PULMONARY BLEEDING (synonym gemoptoe) — allocation of a significant amount of blood from respiratory tracts in pure form or in the form of plentiful impurity to a phlegm. L. to. it is necessary to distinguish from blood spitting (see), at Krom impurity of blood in a phlegm is small.
Etiology and pathogeny
L. to. is a symptom various, most often inflammatory diseases of a respiratory organs nonspecific (bacterial, virus and fungal) or specific (tuberculosis, syphilis) origins, and also malignant tumors of lungs. Repeated L. to. quite often serve as the only symptom of so-called dry bronchiectasias. Reason of massive L. to. there can be gangrenous abscess or gangrene of a lung. At an aspergillosis of L. to. arises more often than at other fungus diseases of lungs. Thanks to chemotherapy tuberculosis ceased to play the dominating role among the reasons of L. to., however at hron, fibrous and cavernous tuberculosis late L. to. take place and quite often are a cause of death.
At nonspecific and specific inflammatory diseases of lungs of a source of L. to. are it is excessive developed (in a zone of bronchiectasias or tubercular cavities) networks of expanded bronchial vessels (up to development of spindle-shaped and sacculate aneurisms — so-called aneurisms of Rasmussen). L. to. arises at a rupture of aneurism or an arrosion of its wall. At tumors bleeding is caused by a necrosis or disintegration of fabric, destruction of again formed thin-walled lacunas, networks of the smallest vessels deprived of an elastic cover.
The closed injury of a lung with a compression of a thorax and a contusion or a rupture of pulmonary fabric which is followed by damage of vessels causes plentiful L. to. even in the absence of disturbance of an integrity of a visceral pleura. Reason of L. to. there can be also aspirirovanny sharp-pointed or dense foreign bodys of bronchial tubes causing wound of vessels or an arrosion of their wall owing to decubitus. Often L. to. it is observed at long stay in a parenchyma of a lung of foreign bodys of a fire origin.
According to Remy (J. Remy) and soavt. (1977), from 104 patients with L. to. tuberculosis was is intravital a bronchoectatic disease at 27, an aspergillosis at 19, other pneumomycoses at 14, cancer of a lung at 3 is established at 35 people, the pulmonary cyst — at 3, the Echinococcosis at 2 patients, at one patient the reason of bleeding is not established.
Other group of the diseases which are complicated by L. to. — diseases of bodies of blood circulation. Plentiful L. to. at a mitral stenosis are caused by difficulty of outflow from a small circle of blood circulation and a rupture of expanded bronchial veins; at aortic aneurysms of L. to. arises at their opening in a trachea and primary bronchi (left is more often). Repeated L. to. are characteristic of inborn heart diseases with defect of a partition (at Eyzenmenger's complex).
L. to. at diseases of blood it is most often connected with hemorrhagic diathesis. Bleeding from varicose the changed veins of a mucous membrane of a trachea, bronchial tubes and arteriovenous aneurisms is observed at Osler's disease — Randyu. A specific place is held by L. to. at endometriosis of a lung, a cut arises during monthly.
L. to. after lung operations can be owing to formation of bronchial fistula and an empyema of the pleura which is followed by an arrosion of a large vessel and also in connection with difficulty of outflow from a pulmonary vein, on a cut flows blood from the remained ambassador of a resection of a part of a lung. Late post-resection L. to. are possible in connection with a recurrent tumor or other patol, process. L. to. during a bronkhoskopiya are observed at a biopsy of strongly vaskulyarizirovanny tumor or at the time of extraction of the wedged foreign body.
On intensity of L. to. divide on massive and moderate. Assessment of degree of intensity of bleeding is complicated owing to the subjectivity of the patient and the doctor who are differently estimating amount of the emitted blood though under a concept of massive L. to. conditionally mean expectoration of 600 and more milliliters of blood in 24 hours. For definition of intensity of bleeding use also a wedge, signs and a lab. tests: total deficit of volume of the circulating blood and its components (volume of plasma, globular volume, the crude circulating proteins and hemoglobin).
Clinical manifestations and diagnosis
At L. to. blood clears the throat, emitted struyno or to synchronously little tussive pushes. The emitted blood has rose-red color, she foamy, does not curl up. For differential diagnosis with gastric bleeding or bleeding from expanded veins of a gullet alkali reaction of the blood masses allocated with cough matters. Blood, aspirirovanny of upper parts of a digestive tract, keeps acid reaction. At a long delay of blood in abscess cavities or cavities color of expectorated blood becomes dark brown, sometimes «rusty»; clots can remind the porous soft masses included in scarlet foamy blood. To establish on the basis of a physical research localization of a bleeding point and furthermore its reason it is not always obviously possible though sometimes patients as if feel from where there is bleeding and aim to reach the position softening cough.
In all cases of L. to. the comprehensive examination including rentgenol, a research with survey roentgenograms is necessary and bronkhoskopiya (see). The last is especially important since she allows to establish outward of a mucous membrane, the vascular drawing, existence of tumorous and granulematozny growths in bronchial tubes. It allows to specify the diagnosis of bleeding. After a stop of L. to. apply tomography (see) and bronchography (see); the angiography of bronchial arteries is of great importance for topical diagnosis of a bleeding point.
Treatment at L. to. first of all symptomatic and in the main does not differ from the principles of conservative treatment of any internal bleeding. Specific difference is the possibility of a bronchoscopic tamponade as temporary occlusion share or (more rare) than a segmental bronchus the absorbable gelatin sponge withheld in a bronchial tube by a special blocker or a narrow tampon. In rare instances it is possible to execute cauterization of the bleeding site, and the tamponade sometimes directed by the collagenic sponge moistened with solution aminocaproic to - you.
Artificial embolization of bronchial arteries is very effective. After catheterization of a bronchial artery, arteriography and identification of the direct and indirect signs indicating the place of bleeding in a vessel are injected moistened in Polyglucinum - salt solution pieces of Combutecum (length of 0,5 — 1 mm and 1 — 2 mm wide, on 3 — 5 pieces at the same time). It is possible to use for embolization also pieces of teflon, balls from silicone rubber. Pathogenetic treatment is directed to elimination of the reason which caused L. to. At destruction of the pulmonary fabric which is followed by bleeding most often resort to urgent pneumonectomy operations.
As, in addition to the complications inherent in any bleeding, for L. to. the aspiration of blood leading to the pneumonia caused by disturbance of drainage function of a bronchial tree after a stop of L is characteristic. to. careful sanitation of bronchial tubes by means of a bronkhoskopiya is necessary. During operation the toilet of bronchial tubes is carried out fibrobronkhoskopy, entered through an endotracheal tube.
Forecast diseases, at Krom there is a L. to., it is always serious and depends on intensity of bleeding. See also Bleeding .
Bibliography: Fundamentals of pulmonology, under the editorship of A. N. Kokosov, M., 1976, bibliogr.; The guide to an angiography, under the editorship of. And. X. Rabkina, page 139, M., 1977; The Guide to pulmonary surgery, under the editorship of I. S. Kolesnikov, L., 1969; The Guide to pulmonology, under the editorship of N. V. Putov and G. B. Fedoseyev, L., 1978; Yablokov D. D. A bronchopulmonary provoteche-niya and a blood spitting in clinic of tuberculosis and internal diseases, Tomsk, 1971, bibliogr.; Crofton J. Douglas A. Respiratory diseases, Oxford — Philadelphia, 1975; R e m y J. and. o. Treatment of hemoptysis by embolization of bronchial arteries, Radiology, v. 122, p. 33, 1977; S at 1 1 an A. Lungenkrankheiten, Bd 1 — 2, Lpz., 1978, Bibliogr.
G. I. Lukomsky.