Definition of hemoptysis Hemoptysis is defined as bleeding from the respiratory tract below the pharynx through the oral cavity. The amount of hemoptysis can be classified as blood in the sputum and hemoptysis in the large mouth. The site of hemorrhage is mostly confined to the bronchi and lungs. Common causes of hemoptysis (1) diseases of pulmonary origin, such as tuberculosis, pneumonia, lung abscess, pulmonary cyst (congenital or acquired), malignant tumors, etc.; (2) bronchial diseases, such as chronic bronchitis, bronchiectasis, endobronchial tuberculosis, bronchial carcinoma (primary lung cancer), benign bronchiectasis, bronchial foreign bodies, etc.; (3) cardiovascular and pulmonary vascular diseases, such as pulmonary stasis (chronic cardiac insufficiency, mitral stenosis) (4) systemic diseases and other causes, such as acute infectious diseases, hematologic diseases (e.g., thrombocytopenic purpura, leukemia, etc.), connective tissue diseases (systemic lupus erythematosus, rheumatoid arthritis, dry syndrome, etc.), systemic vasculitis (Wegener’s granulomatosis, microscopic vasculitis, etc.), etc. It is believed that more than 100 diseases can cause hemoptysis, and the main cause is respiratory disease. Common causes of hemoptysis in China: tuberculosis: 52.9%; bronchiectasis: 22.7%; lung cancer: 6.6%; pneumonia: 3.1%; classification of hemoptysis: small hemoptysis: daily hemoptysis between 100 ml; medium hemoptysis: daily hemoptysis between 100 and 500 ml; large hemoptysis: daily hemoptysis of more than 600 ml, or a one-time hemoptysis of more than 100 ml, with a bleeding volume of more than 500 ml within 12 hours. The amount of bleeding within 12 hours reaches more than 500ml. Clinical manifestations of common hemoptysis Tuberculosis hemoptysis: generally small to moderate, often lasting several days. Large hemoptysis often occurs secondary to bronchiectasis or tuberculous cavities. Hemoptysis occurs as a result of rupture of the microvasculature due to the rupture of the arteries in the tuberculous cavity. Bronchiectasis: Hemoptysis is caused by congestion of granulation tissue in the bronchus and damage to small blood vessels during infection. Hemoptysis is often accompanied by pus sputum. Dry bronchiectasis is mainly characterized by recurrent hemoptysis without the symbol of bronchial infection. The bronchial dilatation hemoptysis mainly comes from bronchial artery bleeding, and the high pressure and arterial contraction make the bleeding high and the hemostasis fast. However, it often recurs. Chronic purulent inflammation destroys the elastic fibers of blood vessels in the bronchial wall, which can form pseudo-angiomas and easily rupture and bleed. Bronchial carcinoma: Most commonly seen in people over 40 years old. Surface erosion of cancerous tumors, usually bloody sputum or small amount of hemoptysis, and large hemoptysis is rare. Metastatic lung cancer in rare cases, the tumor encroaches on the bronchial tree and hemoptysis occurs. Other diseases: Bronchial stones: A history of coughing up “stones” or calcified material is an important clue to the diagnosis of hemoptysis from stones. Bleeding may occur in approximately 30% of cases. Pulmonary abscess: hemoptysis with copious purulent sputum. Amoebic lung abscess hemoptysis: brownish blood or mucus sputum. Pulmonary vascular disease: pulmonary stasis, pulmonary embolism, pulmonary hypertension, pulmonary arteriovenous fistula. There are also pulmonary hemorrhagic leptospirosis, connective tissue diseases (e.g., systemic lupus erythematosus, polyarteritis nodosa, leukoaraiosis, etc.), hemorrhagic disorders, and idiopathic hemoptysis. Diagnosis and differential diagnosis 1. Determine the site of hemorrhage: Pay attention to nasal, pharyngeal and oral bleeding causing the illusion of hemoptysis. Hemoptysis is often associated with a more violent choking or paroxysmal cough. Also note the difference between hemoptysis and vomiting. (1) medical history: patients with vomiting blood have a history of gastric or duodenal ulcers, tumors or hepatic steatosis, while patients with hemoptysis usually have tuberculosis, bronchiectasis or cardiopulmonary disease; (2) bleeding pattern: vomiting blood is mostly caused by vomiting, while hemoptysis is usually spit out after coughing; (3) blood color: vomiting blood is purple-red or coffee-colored without foam, while hemoptysis is bright red with foam; (4) contents: vomiting blood food residue and gastric juice, hemoptysis mixed with sputum; (5) pre-hemorrhagic symptoms: epigastric pain and fullness and discomfort often occur before vomiting; throat tickling, coughing and chest tightness often precede hemoptysis; (6) blood reaction: acidic blood in vomiting; weakly alkaline blood in hemoptysis; (7) stool examination: vomiting patients often have tarry (black)-like stools and positive stool occult blood test; hemoptysis patients often have negative stool occult blood test. Unless blood is swallowed, the stool is usually normal. (1) X-ray examination of hemoptysis, except for emergency hemoptysis that should not be moved, it is best to take a frontal and lateral chest radiograph to determine the site, scope and nature of the lesion; CT can detect lung and bronchial lesions that cannot be detected by chest radiograph; (2) fiberoptic bronchoscopy: it helps to determine the site of bleeding and the nature of the lesion, especially tumors, granulomas, ulcers, etc. that are limited to the airways (3) Sputum examination for Mycobacterium tuberculosis, cancer cells, and worm eggs; (4) Hematologic examination for inflammation with an increased total white blood cell count and leftward nuclear shift. In the presence of bleeding disorders, clotting time, prothrombin time and platelet count should be measured. Hemoptysis-identification For recurrent hemoptysis accompanied by chronic cough with high sputum volume and ring or streak-like shadow or cyst formation on chest radiograph, bronchiectasis is mostly considered; while younger patients, especially female patients, with recurrent chronic hemoptysis without other symptoms mostly support the diagnosis of bronchial adenoma; male smoking patients over 40 years old with hoarseness, choking and weight loss should be highly suspected of primary A previous history of tuberculosis with recent hemoptysis accompanied by low-grade fever, cough, and weight loss mostly suggests the possibility of cavitary tuberculosis; hemoptysis with fever and foul-smelling sputum suggests the possibility of lung abscess; a recent history of blunt chest trauma should be considered as pulmonary contusion; for hemoptysis accompanied by acute pleuritic chest pain, pulmonary embolism and other lesions involving the pleura should be considered; if skin, mucous membrane, or gum Hemorrhage is often indicative of coagulation disorders. Treatment and rescue Large hemoptysis or asphyxia must be rescued in a timely and effective manner 1, general treatment (1) bed rest: patients with large hemoptysis should be absolutely bed rest and should not be moved or transported to a foreign hospital, as the hemoptysis can be aggravated by bumps on the way, or even die midway. Bed rest is generally taken in the lateral position. At the same time, the patient should be encouraged to cough up the stagnant blood in the respiratory tract to avoid airway obstruction and pulmonary atelectasis; (2) sedation: if there is no respiratory insufficiency or general debility, diazepam 2.5mg, PO,TID can be used; (3) cough suppression: for frequent or violent cough, cough suppressants such as pentoxifylline 25mg, orally, 3 times/d; or epradone 40mg, orally, 3 times/d. /If necessary, codeine can be given 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, the application of hemostatic drugs: (1) posterior pituitary hormone: the clinical application of many hemostatic drugs, but can quickly and effectively hemostatic drugs preferred posterior pituitary hormone. This drug has the ability to reduce pulmonary arterial pressure and blood flow in the lungs, which is conducive to hemostasis at the rupture of pulmonary vessels, and is suitable for large hemoptysis or repeated medium hemoptysis. 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, sedation. If necessary, repeat once in 6-8 hours. If the patient develops headache, pale face, sweating, palpitation, chest tightness, abdominal pain, bowel movement and elevated blood pressure, the patient should slow down the rate of sedation or drip. For patients with hypertension, coronary heart disease, arteriosclerosis, pulmonary heart disease, heart failure and pregnancy, they should be used with caution or not. (2) Vasodilators: By dilating the pulmonary vasculature, 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 cardiovascular blood returned is reduced, and the blood in the lungs is shunted to the extremities and visceral circulation, which has the effect of “internal bleeding”. The pressure in the pulmonary artery and bronchial artery is reduced to achieve the purpose of hemostasis. It is particularly useful for patients with hypertension, coronary artery disease, pulmonary artery disease and pregnancy, where the use of posterior pituitary hormone is contraindicated. Phentolamine and procaine are commonly used. (3) 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. The treatment with Yunnan Baiyao combined with atropine also has certain efficacy. (4) General hemostatic drugs: mainly by improving the coagulation mechanism, strengthening capillaries and platelet function. A. Aminohexanoic acid (6-aminocaproic acid, EACA) and aminomethylbenzoic acid (hemostatic aromatic acid, PAMBA): they act as hemostatic agents by inhibiting the lysis of fibrin. Specific usage: Aminohexanoic acid (EACA) 6.0g + 5% glucose solution 250ml, IV, 2 times/d; or aminomethylbenzoic acid (PAMBA) 0.1-0.2g + 25% glucose solution 20-40ml, slow IV, 2 times/d, or aminomethylbenzoic acid (PAMBA) 0.2g + 5% glucose solution 250ml, IV, 1 to 2 times/d; B. B. Phenolsulfonamide: It has the function of enhancing platelet function and adhesion, reducing vascular permeability, thus achieving the effect of hemostasis: specific usage: Phenolsulfonamide 0.25g + 25% glucose solution 40m1, IV, 1~2 times/d; or Phenolsulfonamide 0.75g + 5% glucose solution 500ml, IV, 1 time/d. C. Bactrim: It is prepared from the venom of Brazilian snake (Brazilian pit viper) through separation and purification. It is a kind of thrombin prepared by separating and purifying the venom of Brazilian viper. Each ampoule contains 1 gram unit (KU) of bactrim. After injecting 1 KU of bactrim for 20 min, the bleeding time in healthy adults is reduced to 1/2 or 1/3, and the effect can be maintained for 2 to 3 days. This product has only hemostatic effect, the blood prothrombin number 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. In addition, there are also Kabacluo (Anluo blood), which reduces capillary leakage; vitamin K, which is involved in prothrombin synthesis; fisetin, which counteracts 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 adjunctive treatment for hemoptysis. In addition, glucocorticoids are also used. They can be used in cases of intractable hemoptysis of pulmonary tuberculosis, which is not treated by general therapy and other drugs. Prednisone acetate, 10 mg po, tid, for 1~2 weeks should be added along with active anti-tuberculosis treatment. The efficacy is related to the fact that corticosteroids are anti-inflammatory, anti-allergic, anti-toxic, and stabilize cell membranes, thus reducing local inflammation. Hormones may cause the spread of tuberculosis lesions and other complications, so it is advisable to choose strictly. 3, the application of fibronectomy: A local medication. A local medication: 1~2ml of (1:20000) epinephrine solution or 5~10ml of (40U/ml) thrombin solution is injected into the bleeding site through fiberoptic bronchoscope, which can play the role of vasoconstriction and promote coagulation, and the effect of hemostasis is sure; B balloon filling: after sending the Fogarty4Fr balloon catheter to the lung segment or sub-segment bronchus of the bleeding site through fiberoptic bronchoscope, the balloon is inflated or filled with water through the catheter. C laser-fiberscope hemostasis: insert the quartz light-guiding fiber through the fiberscope and perform Nd-YAG laser treatment (30~40,0.6~1.0s) on the bleeding lesion on the wall of the tube to achieve the purpose of hemostasis. 4.Selective bronchial artery embolization: According to the dual blood supply of bronchial artery and pulmonary artery to the lung, 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. Arterial embolization is a good alternative to surgery for those with poor lung function that cannot tolerate surgery or for those with advanced lung cancer invading the mediastinum and large blood vessels. Embolization 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 chest x-ray, 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 hemorrhage, thus creating the conditions for selective bronchial arteriography and bronchial artery embolization. Once the site of hemorrhage is clearly identified, 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 in the suspected lesion. If bleeding persists after embolization of the bronchial and collateral system arteries, the possibility of pulmonary artery hemorrhage should 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 if the presence of lesions 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%. Radiation therapy: It has been reported in the literature that limited radiation therapy may be effective for patients with advanced lung cancer and some patients with massive hemoptysis caused by pulmonary varicose infection who are not suitable for surgery and bronchial artery embolization. It is presumed that radiotherapy causes edema of extravascular tissue, swelling and necrosis of blood vessels, resulting in embolism and occlusion of blood vessels, which has a hemostatic effect. 6, other symptomatic treatment: A blood transfusion, a small number of fresh transfusions 200-300ml, replenishing blood volume at the same time, has a role in promoting hemostasis. B artificial pneumoperitoneum, suitable for recurrent hemoptysis, especially in the lesions in the two lungs, the lower lung field is more effective. If the lung fibrosis is stiff, the efficacy is poor. The first air injection volume is 1000-1500ml, if necessary, can be repeated every 1 to 2 days to inject air once. 7, surgical treatment: the vast majority of patients with hemoptysis, bleeding can be controlled after the treatment of the above measures. However, surgical treatment should be considered for some patients who have difficulty stopping hemorrhage despite active conservative treatment and whose hemoptysis is directly life-threatening. Complications of hemoptysis and its management 1. Asphyxia: ① Remove the blood that blocks the airway as soon as possible and keep the airway open: quickly pick up the patient and place him/her head down, with the upper body at an angle of 45°C to 90°C to the edge of the bed. The assistant should gently support the patient’s head and bend it toward the back to reduce the bending of the airway. The patient’s back is tapped to pour out as much blood as possible that is trapped in the airway. 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 insert the trachea through the nose to aspirate the blood; ② oxygen: immediately give high-flow oxygen inhalation; ③ quickly establish intravenous access: preferably establish two intravenous channels, and give respiratory stimulants, hemostatic drugs and blood volume supplementation as needed; ④ absolute bed rest: after the asphyxia is released, keep the patient in a head-low-foot position to facilitate postural priming. ④ Absolute bed rest: after the asphyxia is released, keep the patient in a head-down, foot-high position to facilitate postural drainage. 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, decreased 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, leftward nuclear shift, and increased lesions on chest radiograph, 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, clots block the bronchi; or because the patient is extremely weak, the amount of sedatives and cough suppressants is excessive, preventing the discharge of bronchial secretions and blood, which can easily cause pulmonary atelectasis. The first step in the management of atelectasis is to drain blood or sputum and to encourage and help 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 blockages. 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.