Massive hemoptysis

Introduction Generally, large hemoptysis refers to one case where the amount of hemoptysis exceeds 100 ml, or the amount of hemoptysis exceeds 600 ml within 24 hours. It should be emphasized that the judgment of the severity of hemoptysis patients should not be too restrictive on the amount of hemoptysis, but should be combined with the general condition of the patient, including nutritional status, complexion, pulse, respiration, blood pressure and whether or not there is any convulsion. Judge. For those who have chronic illness or old cough and fatigue, even a small amount of hemoptysis can cause suffocation and death of patients. Therefore, such patients should also be treated according to the principle of large hemoptysis.

Cause

Causes

There are two groups of blood vessels in the lungs, namely the pulmonary circulation and the bronchial circulation. The pulmonary artery and its branches from the right ventricular artery cone are low-pressure systems, providing about 95% blood supply to the lungs. The bronchial artery is from the aorta and is a high-pressure system. About 5% of the blood is supplied to the lungs, mainly supplying blood to the airway and the supporting structure. According to statistics, 90% of the bleeding in the patients with massive hemoptysis comes from the bronchial circulation, and only about 10% of the bleeding from the pulmonary circulation.

At present, there are nearly 100 kinds of diseases that can cause hemoptysis. According to their different anatomical parts, they can be divided into four categories, namely:

1 trachea, bronchial disorders;

2 lung disease;

3 cardiovascular disease;

4 systemic diseases.

According to a recent comprehensive series of internal surgery series, the common causes of massive hemoptysis in the above common causes are:

Bronchiectasis:

Bronchiectasis is characterized by an irreversible anatomical abnormality of the local bronchus due to chronic suppurative inflammation and fibrosis of the bronchus and surrounding lung tissue, which destroys the muscles and elastic tissues of the bronchial wall, resulting in bronchial deformation and persistent expansion.

Lung cancer:

Lung cancer occurs in the bronchial mucosa epithelium, also known as bronchial carcinoma. In the past 50 years, the incidence of lung cancer has been reported to increase significantly in many countries. Among male cancer patients, lung cancer has ranked first, and the incidence rate in women has also increased rapidly, accounting for the second or third place of common malignant tumors in women. The etiology of lung cancer is still not fully clear. A large amount of data indicates that long-term large amount of cigarette smoking is an important cause of lung cancer.

tuberculosis:

Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis that can invade many organs and is most common in the form of pulmonary tuberculosis (pulrnonary tuberculosis). Excreted patients are an important source of infection.

Pathogenesis

Large hemoptysis is caused by inflammation of the bronchus and its surrounding tissues and bronchial obstruction, bronchial wall damage and lumen expansion, deformation, often accompanied by telangiectasia or bronchial artery and pulmonary artery collateral expansion, forming an aneurysm rupture, Therefore, a large number of hemoptysis can be repeated.

an examination

Related inspection

Bronchoscopy chest radiograph

Hematological examination

In the case of inflammation, the total number of white blood cells often increases, and there is a nuclear left shift. If there are naive white blood cells, the possibility of leukemia should be considered. Eosinophilia often indicates the possibility of parasitic diseases. When there is bleeding disease, blood coagulation should be determined. Time, prothrombin time and platelet count, etc., if necessary, bone marrow examination.

2. Sputum examination

Through sputum smear and culture, look for general pathogens, tuberculosis, fungi, parasite eggs and tumor cells.

3. Chest X-ray examination

Chest X-ray film is of great significance for the diagnosis of hemoptysis. Therefore, it should be used as a routine examination item. It requires multiple position projections. If necessary, the anterior arch position, spot and fault slices should be added. Shadow, more suggestive of bronchiectasis, liquid level more common in lung abscess; substantial lesions more consider lung tumors, it is worth noting that blood can be inhaled into the adjacent airway when the lesion is massively bleeding, this inhalation can lead to alveolar filling, formation Blood aspiration pneumonia is easily confused with lung lesions in the early stage, but blood aspiration pneumonia is often absorbed within 1 week, so re-imaging will help identify the two.

4. Chest CT

It is a non-invasive test, which is safe for patients with pulmonary dysfunction, but for patients with active hemoptysis, it should be performed after hemoptysis is stopped. Compared with common chest X-ray, it is found to overlap with heart and hilar vessels. CT examination has its unique advantages in terms of lesions and local small lesions. In the evaluation of patients with stable bronchiectasis, chest CT has basically replaced bronchography. A foreign study reported that CT is sensitive to cystic bronchiectasis. Sexuality is 100%, sensitivity to columnar bronchiectasis is 94%; specificity is 100%, affected by price factors. Currently, for patients with massive hemoptysis, chest CT is still only used as a second-line examination.

5. Bronchoscopy

For the diagnosis of massive hemoptysis, or the poor treatment of hemostasis by conservative medical treatment, it is currently advocated to perform bronchoscopy early in hemoptysis. The basis is:

(1) Early bronchoscopy can more accurately determine the location of bleeding.

(2) can significantly improve the correct rate of hemoptysis diagnosis.

(3) Provide a basis for the selection and implementation of treatment methods (such as surgery, bronchial artery embolization, etc.).

(4) Local hemostasis can be directly performed on the bleeding site.

The types of bronchoscopy can be divided into rigid bronchoscopy and flexible bronchoscopy (ie, fiberoptic bronchoscopy). Usually, surgeons prefer to use rigid bronchoscopes, while pulmonary surgeons prefer fiberoptic bronchoscopy. In comparison, The fiberoptic bronchoscope has the advantages of simple operation, no need for general anesthesia, wide visible area and small damage, so it has been widely used in clinical practice. However, once the amount of bleeding exceeds the attraction capacity of the fiberoptic bronchoscope, or the blood clots smear and block the fiber repeatedly In the case of bronchoscopy, etc., the hard bronchoscope should be used for examination, or the tracheal intubation should be given to prevent suffocation caused by excessive bleeding, and it is also convenient for the fiberoptic bronchoscope to attract the lumen or the tip to be blocked by the blood clot. The withdrawal of washing and re-entry should emphasize that bronchoscopy during hemoptysis is dangerous. Therefore, necessary rescue preparations should be made before the examination, especially for the rescue of asphyxia. At the same time, attention should be paid to the oxygen supply during the examination. And monitoring of ECG, blood pressure, oxygen saturation, etc., to reduce the occurrence of adverse consequences.

6. Bronchography

With the wide application of chest CT and fiberoptic bronchoscopy, it is now possible to directly observe the airway with a diameter of only a few millimeters. In addition, the operation of bronchography has the potential danger of causing hypoxia and bronchospasm in patients. Hemoptysis patients are often difficult to tolerate, so the diagnostic value of patients with recent or active hemoptysis is quite limited. Currently, bronchography is mainly used for:

1 to confirm the presence of localized bronchiectasis (including isolated lung lobes);

2 There is a wider range of lesions in patients with localized bronchiectasis who are excluded from surgical treatment.

7. Angiography

(1) Selective bronchial angiography: In recent years, 1 group of data showed that 306 patients with hemoptysis, 280 patients (91.5%) from the bronchial artery, 26 patients (only 8.5%) from the pulmonary artery, and another group A study of 72 patients with massive hemoptysis found that bleeding was only 8.4% from the pulmonary artery. Hemorrhage in hemoptysis patients was mostly from the bronchial artery system. Selective bronchial angiography not only confirmed the exact location of the bleeding, but also Abnormal expansion of the bronchial artery, distortion, aneurysm formation, and the presence of the systemic circulation-pulmonary circulation branch were found to provide a basis for bronchial artery embolization.

(2) Pulmonary angiography: refractory large hemoptysis caused by cavity tuberculosis, lung abscess and other diseases. As well as suspected erosive pseudoaneurysm, pulmonary artery malformation should be added for pulmonary angiography while performing selective bronchial angiography.

8. Isotope scanning

Ventilation/perfusion scans after cessation of bleeding help to confirm the diagnosis of pulmonary embolism.

Differential diagnosis

diagnosis

Generally, after inquiring about the medical history and physical examination and the above-mentioned various examinations, the cause of massive hemoptysis can be correctly diagnosed. The hemoptysis is often part of the clinical manifestation of systemic diseases. Comprehensive and detailed physical examination will contribute to the diagnosis of hemoptysis.

Differential diagnosis

For repeated hemoptysis with chronic cough, the amount of sputum is more, and there are ring-shaped or striped shadows on the chest radiograph or cyst formation, and more bronchodilation is considered; while young patients, especially female patients, have recurrent chronic hemoptysis without Other symptoms, more support for the diagnosis of bronchial adenoma, male patients over the age of 40, with hoarseness, cough, weight loss, should be highly suspected of primary lung cancer. In the past, there was a history of tuberculosis with hemoptysis accompanied by symptoms such as hypothermia, cough, weight loss, and more suggestive of cavitary tuberculosis; hemoptysis with fever, cough sputum suggesting the possibility of lung abscess, and recent history of chest blunt trauma should be considered Lung contusion. For patients with hemoptysis associated with acute pleural inflammatory chest pain, pulmonary embolism and other pleural lesions should be considered; such as skin, mucous membranes, bleeding gums, often suggesting coagulopathy.

At the beginning of hemoptysis, the respiratory sounds of the affected side are often weakened, rough or wet voices, the normal lung field breath sounds are normal, the bleeding caused by bronchial diseases, the general amount of bleeding is large, and the affected side often hears each time during auscultation. A variety of different voices, systemic symptoms are not serious, the appearance of pleural friction sounds, often suggesting lesions involving the pleural diseases, such as pulmonary infarction, lung abscess, etc., pulmonary hypertension increased suggestive of primary pulmonary hypertension, mitral stenosis, repeated Chronic pulmonary embolism; systemic circulatory, venous traffic or murmurs in the lung field, support hereditary hemorrhagic telangiectasia with pulmonary malformations; wheezing sounds confined to the larger bronchial area, more suggestion A disease in which the bronchus is not completely blocked, such as bronchial lung cancer or bronchial foreign body.

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