Treatment of massive hemoptysis, massive hemoptysis should be treated

hemoptysis should be treated?

(a) treatment

1. the general treatment of patients with massive hemoptysis requires absolute bed rest, medical staff should take the affected side to guide the patient supine, and do explanatory work, to eliminate the patients stress and fear, hemoptysis, you should minimize the number of non- necessary move to avoid bumps on the way due to increased bleeding, choking to death, should also encourage patients to cough up blood remaining in the respiratory tract of Chen to avoid airway obstruction and atelectasis, such as psychological stress of patients, used a small dose of sedatives, such as diazepam 2.5mg, oral, 2 times / d, or diazepam 10mg intramuscular injection of frequent or severe cough may be given antitussives, such as Pentoxyverine 25mg, orally, 3 times / d ; or by Chopra ketone 40mg, orally, 3 times / d, if necessary, give codeine 15 ~ 30mg, orally, 3 times / d, but the elderly and infirm patients, should not take cough suppressants, on lung function insufficiency, disable morphine, pethidine, so as not to inhibit the cough reflex, causing suffocation.

2. hemostasis

(1) drugs to stop bleeding:

① vasopressin: role in vascular smooth muscle directly, with a strong vasoconstriction after treatment because the contraction of small pulmonary arteries, pulmonary blood flow to the sharp drop in pulmonary pressure is reduced, thus contributing to pulmonary vascular rupture formation of blood clots, to achieve hemostasis purposes, the specific usage: Vasopressin 5 ~ 10U 25% glucose solution 20 ~ 40ml, slow intravenous injection (10 ~ 15min Notes complete); or vasopressin 10 ~ 20U 5% glucose liquid 250 ~ 500m1, infusion, if necessary, repeated at 6 ~ 8h, the medication process, if the patients had headache, pale, sweating, heart palpitations, chest tightness, abdominal pain, it is intended and elevated blood pressure and other side effects, attention should be reduced slow intravenous injection or infusion rate of hypertension, coronary heart disease, atherosclerosis, pulmonary heart disease, heart failure and patients with pregnancy, should be used with caution or not.

② vasodilators: the expansion of the lung through the blood vessels, reducing pulmonary artery pressure and pulmonary wedge pressure and pulmonary wedge pressure; also decreased systemic vascular resistance, decreased venous return, pulmonary shunt blood to the limbs and viscera cycle of play "in bleeding" effect, resulting in pulmonary and bronchial arterial pressure decreased to stop the bleeding purposes, for the use of vasopressin contraindicated high blood pressure, coronary heart disease, pulmonary heart disease and pregnancy are particularly applicable to such patients, are commonly used:

A. phentolamine: the α-blocker, the general amount of 10 ~ 20mg 5% glucose solution 250 ~ 500ml, intravenous infusion, 1 / d, for 5 to 7 days, US outside are It has been reported using this method for massive hemoptysis, effective in about 80% fewer treatment side effects, but in order to prevent orthostatic hypotension and blood pressure drop occurs, medication should rest in bed for patients with hypovolemia, should complement blood volume based on the re-use this drug.

B. procaine: The usual dose is 50mg 25% glucose solution 20 ~ 40m1, intravenous injection, 4 ~ 6h; or 300 ~ 500mg 5% glucose 500ml, intravenous infusion, 1 / d, for the first time with the drug, should be skin test.

③ atropine, anisodamine: anisodamine atropine 1mg or 10mg, intramuscular or subcutaneous injection, for patients with massive hemoptysis have good hemostatic effect, has also been used Isosorbide and chlorpromazine triazine and other treatment of massive hemoptysis, and achieved a certain effect.

④ general hemostatic: mainly by improving blood clotting mechanisms, strengthen capillary and platelet function in the work, such as:

A. aminocaproic acid (6 - aminocaproic acid, EACA) and aminomethyl benzoic acid (bleeding aromatic acid, PAMBA): by inhibiting the dissolution of fibrin, play a role in hemostasis, specific usage: aminocaproic acid (EACA) 6.0g 5% glucose solution 250ml, intravenous infusion, 2 times / d; or aminomethyl benzoic acid (PAMBA) 0.1 ~ 0.2g 25% glucose solution 20 ~ 40ml, by slow intravenous injection, 2 times / d, or aminomethyl benzoic acid ( PAMBA) 0.2g 5% glucose solution 250ml, intravenous infusion, 1 or 2 times / d.

B. Etamsylate: with enhanced adhesion of platelet function and reduce the role of vascular permeability, so as to achieve hemostasis: Specific Usage: Etamsylate 0.25g 25% glucose solution 40m1, intravenous, 1 to 2 times / d; or Etamsylate 0.75g 5% glucose 500ml, intravenous infusion, 1 / d.

C. batroxobin: Snake from Brazil (Brazil is a viper) venom after separation and purification and a thrombin preparation, each ampoule containing 1 gs units (KU) of batroxobin injection 1KU of batroxobin 20min after the bleeding time in healthy adults will be shortened to 1 / 2 or 1 / 3, the effect can be maintained 2 to 3 days, this product only has a hemostatic effect, blood prothrombin is not thereby increased the number of , it is generally no risk of thrombosis, the onset for intravenous or intramuscular injection, is also available for local use, adult daily dosage of 1.0 ~ 2.0KU, children 0.3 ~ 1.0KU, pay attention to the effectiveness of drug overdose will make it fall.

There are also reduced capillary leakage Ka Bake network (security network of blood); in prothrombin synthesis of vitamin K; against the heparin-protamine and medicine Yunnanbaiyao, various hemostatic powder, given the large clinical mostly due to hemoptysis of bronchial or pulmonary blood vessels caused by rupture, so the drugs are generally only as a secondary treatment of massive hemoptysis.

(2) bronchoscopy in the treatment of massive hemoptysis: use of drug treatment for poor patients with refractory massive hemoptysis, bronchoscopy should be promptly checked, and its purpose: First, a clear bleeding site; the second is clear Chen airway blood; third with vasoconstrictor, thrombin, balloon tamponade and other methods to effectively stop bleeding, bleeding more, generally the first use of rigid bronchoscope removal of blood, then the application of rigid bronchoscopy fiberoptic bronchoscopy to find the bleeding site to stop the bleeding, now commonly used with bronchoscopy hemostatic measures:

① bronchial lavage: ice using 4 ℃ saline 50ml, through the bronchoscope into the bleeding lung segment, retention 1min after the aspiration for several consecutive weeks, each patient is generally required to 500ml of fluid volume to date, has reported a foreign group of 23 patients with massive hemoptysis patients, using this method of treatment, all patients with hemoptysis were under control, including 2 patients in the lavage bleeding again after a few days, but the first 2 times using the same method of irrigation washed bleeding stopped, I have repeatedly used this method for massive hemoptysis patients, the effect is very good, suggesting that making local ice saline lavage, blood vessels, blood flow slows down, thus promoting coagulation.

② local administration: through the bronchoscope to (1:20000) adrenaline solution 1 ~ 2ml, or (40U/ml) 5 ~ 10ml infusion of thrombin solution to bleeding sites, may play a contraction of blood vessels and promote coagulation role in hemostasis sure, there were also reported in 40U/ml of thrombin solution 5 ~ 10m1, add 2% fibrinogen solution 5 ~ 10ml, mixing after the infusion of the bleeding site, the hemostatic effect is more good.

③ balloon tamponade: bronchoscopy Fogarty balloon catheter will be sent to the bleeding site of the lung segment or sub-segmental bronchi, through the catheter to the balloon inflated or filled with water, resulting in bronchial tamponade the bleeding site, to stop the bleeding , but can also prevent excessive bleeding caused by the blood spilled into the healthy lung, thus effectively protecting the contralateral lung gas exchange function, generally 24 ~ 48h after balloon catheter, balloon relax, observe that after a few hours no further bleeding to extubation, a group of 14 patients with balloon tamponade in the treatment of patients with massive hemoptysis, 10 cases of bleeding under control, after 6 weeks to 9 months of follow-up, no further bleeding, the other, balloon tamponade technique is also often used to arterial embolization and surgery in patients with preoperative support, operation, should pay attention to prevent over-inflated balloon and the retention time is too long, caused by bronchial mucosal ischemic injury and obstructive pneumonia.

(3) selective bronchial artery embolization: According to the lungs by the bronchial artery and pulmonary artery of the dual blood supply, often between two sets of the circulatory system there is a potential traffic channels, and with phase adjustment function or mutual compensation, when the bronchial artery embolization, usually does not cause bronchial and lung tissue necrosis, which is bronchial artery embolization for massive hemoptysis provide an objective basis for the past 20 years, arterial embolization has been widely used in the treatment of patients with massive hemoptysis, especially For bilateral lesions or multiple parts of the bleeding; heart, poor lung function can not tolerate surgery or advanced lung cancer invading the mediastinum and great vessels by arterial embolization is a good alternative to surgical treatment.

selective embolization of bronchial arteriography is usually to determine the bleeding site at the same time, but X-ray-negative patients, bilateral disease or are not explain the source of bleeding lesions on one side, the selective bronchial arteriography will not be able, when first bronchoscopy, can often help identify the causes of hemoptysis and bleeding site, thus selective bronchial arteriography and bronchial artery embolization to create the conditions, once the bleeding site clear later, to the use of absorbent gelatin sponge (Gelfoam), oxidized cellulose, polyurethane, or anhydrous alcohol embolic material, as will all suspicious lesions artery embolization, and ancillary systems if the bronchial artery embolization after bleeding persists, the need Taking into account the possibility of pulmonary hemorrhage, the most common is the erosion of the false aneurysm, pulmonary abscess, pulmonary artery and pulmonary artery malformation rupture, this time should also be pulmonary angiography, once the clear lesions existed in favor of both pulmonary embolism accordingly, bronchial artery embolization for massive hemoptysis is certainly short-term effect, generally reported in the literature up to about 80% efficient, but after all is only a palliative treatment, not a substitute for surgery, anti-inflammatory, anti-TB and other causes of treatment.

Note that when angiography, spinal artery from bleeding bronchial artery, the embolization is contraindicated, because it causes the risk of spinal cord injury and paraplegia.

(4) radiation therapy: a literature, not suitable for surgery and bronchial artery embolization with advanced lung cancer and some lung infection aspergillosis patients with massive hemoptysis, localized radiation therapy may be effective, suggesting that radiation exposure caused by local vascular outside the tissue edema, vascular swelling and necrosis, resulting in blood clots and blocking, play hemostasis.

3. the vast majority of surgical treatment of massive hemoptysis patients after treatment of these measures can be under control of bleeding, however, despite some aggressive conservative treatment is still difficult to stop bleeding, hemoptysis, and its large amount of direct patients with life-threatening, surgical treatment should be considered.

(1) surgical indications: ① 24h hemoptysis over 1500ml, or hemoptysis reached within 24h 1 500ml, no bleeding tendency after medical treatment, ② repeated hemoptysis, when threatened with suffocation, ③ leaf or a lung side of the lung have a clear irreversible chronic disease (such as bronchiectasis, cavitary tuberculosis, lung abscess, pulmonary aspergilloma, etc.).

(2) surgical contraindications: ① a wide range of diffuse lesions in both lungs, (such as the lungs extensive bronchiectasis, multiple bronchopulmonary cyst), ② poor general condition, heart, pulmonary insufficiency compensatory, ③ non- primary pulmonary lesions caused by hemoptysis.

(3) the choice of timing of surgery: before surgery, patients should chest, bronchoscopy and other tests, a clear bleeding site, while also addressing the patients general health, heart, lung function have a comprehensive evaluation, can not accept heart and lung function tests, patients should be based on history, physical examination and other comprehensive judgments, especially in lung function after lung resection estimate, to be accurate, the timing of surgery in hemoptysis to select the gap period as well, with few complications of this surgery, high success rate, according to the foreign one set of data shows that in the event of massive hemoptysis during an operation, the mortality rate of up to 37%, of which the direct cause of death in most patients is due to inhalation of blood during surgery due to the contrary in hemoptysis clearance surgery, the mortality rate of only 8%, showing that the surgery at a large hemoptysis gap phases, can significantly reduce mortality.

4. complications of

(1) asphyxia: a major risk patients with massive hemoptysis is asphyxia, which is the main reason leading to the death of the patient, therefore, in the course of the treatment of massive hemoptysis should be alert to the occurrence of choking, chest tightness Once the patients had significant , irritability, throat sounds, rapid shallow breathing, sweating, one side (or both) disappearance of breath sounds, and even unconsciousness and other clinical manifestations of suffocation, should immediately take the following steps, go all out to rescue .

① clear as soon as possible airway blockage of blood to maintain airway patency: the patient picked up quickly, so head down, upper body and the edge of the bed into a 45 ℃ ~ 90 ℃ angle, assistant head of light to the patients care to the back flexion, in order to reduce the airway bend and break on the patient back, pour as much as possible remain in the airway of blood, and forced open the mouth (note the denture), clean up the blood in the oropharynx, then with a thick catheter (or bronchoscopy) inserted through the nose endotracheal aspirate blood.

② oxygen: immediate high-flow oxygen inhalation.

③ rapid establishment of intravenous access: the best set up two intravenous access, and provide necessary breathing stimulant, hemostatic drugs and to add volume.

④ absolute bed: to be the lifting of suffocation, keep the patient in the head high low enough to facilitate postural drainage and chest can be placed on ice, and to encourage patients to cough up blood in the airway.

⑤ to strengthen monitoring of vital signs, to prevent further asphyxia: their blood pressure, heart rate, ECG, respiration and blood oxygen saturation monitoring, ready to tracheal intubation and ventilator and other facilities to prevent further choking.

(2) hemorrhagic shock: If the patient is there because of massive hemoptysis and pulse rate, clammy, blood pressure, pulse pressure reduction, or even consciousness of hemorrhagic shock and other clinical manifestations should be in accordance with hemorrhagic shock treatment principles for emergency treatment.

(3) aspiration pneumonia: hemoptysis, the patient often is absorbed by blood and fever, body temperature around 38 ℃, or persistent, severe cough, elevated WBC, left shift, chest X-ray showed lesions compared with the previous increased, often prompts associated with aspiration pneumonia or tuberculosis spread, should be given adequate antibiotics or anti-TB drug treatment.

(4) atelectasis: Due to massive hemoptysis, blood clots blocking the bronchial; or because the patient is extremely weak, sedative, antitussive dosage excessive bronchial secretions and prevent the discharge of blood, could easily lead to atelectasis, pulmonary Zhangs treatment, the first row is the drainage of blood or sputum, and to encourage and help patients cough, atelectasis, if not long, try aminophylline, α-chymotrypsin, etc., inhalation, airway humidification, in order to facilitate the discharge of obstruction, of course, to eliminate atelectasis of the most effective solution is partial in the fiber bronchoscopic bronchial washing to remove the airway obstruction.

(b) the prognosis

Although hemoptysis patients, massive hemoptysis were less than 5%, but mortality is as high as 7% to 32%, it should be taken seriously enough.