看图识病：患者咳出树杈样的完整血凝块？

A 36-year-old man was admitted to the intensive care unit with an acute exacerbation of chronic heart failure. His medical history included heart failure with an ejection fraction of 20%, bioprosthetic aortic-valve replacement for bicuspid aortic stenosis, endovascular stenting of an aortic aneurysm, and placement of a permanent pacemaker for complete heart block. An Impella ventricular assist device was placed for management of acute heart failure, and a continuous heparin infusion was initiated for systemic anticoagulation. 

患者为一名36岁男性，因慢性心力衰竭急性发作入住重症监护病房。他既往有心衰病史，射血分数为20％，进行过用于双尖主动脉瓣狭窄的生物假体主动脉瓣置换术，主动脉瘤的血管内支架植入术以及植入了用于完全心脏传导阻滞的永久起搏器。放置了Impella心室辅助装置用于治疗急性心力衰竭，并且开始连续肝素输注用于全身抗凝。

During the next week, the patient had episodes of small-volume hemoptysis, increasing respiratory distress, and increasing use of supplemental oxygen (up to 20 liters delivered through a high-flow nasal cannula). During an extreme bout of coughing, the patient spontaneously expectorated an intact cast of the right bronchial tree. The right bronchial tree consists of three segmental branches in the upper lobe (blue arrows), two segmental branches in the middle lobe (white arrows), and five segmental branches in the lower lobe (black arrows). The patient’s trachea was subsequently intubated, and flexible bronchoscopy revealed a small amount of blood in the basilar branches of the right lower lobe. The patient was extubated 2 days later and had no further episodes of hemoptysis. One week after extubation, he died from complications of heart failure (volume overload and poor cardiac output) despite placement of the ventricular assist device.

在接下来的一周内，患者出现小量咯血，呼吸窘迫加重，并且吸氧增加（通过高流量鼻导管输送高达20升）。在极端的咳嗽期间，患者自发地咳出右支气管树的完整血凝块。右支气管树由上叶（蓝色箭头）中的三个节段分支，中叶（白色箭头）中的两个节段分支和下叶（黑色箭头）中的五个节段分支组成。

随后对患者进行气管插管检查，活动性支气管镜检查显示右下叶的基底分支中有少量血液。患者在2天后拔管，没有再次出现咯血。拔管后一周，尽管放置了心室辅助装置，他仍死于心力衰竭并发症（容量超负荷和心输出量不足）。

原始出处：Gavitt A. Woodard,et al. Cast of the Right Bronchial Tree.N Engl J Med 2018;https://www.nejm.org/doi/full/10.1056/NEJMicm1806493

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