How to judge the severity of hemoptysis

Hemoptysis refers to the bleeding of respiratory tract or lung tissue below larynx, which is coughed up by mouth.

There are many causes, which can be caused by bronchial, pulmonary, cardiovascular or systemic diseases (according to anatomical sites). According to the etiology, it can be divided into infectious diseases, tumors, abnormal bronchopulmonary and pulmonary vascular structures, hematological diseases, immune diseases, lung injury and physical factors.

For example, from the frequency of occurrence, the most common causes are bronchiectasis, tuberculosis, lung cancer, lung abscess and so on. In addition, despite the detailed examination, there are still 20% patients with hemoptysis whose etiology is always difficult to determine.

When you ask about the medical history, you should know it in detail.

1. Acute and chronic hemoptysis, expectoration, characteristics, whether it is the first time or many times, whether there is throat itching before hemoptysis, etc.

2. Accompanying symptoms: fever, chest pain, cough, chest tightness, sweating, fear, dyspnea, palpitation, and the relationship with menstruation.

physical examination

Observe the quantity, nature and color of hemoptysis; The general state of the patient, especially blood pressure, pulse, respiration and heart rate; Consciousness, skin color, anemia, bleeding point, subcutaneous nodules and clubbed fingers (toes), lymph node size; Changes of lung breath sounds, presence or absence of rales, heart murmur, heart rhythm, size of liver and spleen, edema of lower limbs, etc.

Laboratory inspection and other special inspection

1. Three routines: hemoglobin, red blood cell count, red blood cell backlog and its dynamic changes, white blood cell count and classification, platelet count, urine test for red blood cells or white blood cells, occult blood, etc.

2. Coagulation function: bleeding time, coagulation time, prothrombin time, fibrinogen, etc.

3. Sputum examination: look for acid-fast bacilli, tumor cells, parasitic eggs, fungi, etc. Sputum, and cultivate sputum bacteria.

4.x-ray examination: chest front and back and side photography, and high-resolution computed tomography (HRCT) examination when necessary.

5. Fiberoptic bronchoscopy: Find the bleeding site, and make clear the nature of the lesion or local hemostasis treatment.

6. Bronchial arteriography: If the bronchial artery bleeds (such as bronchiectasis, etc.). ) is suspected, you can consider this kind of examination, in order to determine the bleeding site and treatment.

7. Pulmonary angiography: If pulmonary artery bleeding such as pulmonary embolism and pulmonary arteriovenous fistula is suspected, consider this examination.

8. Others: echocardiography, bone marrow examination, immune system examination, etc.

Diagnosis and differential diagnosis

1. It should be distinguished from vomiting blood.

2. Determination of cough volume

A small amount of hemoptysis: 24 hours hemoptysis.

Moderate hemoptysis: 4 hours hemoptysis100 ~ 500ml.

Massive hemoptysis: 24-hour hemoptysis > 500ml (or one hemoptysis >); 100 ml) is massive hemoptysis.

Hemorrhagic shock can occur when the blood volume reaches 1500~2000 ml at a time. Sometimes the amount of hemoptysis is not completely consistent with the severity of the disease. Even a small amount of hemoptysis can be fatal when lung function is seriously damaged or blood clots are blocked and suffocated.

3. Preliminary determination of bleeding point

According to the medical history, physical examination and chest X-ray examination, the source of hemoptysis can be preliminarily judged.

4. Make further etiological diagnosis.

Comprehensive medical history, physical examination, laboratory examination and special examination results, clear the cause of hemoptysis.

(1) bronchiectasis suffers from measles, whooping cough and bronchopneumonia. In childhood, I had a long history of coughing and expectoration, with a large amount of sputum, which can reach hundreds of milliliters every day; Intermittent purulent sputum, which is stratified after standing (the upper layer is foam, the middle layer is serous purulent, and the lower layer is necrotic tissue). About 10% of patients have no symptoms at ordinary times, and hemoptysis is the only symptom (bronchiectasis sicca). The patient's lungs may have localized and persistent moist rales, clubbed fingers (toes), and X-ray plain films show heavy lung texture, curly or honeycomb changes. HRCT and bronchography are helpful for definite diagnosis.

⑵ In addition to hemoptysis, pulmonary tuberculosis may also have symptoms of pulmonary tuberculosis poisoning, such as low fever, night sweats, emaciation, fatigue, loss of appetite, blood in sputum, and moist rales at the apex of the lungs. X-ray chest film examination can often find tuberculosis lesions, sputum smear to find acid-fast bacilli is helpful for a clear diagnosis, and mycobacterium tuberculosis can be cultivated if necessary and conditional.

⑶ Bronchial lung cancer is more common in people over 45 years old, with more males than females, and most of them are long-term heavy smokers. Symptoms are mostly blood in the sputum, which is small but often repeated, often accompanied by chest pain, limited wheezing and clubbed fingers (toes). X-ray chest film, CT, fiberoptic bronchoscopy and sputum cytology are helpful to make a clear diagnosis.

(4) Chronic bronchitis has a long history of smoking, chronic cough and expectoration for many years, and it often occurs or gets worse in winter. It is usually a small amount of hemoptysis, which is often related to the aggravation of infection. After anti-infection treatment, with the improvement of cough, asthma and other symptoms, it will stop bleeding by itself. Physical examination can smell diffuse dry rales or scattered wet rales.

5. Endobronchial tuberculosis mostly occurs in young adults, with long-term cough, expectoration and a small amount of hemoptysis, accompanied by low fever, night sweats and emaciation. X-ray chest film is normal, acid-fast bacilli found in sputum and fiberoptic bronchoscopy are helpful for definite diagnosis.

[6] Patients with pneumococcal pneumonia with hemoptysis are typically characterized by rust-colored sputum accompanied by high fever, pleural chest pain when the lesion involves the pleura, dullness or consolidation of the lung in local percussion, and wet rales can be heard during auscultation. White blood cells are elevated by routine blood examination, and inflammatory lesions can be seen on X-ray chest film. How effective antimicrobial therapy is. In addition, the sputum of typical patients with Klebsiella pneumoniae is brick red jelly.

(7) In addition to hemoptysis, pulmonary infarction is often accompanied by chest pain and sudden dyspnea, and hemoptysis often occurs after chest pain and dyspnea. Deep venous thrombosis of lower limbs often occurs. Electrocardiogram, echocardiography, arterial blood gas analysis, D- dimer and chest enhanced CT are helpful for diagnosis.

Being lung abscess with high fever, a lot of purulent and smelly phlegm, white blood cells increased. Chronic patients have clubbed fingers (toes) X-ray chest film shows that the lesions are mainly located in the posterior segment of the upper lobe or the dorsal segment and basal segment of the lower lobe, surrounded by fluid plane and inflammatory infiltration.

(9) Cough, expectoration and hemoptysis occur during secondary infection of bronchial pulmonary cyst. Chest X-ray and CT showed round or oval transparent area with thin wall, clear boundary and uniform density.

⑽ Intractable cough, expectoration and hemoptysis in pneumoconiosis. Chest X-ray shows nodular shadows scattered in the middle and lower fields of both lungs, and the diagnosis mainly depends on occupational history.

⑾ Pulmonary hemorrhage-nephritis syndrome is common in middle-aged men, with repeated hemoptysis and dyspnea, followed by proteinuria and hematuria. X-ray chest film shows small nodules or patchy shadows in both lungs, mostly in the middle and lower lungs. Positive serum anti-basement membrane antibody or renal biopsy can make a definite diagnosis.

⑿ Menstrual hemoptysis generally occurs 2~3 days before menstruation, stops after menstruation and occurs repeatedly.

[13] When lung injury and hemoptysis caused by immune system diseases are accompanied by long-term fever, joint damage, skin and mucosa damage, multiple organ involvement, lung shadow and ineffective antibiotic treatment, the possibility of immune system diseases should be considered.

5. Significance of accompanying symptoms

Hemoptysis with fever: more common in tuberculosis, pneumonia, lung abscess, pulmonary hemorrhagic leptospirosis, epidemic hemorrhagic fever, vasculitis and bronchial cancer.

Hemoptysis with chest pain: it can be seen in lobar pneumonia, pulmonary embolism, tuberculosis and bronchial cancer.

There is a lot of pus and phlegm in hemoptysis: it can be seen in lung abscess, bronchiectasis and bronchial cancer complicated with infection.

Hemoptysis with choking cough: it can be seen in bronchial cancer and pneumonia.

Hemoptysis with skin and mucous membrane bleeding: it can be seen in leptospirosis, epidemic hemorrhagic fever, hematological diseases and autoimmune diseases.

Hemoptysis with jaundice: it can be seen in leptospirosis, lobar pneumonia and pulmonary embolism.

deal with

Treatment principle: treat the primary disease, stop bleeding, prevent complications and maintain the patient's life function.

1. Sedative rest: a small amount of hemoptysis needs no special treatment, just rest and symptomatic treatment. Moderate or above hemoptysis requires bed rest, the affected side or supine position. For those who are nervous and fearful, they should be relieved of their worries and given a small amount of sedatives when necessary. For severe hemoptysis with severe cough, antitussive drugs can be given appropriately, but morphine is prohibited to avoid suffocation due to excessive cough suppression.

2. Strengthen nursing and observe closely: those with moderate or above hemoptysis should measure their blood pressure, pulse and breathing regularly. Encourage patients to cough lightly and hemoptysis to avoid staying in respiratory tract. Keep the respiratory tract clear and keep the stool clear.

3. Patients with massive hemoptysis should open veins, prepare blood and replenish blood volume when necessary.

4. Application of hemostatic drugs

⑴ Pituitrin: It can contract pulmonary arterioles, reduce local blood flow and stop bleeding and thrombosis.

⑵ Phentolamine: directly dilate vascular smooth muscle and reduce pulmonary arteriovenous pressure, which can stop bleeding.

⑶ procaine: It has vasodilating and sedative effects.

(4) Hemostatic drugs:

6- aminocaproic acid: inhibit the activation of plasminogen into plasmin, thus inhibiting fibrinolysis;

Benzenesulfonamide (hemostatic sensitivity): enhance the function of platelets and capillaries;

Annuoxin (Anluoxue): Enhance the resistance of capillaries to injury;

Vitamin k: promote the synthesis of prothrombin in liver and promote blood coagulation;

Fibrinogen: many fibrin monomers can be formed under the action of thrombin, and the latter forms fibrin under the action of coagulation factor XII, which promotes hemostasis.

Yunnan Baiyao: 0.3~0.5g, taken orally three times a day.

⑸ Glucocorticoid: It has nonspecific anti-inflammatory effect, reduces vascular permeability, and can be used in a small amount for a short time.

5. Hemostasis through bronchoscope: If the drug treatment fails, consider using hard bronchoscope to remove hematocele and stop bleeding.

Cold saline lavage: 500 ml of 4℃ cold saline and 5 mg of epinephrine were injected into the bleeding lung segment in several times, and were aspirated after staying for 65438 0 minutes.

Balloon catheter hemostasis: the balloon blocks the bleeding bronchus, compresses and stops bleeding, and prevents suffocation. After 24 hours, relax the airbag and observe for several hours without bleeding.

Laser freezing to stop bleeding.

6. Bronchial artery embolization

7. Surgical therapy

8. Treatment of massive hemoptysis and asphyxia

Asphyxia: The patient suddenly feels unbearable chest tightness, irritability, pallor cyanosis, hemoptysis stops suddenly, breathing is difficult, and consciousness is lost.

Treatment: keep the respiratory tract unblocked, keep your feet high and your head low, and pat your back; Open your mouth with a mouth opener, pull out your tongue, quickly remove blood from your mouth and throat, intubate or cut the trachea, inhale oxygen, and properly apply respiratory stimulants.

Hemoptysis refers to the bleeding of respiratory tract or lung tissue below larynx, which is coughed up by mouth.

There are many causes, which can be caused by bronchial, pulmonary, cardiovascular or systemic diseases (according to anatomical sites). According to the etiology, it can be divided into infectious diseases, tumors, abnormal bronchopulmonary and pulmonary vascular structures, hematological diseases, immune diseases, lung injury and physical factors.

For example, from the frequency of occurrence, the most common causes are bronchiectasis, tuberculosis, lung cancer, lung abscess and so on. In addition, despite the detailed examination, there are still 20% patients with hemoptysis whose etiology is always difficult to determine.

When you ask about the medical history, you should know it in detail.

1. Acute and chronic hemoptysis, expectoration, characteristics, whether it is the first time or many times, whether there is throat itching before hemoptysis, etc.

2. Accompanying symptoms: fever, chest pain, cough, chest tightness, sweating, fear, dyspnea, palpitation, and the relationship with menstruation.

physical examination

Observe the quantity, nature and color of hemoptysis; The general state of the patient, especially blood pressure, pulse, respiration and heart rate; Consciousness, skin color, anemia, bleeding point, subcutaneous nodules and clubbed fingers (toes), lymph node size; Changes of lung breath sounds, presence or absence of rales, heart murmur, heart rhythm, size of liver and spleen, edema of lower limbs, etc.

Laboratory inspection and other special inspection

1. Three routines: hemoglobin, red blood cell count, red blood cell backlog and its dynamic changes, white blood cell count and classification, platelet count, urine test for red blood cells or white blood cells, occult blood, etc.

2. Coagulation function: bleeding time, coagulation time, prothrombin time, fibrinogen, etc.

3. Sputum examination: look for acid-fast bacilli, tumor cells, parasitic eggs, fungi, etc. Sputum, and cultivate sputum bacteria.

4.x-ray examination: chest front and back and side photography, and high-resolution computed tomography (HRCT) examination when necessary.

5. Fiberoptic bronchoscopy: Find the bleeding site, and make clear the nature of the lesion or local hemostasis treatment.

6. Bronchial arteriography: If the bronchial artery bleeds (such as bronchiectasis, etc.). ) is suspected, you can consider this kind of examination, in order to determine the bleeding site and treatment.

7. Pulmonary angiography: If pulmonary artery bleeding such as pulmonary embolism and pulmonary arteriovenous fistula is suspected, consider this examination.

8. Others: echocardiography, bone marrow examination, immune system examination, etc.

Diagnosis and differential diagnosis

1. It should be distinguished from vomiting blood.

2. Determination of cough volume

A small amount of hemoptysis: 24 hours hemoptysis.

Moderate hemoptysis: 4 hours hemoptysis100 ~ 500ml.

Massive hemoptysis: 24-hour hemoptysis > 500ml (or one hemoptysis >); 100 ml) is massive hemoptysis.

Hemorrhagic shock can occur when the blood volume reaches 1500~2000 ml at a time. Sometimes the amount of hemoptysis is not completely consistent with the severity of the disease. Even a small amount of hemoptysis can be fatal when lung function is seriously damaged or blood clots are blocked and suffocated.

3. Preliminary determination of bleeding point

According to the medical history, physical examination and chest X-ray examination, the source of hemoptysis can be preliminarily judged.

4. Make further etiological diagnosis.

Comprehensive medical history, physical examination, laboratory examination and special examination results, clear the cause of hemoptysis.

(1) bronchiectasis suffers from measles, whooping cough and bronchopneumonia. In childhood, I had a long history of coughing and expectoration, with a large amount of sputum, which can reach hundreds of milliliters every day; Intermittent purulent sputum, which is stratified after standing (the upper layer is foam, the middle layer is serous purulent, and the lower layer is necrotic tissue). About 10% of patients have no symptoms at ordinary times, and hemoptysis is the only symptom (bronchiectasis sicca). The patient's lungs may have localized and persistent moist rales, clubbed fingers (toes), and X-ray plain films show heavy lung texture, curly or honeycomb changes. HRCT and bronchography are helpful for definite diagnosis.

⑵ In addition to hemoptysis, pulmonary tuberculosis may also have symptoms of pulmonary tuberculosis poisoning, such as low fever, night sweats, emaciation, fatigue, loss of appetite, blood in sputum, and moist rales at the apex of the lungs. X-ray chest film examination can often find tuberculosis lesions, sputum smear to find acid-fast bacilli is helpful for a clear diagnosis, and mycobacterium tuberculosis can be cultivated if necessary and conditional.

⑶ Bronchial lung cancer is more common in people over 45 years old, with more males than females, and most of them are long-term heavy smokers. Symptoms are mostly blood in the sputum, which is small but often repeated, often accompanied by chest pain, limited wheezing and clubbed fingers (toes). X-ray chest film, CT, fiberoptic bronchoscopy and sputum cytology are helpful to make a clear diagnosis.

(4) Chronic bronchitis has a long history of smoking, chronic cough and expectoration for many years, and it often occurs or gets worse in winter. It is usually a small amount of hemoptysis, which is often related to the aggravation of infection. After anti-infection treatment, with the improvement of cough, asthma and other symptoms, it will stop bleeding by itself. Physical examination can smell diffuse dry rales or scattered wet rales.

5. Endobronchial tuberculosis mostly occurs in young adults, with long-term cough, expectoration and a small amount of hemoptysis, accompanied by low fever, night sweats and emaciation. X-ray chest film is normal, acid-fast bacilli found in sputum and fiberoptic bronchoscopy are helpful for definite diagnosis.

[6] Patients with pneumococcal pneumonia with hemoptysis are typically characterized by rust-colored sputum accompanied by high fever, pleural chest pain when the lesion involves the pleura, dullness or consolidation of the lung in local percussion, and wet rales can be heard during auscultation. White blood cells are elevated by routine blood examination, and inflammatory lesions can be seen on X-ray chest film. How effective antimicrobial therapy is. In addition, the sputum of typical patients with Klebsiella pneumoniae is brick red jelly.

(7) In addition to hemoptysis, pulmonary infarction is often accompanied by chest pain and sudden dyspnea, and hemoptysis often occurs after chest pain and dyspnea. Deep venous thrombosis of lower limbs often occurs. Electrocardiogram, echocardiography, arterial blood gas analysis, D- dimer and chest enhanced CT are helpful for diagnosis.

Being lung abscess with high fever, a lot of purulent and smelly phlegm, white blood cells increased. Chronic patients have clubbed fingers (toes) X-ray chest film shows that the lesions are mainly located in the posterior segment of the upper lobe or the dorsal segment and basal segment of the lower lobe, surrounded by fluid plane and inflammatory infiltration.

(9) Cough, expectoration and hemoptysis occur during secondary infection of bronchial pulmonary cyst. Chest X-ray and CT showed round or oval transparent area with thin wall, clear boundary and uniform density.

⑽ Intractable cough, expectoration and hemoptysis in pneumoconiosis. Chest X-ray shows nodular shadows scattered in the middle and lower fields of both lungs, and the diagnosis mainly depends on occupational history.

⑾ Pulmonary hemorrhage-nephritis syndrome is common in middle-aged men, with repeated hemoptysis and dyspnea, followed by proteinuria and hematuria. X-ray chest film shows small nodules or patchy shadows in both lungs, mostly in the middle and lower lungs. Positive serum anti-basement membrane antibody or renal biopsy can make a definite diagnosis.

⑿ Menstrual hemoptysis generally occurs 2~3 days before menstruation, stops after menstruation and occurs repeatedly.

[13] When lung injury and hemoptysis caused by immune system diseases are accompanied by long-term fever, joint damage, skin and mucosa damage, multiple organ involvement, lung shadow and ineffective antibiotic treatment, the possibility of immune system diseases should be considered.

5. Significance of accompanying symptoms

Hemoptysis with fever: more common in tuberculosis, pneumonia, lung abscess, pulmonary hemorrhagic leptospirosis, epidemic hemorrhagic fever, vasculitis and bronchial cancer.

Hemoptysis with chest pain: it can be seen in lobar pneumonia, pulmonary embolism, tuberculosis and bronchial cancer.

There is a lot of pus and phlegm in hemoptysis: it can be seen in lung abscess, bronchiectasis and bronchial cancer complicated with infection.

Hemoptysis with choking cough: it can be seen in bronchial cancer and pneumonia.

Hemoptysis with skin and mucous membrane bleeding: it can be seen in leptospirosis, epidemic hemorrhagic fever, hematological diseases and autoimmune diseases.

Hemoptysis with jaundice: it can be seen in leptospirosis, lobar pneumonia and pulmonary embolism.

deal with

Treatment principle: treat the primary disease, stop bleeding, prevent complications and maintain the patient's life function.

1. Sedative rest: a small amount of hemoptysis needs no special treatment, just rest and symptomatic treatment. Moderate or above hemoptysis requires bed rest, the affected side or supine position. For those who are nervous and fearful, they should be relieved of their worries and given a small amount of sedatives when necessary. For severe hemoptysis with severe cough, antitussive drugs can be given appropriately, but morphine is prohibited to avoid suffocation due to excessive cough suppression.

2. Strengthen nursing and observe closely: those with moderate or above hemoptysis should measure their blood pressure, pulse and breathing regularly. Encourage patients to cough lightly and hemoptysis to avoid staying in respiratory tract. Keep the respiratory tract clear and keep the stool clear.

3. Patients with massive hemoptysis should open veins, prepare blood and replenish blood volume when necessary.

4. Application of hemostatic drugs

⑴ Pituitrin: It can contract pulmonary arterioles, reduce local blood flow and stop bleeding and thrombosis.

⑵ Phentolamine: directly dilate vascular smooth muscle and reduce pulmonary arteriovenous pressure, which can stop bleeding.

⑶ procaine: It has vasodilating and sedative effects.

(4) Hemostatic drugs:

6- aminocaproic acid: inhibit the activation of plasminogen into plasmin, thus inhibiting fibrinolysis;

Benzenesulfonamide (hemostatic sensitivity): enhance the function of platelets and capillaries;

Annuoxin (Anluoxue): Enhance the resistance of capillaries to injury;

Vitamin k: promote the synthesis of prothrombin in liver and promote blood coagulation;

Fibrinogen: many fibrin monomers can be formed under the action of thrombin, and the latter forms fibrin under the action of coagulation factor XII, which promotes hemostasis.

Yunnan Baiyao: 0.3~0.5g, taken orally three times a day.

⑸ Glucocorticoid: It has nonspecific anti-inflammatory effect, reduces vascular permeability, and can be used in a small amount for a short time.

5. Hemostasis through bronchoscope: If the drug treatment fails, consider using hard bronchoscope to remove hematocele and stop bleeding.

Cold saline lavage: 500 ml of 4℃ cold saline and 5 mg of epinephrine were injected into the bleeding lung segment in several times, and were aspirated after staying for 65438 0 minutes.

Balloon catheter hemostasis: the balloon blocks the bleeding bronchus, compresses and stops bleeding, and prevents suffocation. After 24 hours, relax the airbag and observe for several hours without bleeding.

Laser freezing to stop bleeding.

6. Bronchial artery embolization

7. Surgical therapy

8. Treatment of massive hemoptysis and asphyxia

Asphyxia: The patient suddenly feels unbearable chest tightness, irritability, pallor cyanosis, hemoptysis stops suddenly, breathing is difficult, and consciousness is lost.

Treatment: keep the respiratory tract unblocked, keep your feet high and your head low, and pat your back; Open your mouth with a mouth opener, pull out your tongue, quickly remove blood from your mouth and throat, intubate or cut the trachea, inhale oxygen, and properly apply respiratory stimulants.