1. Keep respiratory tract unobstructed
(1) Postural drainage: raise the position of the affected lung, lower the opening of the drainage bronchus, and make the sputum flow into the big bronchus and trachea, and then be discharged by coughing. If the lesion is in the lower lobe, the patient lies prone on his chest, clings to the edge of the bed, and coughs deeply with both hands to improve the drainage effect.
(2) Eliminating phlegm: It helps to restore the cilia swinging function, make the thick phlegm thinner, and is beneficial to cough. The following drugs can be selected: bromhexine 8 ~ 16 mg 3 times/d; Ambroxol (ambroxol) 30mg3 times/d; Standard extract of Myrtaceae leaves (strong dilute mucin) 300mg3 times/d; Fresh bamboo juice (fresh bamboo juice) 10ml3 times /d, or bromhexine 8mg solution atomized inhalation of bromhexine 8mg or mucosolvan 15 ~ 30 mg intravenous injection twice/d.
(3) Fiberoptic bronchoscope drainage for expectoration: It is an effective treatment measure, especially for patients who still can't expectorate after postural drainage, 1% epinephrine can be dripped into the bronchus to eliminate mucosal edema, reduce obstruction and be beneficial to expectoration.
(4) Bronchodilator: Appropriate bronchodilator is given to relieve airway spasm, which is beneficial to sputum discharge, such as oral aminophylline agonist; You can also inhale β2 receptor agonists.
2. The choice of antibiotics to actively control infection should be based on the type of infected bacteria and the penetration of infected bacteria into lung tissue and airway secretions. The patients with mild illness are mainly taken orally, and those with severe illness are given intravenous drugs. Generally, broad-spectrum antibiotics such as sulfamethoxazole/trimethoprim (compound sulfamethoxazole TMP-SMZ) are twice the first oral dose. New macrolide antibiotics such as clarithromycin 0.75g2 /d orally or azithromycin 0. 1g2.
Spoken language/d; Second-generation cephalosporins can also be selected, such as: intravenous injection of cefuroxime sodium 0.75g3 /d or oral administration of cefaclor 0.25g3 /d; Fluoroquinolones such as ciprofloxacin
0.5 ~ 0.75 G2 /d oral levofloxacin (0.1G2/d) It has been reported that injection of antibiotics after local lavage by fiberoptic bronchoscope can have a significant effect.
3. Treatment of complex hemoptysis Bronchiectasis is often complicated with hemoptysis. The amount of cough varies from a few sputum to a dozen or a lot of hemoptysis. The definition of massive hemoptysis is inconclusive. Some people think that the blood volume at a time is greater than 100ml, while others emphasize that the blood volume within 24 hours is greater than 300ml. In fact, the estimation of hemoptysis should not be limited to numbers, but should be combined with the patient's complexion, pulse, respiratory blood pressure, cyanosis and so on.
(1) Hemostatic drugs:
① General hemostatic drugs usually work by improving the functions of capillaries and platelets. In fact, the common hemoptysis is not or not entirely due to the above mechanism, so their therapeutic effect is not exact, so they can not be used as the main method to treat hemoptysis. These drugs include aminocaproic acid (6- aminocaproic acid, PAMBA) and aminotoluic acid (4-carboxybenzylamine, EACA) which resist fibrinolysis; Phenylsulfonamide for increasing platelet and capillary function
Carbachlor (hemostatics) (Roan blood); Vitamin k involved in prothrombin synthesis; The traditional Chinese medicines of protamine against heparin include Yunnan Baiyao and various hemostatic powders.
② pituitrin: It has a strong vasoconstrictive effect. Usually, 10 ~ 20u is added into 250~500ml of liquid for intravenous drip, and 10~20U is injected into 20 ~ 40ml of liquid for massive hemoptysis, and then 10 ~ 20u for intravenous drip, and the daily dosage can reach 20 ~. For massive hemoptysis, continuous medication 1.2 ~ 24 hours is usually recommended to avoid gradual reduction after a single large dose of medication takes effect. Use with caution in patients with hypertension, coronary heart disease and pregnancy.
(2) Vasodilators: The hemostatic mechanisms of these drugs include:
① Dilating blood vessels reduces pulmonary artery pressure, and pulmonary wedge pressure reduces pulmonary blood flow;
② The systemic vascular resistance decreases, and the blood flowing to the pulmonary vascular bed decreases, which plays the role of "internal bleeding". Usually, phentolamine 10 ~ 20 mg, an α receptor blocker, is added into 250 ~ 500 ml liquid for intravenous drip for 5 ~ 7 days. When the blood volume is large and insufficient, the drug should be used again on the basis of supplementing the blood volume. Other similar drugs include atropine 654-2 isosorbide dinitrate and calcium antagonist, and procaine is also commonly used in the treatment of hemoptysis, which can dilate blood vessels, reduce the pressure of pulmonary circulation, and achieve the purpose of hemostasis by sedation. Usually, 300 ~ 500mg is added into 250 ~ 500ml of liquid, and it is intravenously dripped, 65,438+0 ~ 2 times a day. A few people who are allergic to this drug should have a skin test.
The main indication of vasodilators is the contraindication of pituitrin, followed by the poor curative effect of pituitrin. Sometimes pituitrin combined with vasodilator can not only reduce the pulmonary circulation pressure, reduce the pulmonary blood content, but also contract the pulmonary arterioles, help stop bleeding, prevent blood pressure from falling, and achieve complementary effects.
(3) Fiberoptic bronchoscope: For some patients without sudden bleeding, 0. 1% epinephrine or 5m 1 norepinephrine can be dripped into the bleeding focus through fiberoptic bronchoscope, but the drug treatment is ineffective. For patients who can't determine the specific bleeding focus, 500ml of 4℃ cold normal saline and 4mg of epinephrine can be injected into the bleeding lung segment in batches for 65438±0min, and then oxygen is given by mask or high frequency ventilation to treat inoperable massive hemoptysis or above. After treatment with fiberoptic bronchoscope, patients who still have a lot of bleeding can send balloon catheter into the corresponding bleeding bronchus through fiberoptic bronchoscope to inflate the balloon or fill it with water to block the bleeding bronchus, so as to prevent bleeding, submerge healthy lungs, and relax the balloon after 24 hours of hemostasis. When there is no bleeding again, the catheter can be removed.
(4) Bronchial artery embolization: As an effective method to treat hemoptysis, selective bronchial artery embolization has a wide range of indications. It is generally believed that bronchial artery embolization, especially for the first aid of acute fatal massive hemoptysis, can be considered for those who suspect that bronchial hemoptysis is ineffective after medical treatment and have no contraindications to angiography. The treatment of long-term recurrent hemoptysis, as well as the treatment of patients with massive hemoptysis and low pulmonary function who can't tolerate surgery, is as follows: selective bronchial arteriography shows that the communication between dilator and pulmonary artery is abnormal and the contrast agent is extravasated. It is suggested that the diseased bronchial artery should be completely embolized with absorbent gelatin sponge oxidized cellulose as far as possible.
The long-term effect of bronchial artery embolization is affected by the severity of preoperative basic lesions and postoperative infection control in patients with hemoptysis. Due to the universality and irreversibility of bronchiectasis, abnormal blood vessels involved in blood supply in the focus area are abundant, and sometimes pulmonary artery may also participate in bleeding. Therefore, incomplete embolization is inevitable. In addition, severe bronchial distortion, poor expectoration, persistent infection, and easy reconstruction of local bronchial artery collateral circulation can all make hemoptysis recur. Selective bronchial artery embolization, as a traumatic technique to treat hemoptysis, should also be paid great attention to in clinic, mainly because spinal artery embolization can cause transverse injury to the spinal cord.
4. Surgical treatment: Lung resection is the only way to radically cure bronchiectasis. The specific surgical indications should be determined according to the chest X-ray film and the results of pulmonary function examination. Indications are repeated acute respiratory infections and/or massive hemoptysis. The lesion range is less than 40 years old and the whole body is in good condition. Lobectomy can be performed according to the scope of the lesion. Whether to perform bilateral extensive bronchiectasis has been controversial. For those with complicated emphysema or the elderly and infirm, surgery is not suitable. For those who cannot tolerate surgery due to repeated massive hemoptysis, bronchial artery embolization can be used to stop bleeding after bronchial arteriography confirms vascular lesions.