Hemoptysis 是來自呼吸道的
Expectorated blood is bright red if the source is the upper airway or lungs
先排除 GI or ENT sourse
- 咳血 or 吐血
- NG 有血 -> GI
- 黑色的 -> GI
- 流鼻血、牙齦流血、胃部出血、食道出血
Massive hemoptysis = 600 mL in 24 hours
Minor hemoptysis as self-limited, small-volume expectoration of blood
in a patient with no comorbid lung disease, normal/stable oxygenation and ventilation,
normal vital signs, and no risk factors for continued bleeding.
The pulmonary arteries account for 99% of the blood flow to the lungs
but are a low-pressure system involved in gas exchange and rarely the source of massive hemoptysis.
The bronchial arteries accounts for only 1% of the blood flow to the lungs
but 90% of the cases of hemoptysis because it is a high-pressure system
D/D :
Bronchitis
Bronchiectasis
TB, fungus
Pneumonia
Malignancy
PE
Vasculitis (Wegener, Goodpasture, SLE)
Pulmonary edema (肺水腫, 粉紅泡沫痰)
Coagulopathy (Survey drug)
Aortic aneurysm
Rasmussen's aneurysm is an inflammatory pseudo-aneurysmal dilatation of a branch of pulmonary artery adjacent to a tuberculous cavity.
Squamous cell carcinoma accounts for a large number of cases of massive hemoptysis
Cardiopulmonary processes (e.g., pulmonary embolism and pulmonary hypertension) compromise the pulmonary artery blood flow,
causing compensatory increased bronchial artery blood flow via dilation and hypertrophy at the anastomotic level and resulting in hemoptysis within the alveoli.
Hematuria or renal insufficiency could suggest Goodpasture’s syndrome or granulomatosis with polyangiitis,
which is also associated with saddle nose deformity from septal perforation.
Cocaine and heroin inhalation and nitrogen dioxide exposure
排除 鼻血, 吐血,牙齦出血
消化道：嘔吐, 咖啡色(coffee ground) , 食物殘渣
咳血：會是鮮紅色的血, 混在痰中, 有泡沫
Q 出血大約多少？只有衛生紙上有？咳了多少量的血？
O 哪時開始有這樣的狀況？以前有沒有類似的經驗？
P 這次咳血有沒有特別的誘發因子？
E 有甚麼樣的狀況，會讓咳血更為嚴重？
R 現在還有在流血嗎？是自己止住的嗎？
A 其他症狀？
- 心臟衰竭、肺水腫：粉紅泡沫痰、喘、端坐呼吸, 水腫
- 凝血功能異常：身上有其他出血點、瘀青
- 慢性支氣管炎：多痰、慢性咳嗽、抽菸史
- TB/fungal：咳嗽、體重減輕、胸痛、發燒
- 血管炎：紫斑、腎衰竭、水腫
- SLE：是否合併有malar rash、關節痛、落髮
- 腫瘤：體重減輕、咳嗽
- 醫源性：最近是否有做過肺部的侵入性檢查
- PH 系統性疾病, 開刀,免疫抑制的狀況
(HIV, 移植, 自體免疫疾病, 化療)
- FH
- ABC
- 藥物 ( 抗凝血劑, 免疫抑制藥物 ) 過敏
- TOCC
診斷 :
- Lab : CBC/DC, 凝血功能(PT/aPTT/INR), 基本生化, 痰液培養 (TB)
如果懷疑血管炎 : 抽 ANCA, anti-GBM antibody
- 影像學 : CXR, CT
Chest radiography is the initial imaging modality, yielding a diagnosis up to 50% of the time
Advances in CT, specifically multidetector CT, have led to a decrease in cryptogenic cases.
- 氣管鏡 Bronchoscopy : 2/3 能夠定位出血點
- 反覆性大出血, 可以考慮做 angiography, 診斷並治療(栓塞)
Bronchial artery embolization and with cardiothoracic surgery or pulmonology for emergent bronchoscopy
Recent studies suggest that both multidetector CT and bronchoscopy provide the best outcomes in treating massive hemoptysis,
with most recommending multidetector CT prior to bronchoscopy
治療 :
先確定 Vital sign, 並區分病人是 Massive or Non - massive hemoptysis
If the patient has a tracheostomy, look for a Trachea-innominate fistula;
Control this with direct digital pressure on the anterior portion of the trachea against the posterior aspect of the sternum
using the tracheostomy as the point of access.
If the patient does not have a tracheostomy and requires airway control,
proceed immediately with RSI -> Larger-diameter endotracheal tube to allow for bronchoscopy !
Position : Affected lung is in a dependent position
可以 RSI !!
If bleeding is uncontrollable, you may preferentially intubate the main bronchus of the unaffected lung.
Fogarty catheter
If attempts at intubation fail, cricothyrotomy is an option.
Awake flexible, fiberoptic bronchoscopy :
Provides visualization of the more peripheral and upper lobes but does not provide optimal suctioning and does not allow for local treatment.
Rigid bronchoscopy usually requires general anesthesia but is possible with deep sedation; it allows for improved airway control.
Rigid bronchoscopy cannot fully view the upper lobes and peripheral lesions, but it offers greater suctioning ability than fiberoptic bronchoscopy and can provide treatment,
such as the passage of Fogarty balloon catheters for tamponade of bleeding, epinephrine instillation, and ice water lavage.
光纖支氣管鏡軟式的比較好找到病灶但是suction不足，治療不易
硬式的支氣管鏡比較好針對出血做處置
Surgery was the treatment of choice if bronchoscopic interventions failed,
but now it is reserved for massive hemoptysis resulting from specific conditions including
iatrogenic pulmonary artery injury, thoracic trauma, or bleeding from a tracheoinnominate artery fistula at a tracheostomy site
Bronchial artery embolization followed by bronchoscopy
Risks of bronchial artery embolization include transverse myelitis due to spinal cord ischemia and pulmonary artery infarction
- Non - massive
保守治療, 並處理 underlying
處理凝血功能異常 + 止咳
- Massive (24小時 > 600mL) → 需要緊急進行處理
先確定 Vital signs, 確保呼吸道維持通暢
Bad lung down：側躺
Angiography：早期做栓塞治療
* 手術治療：Lobectomy
→ 各種治療後仍持續大量出血可考慮
→ 禁忌症：pulmonary reserve 差、末期癌症、廣泛性肺部疾病、廣泛性肺泡出血等
→ 緊急手術的死亡率高
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