10U 25% glucose solution 20-40ml, slow sedation (10-15min injection); or posterior pituitary 10-20U 5% glucose solution 250-500m1, static drip. Repeat once for 6-8h if necessary. During the course of medication, if the patient develops headache, pale face, sweating, palpitation, chest tightness, abdominal pain, bowel movement and blood pressure increase and other side effects, attention should be paid to slow down the sedative injection or drip rate. For patients with hypertension, coronary heart disease, arteriosclerosis, pulmonary heart disease, heart failure and pregnancy, should be used with caution or not.
②Vasodilator: By dilating the pulmonary vessels, the pulmonary artery pressure, pulmonary wedge pressure and pulmonary wedge pressure are lowered; at the same time, the vascular resistance of the body circulation decreases, the amount of return blood is reduced, and the blood in the lungs is shunted to the extremities and visceral circulation, playing the role of “internal bleeding. This causes a decrease in pulmonary and bronchial artery pressure to achieve the purpose of hemostasis. It is especially suitable for patients with hypertension, coronary artery disease, pulmonary artery disease and pregnancy, where the use of posterior pituitary hormone is contraindicated. Commonly used are.
A. Phentolamine: It is an alpha-blocker, and the general dosage is 10-20 mg 5% glucose solution 250-500 ml, IV, 1 time/d, for 5-7 days. It has been reported at home and abroad that this method is used to treat hemoptysis with an efficiency of about 80%. There are few side effects in treatment, but to prevent the occurrence of postural hypotension and blood pressure drop, bed rest should be taken during the medication. For patients with insufficient blood volume, this drug should be used on the basis of replenishing blood volume.
B. Procaine: The commonly used dose is 50mg 25% glucose solution 20-40m1, intravenous injection, 4-6h; or 300-500mg 5% glucose solution 500ml, static drip, 1 time/d. For the first time using this drug, skin test should be done.
Atropine and scopolamine: Atropine 1mg or scopolamine 10mg, injected intramuscularly or subcutaneously, also has good hemostatic effect on patients with hemoptysis. In addition, isosorbide and chlorpromazine have also been used to treat hemoptysis, and have achieved certain efficacy.
④General hemostatic drugs: mainly through improving the coagulation mechanism, strengthening capillaries and platelet function and play a role. Such as.
A. Aminohexanoic acid (6-aminocaproic acid, EACA) and aminomethylbenzoic acid (hemostatic aromatic acid, PAMBA): they act as hemostatic agents by inhibiting the dissolution of fibrin. Specific usage: Aminohexanoic acid (EACA) 6,0g in 5% glucose solution 250ml, IV, 2 times/d; or aminomethylbenzoic acid (PAMBA) 0,1~0,2g in 25% glucose solution 20~40ml, slow IV, 2 times/d, or aminomethylbenzoic acid (PAMBA) 0,2g in 5% glucose solution 250ml, IV, 1~2 times/d.
B. Phenolsulfonamide: It has the effect of enhancing platelet function and adhesion and reducing vascular permeability to achieve hemostasis: specific usage: Phenolsulfonamide 0, 25g in 25% glucose solution 40m1, IV, 1~2 times/d; or Phenolsulfonamide 0, 75g in 5% glucose solution 500ml, IV, 1 time/d.
C. Bacitracin: A kind of thrombin prepared by isolating and purifying the venom of Brazilian snake (Brazilian pit viper genus). Each ampoule contains 1 gram unit (KU) of bactrimase. After injecting 1 KU of bactrim for 20 min, the bleeding time in healthy adults is reduced to 1/2 or 1/3, and its effect can be maintained for 2 to 3 days. This product has only hemostatic effect, the prothrombin number of blood does not increase as a result, so there is generally no risk of thrombosis. It can be injected intravenously or intramuscularly, and can also be used topically. The daily dosage is 1.0-2.0 KU for adults and 0.3-1.0 KU for children, noting that overdose may reduce its efficacy.
In addition, there are also Kabakloo (Anluo blood), which reduces capillary leakage; vitamin K, which is involved in thrombinogen synthesis; fisetin, which fights against heparin; and Yunnan Baiyao, a traditional Chinese medicine, and various hemostatic powders. In view of the fact that clinical hemoptysis is mostly due to rupture of bronchial or pulmonary vessels, the above-mentioned drugs are generally used only as adjuvant therapy for hemoptysis.
(2) Application of bronchoscopy in the treatment of hemoptysis: for patients with persistent hemoptysis who do not achieve good results with drug therapy, fiberoptic bronchoscopy should be performed in a timely manner. Its purpose is: first, to clarify the site of bleeding; second, to remove the stale blood in the airway; third, to effectively stop bleeding with vasoconstrictors, thrombin, and balloon tamponade. When there is more bleeding, rigid bronchoscopy is usually used to remove the accumulated blood first, and then fiberoptic bronchoscopy is applied through rigid bronchoscopy to find the bleeding site for hemostasis. The commonly used hemostatic measures currently employed with the aid of bronchoscopy are.
① Bronchial lavage: 50 ml of iced saline at 4°C is used and injected into the bleeding lung segment through the fiberoptic bronchoscope, left for 1 min and then aspirated, several times in succession. Generally the total amount of lavage fluid required for each patient is 500ml. In one group of 23 patients with hemoptysis, the hemoptysis was controlled in all patients after treatment with this method, and in two of them the hemoptysis was re-injected a few days after lavage, but the hemoptysis stopped after the second lavage with the same method. The author has also used this method several times to treat patients with hemoptysis, with excellent results. It is presumed that the ice saline irrigation caused local vasoconstriction and slowed down blood flow, thus promoting coagulation.
Local medication: 1 to 2 ml of (1:20,000) epinephrine solution or 5 to 10 ml of (40 U/ml) thrombin solution is dripped into the bleeding site through fiberoptic bronchoscopy, which can play the role of vasoconstriction and promote coagulation, with positive hemostatic effect. Others have reported that adding 5-10 ml of 2% fibrinogen solution to 5-10 ml of 40 U/ml of thrombin solution, mixing well and then dripping into the bleeding site, its hemostatic effect is better.
③Balloon filling: After delivering the Fogarty balloon catheter to the lung segment or sub-segment bronchus at the bleeding site through fiberoptic bronchoscopy, the balloon is inflated or filled with water through the catheter, resulting in filling the bronchus at the bleeding site and achieving hemostasis. It also prevents the overflow of blood into the healthy lung due to excessive bleeding, thus effectively protecting the gas exchange function of the healthy lung. Generally, after 24-48 hours of balloon placement, the balloon was relaxed and the tube was removed after a few hours of observation without further bleeding. 14 patients with hemoptysis treated by balloon tamponade technique in one group, 10 of which had controlled bleeding. After 6 weeks to 9 months of follow-up, no rebleeding occurred. In addition, the balloon tamponade technique is often used for preoperative support in patients undergoing arterial embolization and surgical procedures. During the operation, care should be taken to prevent the occurrence of ischemic injury to the bronchial mucosa and obstructive pneumonia caused by overinflation of the balloon and prolonged retention time.
(3) Selective bronchial artery embolization: According to the dual blood supply of the lungs by the bronchial artery and the pulmonary artery, there are often potential traffic ducts between the two circulatory systems, and they have the function of temporal regulation or mutual compensation. When the bronchial artery is embolized, it usually does not cause necrosis of bronchial and lung tissues, which provides an objective basis for bronchial artery embolization to treat hemoptysis. In the past 20 years, arterial embolization has been widely used in the treatment of patients with hemoptysis. In particular, arterial embolization is a better alternative to surgical treatment for patients with bilateral lesions or multiple bleeding sites; poor cardiac or pulmonary function that cannot tolerate surgery or advanced lung cancer invading the mediastinum and large vessels.
Embolization therapy is usually performed at the same time as selective bronchial arteriography, which identifies the site of bleeding. However, selective bronchial arteriography cannot be performed when the patient has a negative X-ray chest radiograph, bilateral lesions or a lesion on one side that does not explain the source of the bleeding. In this case, fiberoptic bronchoscopy can often help to clarify the cause of hemoptysis and the site of bleeding, thus creating conditions for selective bronchial arteriography and bronchial artery embolization. Once the site of hemorrhage is clear, embolization materials such as absorbent gelatin sponge (gelatin sponge), cellulose oxide, polyurethane or anhydrous alcohol can be used to embolize as many arteries as possible with suspected lesions. If bleeding persists after embolization of the bronchial and collateral system arteries, the possibility of pulmonary artery hemorrhage needs to be considered. The most common cases are erosive pseudoaneurysm, pulmonary abscess, pulmonary artery malformation, and pulmonary artery rupture. In this case, angiography of the pulmonary artery should also be performed, and once the presence of the lesion is clear, simultaneous pulmonary artery embolization is recommended. The recent effect of bronchial artery embolization in the treatment of hemoptysis is certain, and the general literature reports that the efficiency can reach about 80%. However, it is only a palliative treatment and cannot replace surgery, anti-inflammatory, anti-TB and other etiological treatments.
Note that embolization is contraindicated when the angiogram shows that the spinal artery is emanating from the bleeding bronchial artery, as this poses a risk of spinal cord injury and paraplegia.
(4) Radiation therapy: It has been reported in the literature that limited radiation therapy may be effective in patients with advanced lung cancer and some patients with massive hemoptysis caused by pulmonary varices infection who are not suitable for surgery and bronchial artery embolization. It is presumed that radiotherapy causes edema of extravascular tissues in the irradiated area, swelling and necrosis of blood vessels, causing vascular embolism and occlusion, which has a hemostatic effect.
3.Surgical treatment The vast majority of patients with hemoptysis can have their bleeding controlled after the treatment of the above measures. However, for some patients who have difficulty in stopping hemorrhage despite active conservative treatment and whose hemoptysis is directly life-threatening, surgical treatment should be considered.
(1) Indications for surgery: (1) Hemoptysis of more than 1500 ml in 24 h, or hemoptysis of 500 ml in 24 h, with no tendency to stop bleeding by medical treatment. (2) Repeated hemoptysis with a precursor of asphyxia. (③ A lobe lung or one lung with clear chronic irreversible lesions (such as bronchiectasis, cavitary tuberculosis, lung abscess, pulmonary aspergillosis, etc.).
(2) Contraindications to surgery: ① extensive diffuse lesions in both lungs, (e.g., extensive bronchiectasis in both lungs, multiple bronchopulmonary cysts, etc.). ②Poor systemic condition, inadequate compensation of cardiac and pulmonary function. (3) Hemoptysis caused by non-primary lung lesions.
(3) Selection of the timing of surgery: Before surgery, the patient should be examined by chest X-ray and fiberoptic bronchoscopy to clarify the site of bleeding. At the same time, there should be a comprehensive evaluation of the patient’s general health status, cardiac and pulmonary function. For patients who cannot undergo cardiac and pulmonary function tests, a comprehensive judgment should be made based on medical history and physical examination. In particular, the estimation of pulmonary function after lung resection should be strived for accuracy. The timing of surgery is best chosen in the interval of hemoptysis. Surgery at this stage has few complications and a high success rate. According to a group of foreign data, the mortality rate of surgery during active hemoptysis can be as high as 37%, and the direct cause of death in the vast majority of patients is due to blood aspiration during surgery. In contrast, the mortality rate is only 8% when surgery is performed in the interval of hemoptysis. It can be seen that the mortality rate can be significantly reduced if the surgery is performed in the interval of hemoptysis.
4. Management of complications
(1) Asphyxia: The main danger of patients with hemoptysis is asphyxia, which is the most important cause of death. Therefore, during the treatment of hemoptysis, one should always be alert to the occurrence of asphyxia. Once a patient is found to have clinical manifestations of asphyxia such as obvious chest tightness, irritability, laryngeal rattling, shallow and rapid breathing, profuse sweating, loss of respiratory sounds on one side (or both sides), or even confusion, the following measures should be taken immediately and all efforts should be made to resuscitate the patient
① Remove the accumulated blood blocking the airway as soon as possible to keep the airway open: quickly pick up the patient so that his head is facing down and his upper body is at an angle of 45℃～90℃ with the edge of the bed. The assistant gently holds the patient’s head in the middle to make it bend toward the back to reduce the bending of the airway. And pat the patient’s back to pour out as much blood trapped in the airway as possible. At the same time, pry the mouth open (pay attention to the denture), clean the blood in the oropharynx, and then use a thick catheter (or fibrinoscope) to aspirate the blood through the nose into the trachea.
②Oxygen inhalation: Give high-flow oxygen inhalation immediately.
③Rapidly establish intravenous access: It is best to establish two intravenous channels and give respiratory stimulants, hemostatic drugs and blood volume supplementation as needed.
④absolute bed rest: after the asphyxia is lifted, keep the patient in head-low foot-high position to facilitate postural drainage. Place an ice pack on the chest and encourage the patient to cough up the blood in the airway.
⑤ Strengthen the monitoring of vital signs to prevent re-asphyxia: pay attention to the monitoring of blood pressure, heart rate, electrocardiography, respiration and oxygen saturation, and prepare facilities such as tracheal intubation and ventilator to prevent re-asphyxia.
(2) Hemorrhagic shock: If the patient develops clinical manifestations of hemorrhagic shock such as fine and rapid pulse rate, wet and cold extremities, decreased blood pressure, reduced pulse pressure difference, or even impaired consciousness due to massive hemoptysis, resuscitation should be performed according to the principles of hemorrhagic shock treatment.
(3) Aspiration pneumonia: After hemoptysis, the patient often develops fever due to the absorption of blood, with a body temperature of about 38℃ or persistently unresolved, violent cough, elevated total leukocyte count, left shift of nucleus, and increased lesions on chest radiograph compared with the previous one, which often indicates combined aspiration pneumonia or tuberculosis focal spread, and should be treated with adequate antibiotics or anti-tuberculosis drugs.
(4) Pulmonary atelectasis: due to massive hemoptysis, blood clots block the bronchi; or because the patient is extremely weak, excessive dosage of sedatives and cough suppressants prevent the discharge of bronchial secretions and blood, which can easily cause pulmonary atelectasis. Treatment of pulmonary atelectasis begins with drainage of blood or sputum, and encouraging and helping the patient to cough. If the pulmonary atelectasis does not last long, try aminophylline, alpha-chymotrypsin, etc., nebulized inhalation, wetting the airway to facilitate the discharge of the blockage. Of course the most effective way to eliminate pulmonary atelectasis is to perform local bronchial flushing under fiberoptic bronchoscopy to clear the blockage in the airway.
(ii) Prognosis
Although hemoptysis accounts for less than 5% of patients with hemoptysis, the death rate is as high as 7% to 32%, so it should be taken seriously.