支气管扩张并咯血

,Chart Rounds Reporter：Dr.Dongping Xu VS：Dr.Jinhua Sun Dr.Liang Chen Date：December 10, 2014,Personal history,Name：Chen xxGender：MaleAge：62Occupation：NoneDate of admission：2014.11.03-2014.11.17Chart number：1034671,Chief complaint,Cough, sputum 40 years, hemoptysis one hour,Q1：What is hemoptysis？,A1：The following supraglottic airway or lung tissue bleeding, tissue out through the mouth,Q2：Identification of hemoptysis？,A2：oral hemorrhagenasal hemorrhagehematemesis,Q3：Causes of hemoptysis？,A3,Airways diseases Pulmonary parenchymal diseasesPulmonary vascular disordersCryptogenic Johnston H, Reisz G. Changing spectrum of hemoptysis. Underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy. Arch Intern Med 1989; 149:1666.,Airways diseases,Bronchitis and bronchiectasisNeoplasmForeign bodiesAirway trauma FistulasDieulafoy lesion,Pulmonary parenchymal diseases,InfectionRheumatic and immune disorders Genetic disorders of connective tissueCoagulopathyIatrogenicCocaine-induced pulmonary hemorrhage,Pulmonary parenchymal diseases,Catamenial hemoptysis Bevacizumab treatment Nitrogen dioxide exposure in indoor ice arenas,US survey shows:The most common cause- bronchitis (26%)Lung cancer (23%)Pneumonia (10%)Tuberculosis (8%) Postgrad Med 2002;112:101-13,A study in South Africa found that the cause of hemoptysis were:TuberculosisBronchiectasisNecrotizing pneumoniaAbscessBronchial arteriovenous fistulaInvasive fungal infectionsBleeding disorders Postgrad Med 2002;112:101-13,Diagnosis Cases (%)Bronchiectasis 48 (26.1)Chronic bronchitis 42 (22.8)Acute bronchitis 27 (14.7)Lung cancer 24 (13)Interstitial lung disease 9 (4.9)Tuberculosis 8 (4.3)Pneumonia 8 (4.3)Nonpulmonary bleeding 4 (2.2)Unknown 10 (5.4)Prospective Analysis of 184 Hemoptysis Cases Respiration 2006;73:808814,Present illness,- 40 years ago- Cough with a lot of yellow sputum ，volume:100+ ml- 35 years ago- Sputum with blood Diagnosed “ Bronchiectasis ” in CGMH, LinKou- 0.5 month ago- Cough/sputum exacerbation with chest pain in LLL/SOB CXR / Bronchial Scope Bronchiectasis with infection Rx-Cefoperazone sulbactam ten days,Present illness,- 1 hours ago - hemoptysis : sputum with blood， fresh blood with clots Volume: 500 ml (total) In ER-CXR - Bronchiectasis with Infection in LLBTranexamic acid 1.0g,Past History,4 months ago- Direct inguinal hernia,Personal Histroy,Alcohol drinking /Smoking : Denied,PE,Consciousness: clear, E4V5M6Vital sign: T 36.0, P 67 bpm, R 22/min, BP 126/77 mmHgHENNT: Eyelid conjunctival no pale lips no cyanosisChest : breath sounds: coarse，rales in LLB Heart: HR 67/min，regular heart beat, murmurs( -) , thrill:-Abdomen: soft /round , no tenderness/rebounding pain/ shifting dullness/ organ megaly - bowel sounds: normoactive,20141028 Bronchoscopy,20141028 Bronchoscopy,20141028 Bronchoscopy,20141028 Bronchoscopy,1.左下肺粘膜肿胀，左下肺基底段可见多量黄色分泌物，吸净后见LB8近端见局部粘膜凸起，LB9、 LB10粘膜增生并远端管腔狭窄，支气管镜无法通过，粘膜表面凹凸不平，未见明显出血。2.于LB9、LB10行支气管内超声，均可见边缘不规整病灶，内部回声不均匀，可见少量钙化，未见支气管气征（待病理等结果）。,20141028 Pathology,肺，LB10，活检术 - 慢性炎,11.3 Lab Data,WBC 11.6 109/L RBC 5.15 1012/L Hemoglobin 148 g/L Platelets 384 109/L Segment 51.0 %Lymphocyte 44.0 %,11.3 Lab Data,P.T 11.6 secNor.plasma mean 11.1 sec INR 1.0 APTT 26.0 sec Nor.plasma mean 28.8 sec Fibrinogen 3.21 g/L D-dimer 0.50 mg/L FDP 3.2 mg/L,11.3 Lab Data,HS-CRP 3.18 mg/LLactate (B) 2.04 mmol/LAlbumin 33.2 g/L Total Bilirubin 6.89 umol/L D. Bilirubin 3.25 umol/L AST/GOT 23 U/L ALT/GPT 27 U/L Creatinine 70.27 umol/LNa 139.7 mmol/L K 4.43 mmol/L Cl 100.4 mmol/LGlucose(PC) 7.06 mmol/L,11.3 Lab Data,pH 7.459 PCO2 41.7 mmHG PO2 111.1 mmHG HCO3 28.9 mmol/LABE 4.6 mmol/L SAT 98.3 %,11.4 Sputum culture,Normal flora,11.3 Chest X-ray,Cardiography Echo,1.心内结构未见明显异常2.左心室收缩功能正常，左室舒张功能正常,Initial Impression,1. Bronchiectasis of LLB with massive Hemoptysis2.Pulmonary Infection of LLB,Q4：The classification of haemoptysis？,A4,A small amount of hemoptysis：100ml/24hModerate hemoptysis:100-500ml/24hMassive hemoptysis:500mL/24h or 100 mL/hour Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000; 28:1642.,Massive Hemoptysis Definition,massive hemoptysis as either 500 mL of expectorated blood over a 24 hour period or bleeding at a rate 100 mL/hour, regardless of whether abnormal gas exchange or hemodynamic instability exists. (Some clinicians argue that a large volume of expectorated blood alone should not define massive hemoptysis, but rather, that abnormal gas exchange and hemodynamic instability should also be present .),Q5：The initial management of massive hemoptysis？,A5：Massive hemoptysis: Initial management,Identify which side is bleedingPosition the patientEstablish a patent airway:a large bore endotracheal tube (size 8.0 or greater, if possible)Insure adequate gas exchange:Insure adequate cardiovascular functionControl the bleeding,Control the bleeding,Non-surgical ：Blood products ：coagulation abnormalities should be rapidly reversedBronchoscopy：include balloon tamponade, iced saline lavage, topical medications, laser therapy, and electrocauteryRemy-Jardin M, Bouaziz N, Dumont P, et al. Bronchial and nonbronchial systemic arteries at multi-detector row CT angiography: comparison with conventional angiography. Radiology 2004; 233:741.,Control the bleeding,Non-surgical ：3.Arteriography Arteriographic embolization1974 French scholar Remy Indications: (1) recurrent hemoptysis, chest extensive lesions is poor, unable to make lung resection (2) require surgery, no surgical conditions (3) hemoptysis recurrence after surgical treatment; (4) refusing surgery (5) BAE recurrence of hemoptysis,Control the bleeding,Surgery Patients with unilateral, uncontrollable bleeding Relative contraindications：severe underlying pulmonary diseaseactive tuberculosisdiffuse underlying lung disease (eg, cystic fibrosis, multiple AVMs, multifocal bronchiectasis)diffuse alveolar hemorrhage.Remy-Jardin M, Bouaziz N, Dumont P, et al. Bronchial and nonbronchial systemic arteries at multi-detector row CT angiography: comparison with conventional angiography. Radiology 2004; 233:741.,Treatment,Left lateral positionDesmopressin injectionTranexamic acidCefoperazon