Hemoptysis

Hemoptysis in children is rare but can be dramatic, frightening, and potentially life-threatening. The expectoration of blood or blood-tinged sputum presents the clinician with significant diagnostic and therapeutic challenges. An understanding of the etiology, diagnosis, and management of hemoptysis is important for all clinicians.The blood supply to the lungs is composed of 2 circulatory systems, bronchial and pulmonary. The bronchial system is high pressure but low volume. Bronchial vessels arise from the aorta and its branches, supplying blood to the conducting airways, down to the terminal bronchioles. The pulmonary system is the opposite, low pressure and high volume. Vessels from this system arise from the right ventricle and supply the acini. Hemoptysis results when endothelial damage occurs, causing either low-volume bleeding if originating from the pulmonary circulatory system or profuse bleeding if occurring in the high-pressure bronchial system.A variety of factors make it difficult to ascertain the incidence of hemoptysis in children: under the age of 6 years, children have a tendency to swallow their sputum; most cases are mild and resolve within 24 hours; and there is no mandatory reporting of most conditions that cause hemoptysis or pulmonary hemorrhage. Hemoptysis may result from a variety of causes (Table), ranging from the most common, such as infections, to more rare causes, such as vasculitides.Evaluation of hemoptysis begins with establishing that the bleeding is from the lower respiratory tract and not from an extrapulmonary source, such as the gastrointestinal tract or the upper airway. Patients with hemoptysis may report a prodromal tingling in the throat or gurgling noise from the chest. If blood is coughed out, it is typically bright red, frothy, and may be mixed with sputum. Patients may note respiratory distress and can have a history of lung disease. In contrast, patients with hematemesis typically note abdominal pain and nausea, and the blood is vomited, usually brown or “coffee grounds” in color, and may be mixed with food particles.In patients who appear critically ill with cardiorespiratory compromise, the priority is to stabilize the airway, breathing, and circulation. Then, the evaluation of hemoptysis begins with a thorough history and physical examination. Questioning should focus on a history of preexisting medical conditions, systemic symptoms, recent illness, and recent travel. A new, sudden-onset cough or wheeze can raise suspicion of foreign body aspiration. A history of hematuria can suggest a pulmonary-renal syndrome, and a history of calf pain raises concern for pulmonary embolus. The physical examination should include a thorough evaluation of the upper airway for sources of bleeding. A detailed pulmonary examination can help to localize the bleed or indicate the underlying cause. Cardiac auscultation may reveal a heart murmur, indicating a cardiac etiology. The skin examination is unlikely to demonstrate pallor but may uncover bruises or signs of trauma.In continuing the evaluation, a complete blood cell (CBC) count, coagulation profile, inflammatory markers (C-reactive protein and erythrocyte sediment rate), and urinalysis should be sent. A CBC count can help quantify the amount of blood lost. Derangement in the coagulation profile can indicate an underlying coagulopathy. Inflammatory markers can suggest inflammation in the setting of infection or vasculitic disease. Proteinuria or hematuria may point to a pulmonary-renal syndrome and require further laboratory studies. Because infection is the most common cause of hemoptysis, sputum from expectoration, nasotracheal suction, or bronchoscopy should be sent to the laboratory to help distinguish among bacterial, fungal, and mycobacterial infections and tailor treatment accordingly.The plain chest radiograph can be useful. Most commonly it can demonstrate focal or diffuse opacities consistent with infection. Other potential findings include hyperinflation suggestive of a foreign body, atelectasis, interstitial infiltrates, pleural effusion, cardiomegaly, and the typical tram-track sign suggestive of bronchiectasis. In 33% to 50% of patients, results of chest radiographs are normal, and patients require further imaging to better assess the origin of their hemoptysis. Computed tomographic (CT) scanning with contrast angiography can be an important tool in depicting and localizing the underlying cause, including a vascular abnormality, infection, or bronchiectasis. On CT scan, an acute bleed manifests as a focal consolidation with surrounding areas of ground glass appearance. Further studies can include magnetic resonance imaging or echocardiography to investigate possible cardiac causes.Bronchoscopy is indicated if the source of the blood remains unknown and bleeding persists. Flexible bronchoscopy allows for better visualization of the distal bronchial tree and can be used to take cytologic, histiopathologic, and microbiologic specimens. In clinical scenarios where a foreign body is suspected, a patient has heavy bleeding, or there is the potential for respiratory compromise, rigid bronchoscopy is the preferred modality: it allows for the removal of foreign bodies, suctioning of blood, and injection of hemostatic agents while providing effective ventilation and airway stability.The treatment of hemoptysis depends on the underlying cause and the severity of the bleed. In pediatrics, most episodes of hemoptysis are mild and resolve spontaneously without invasive treatment. In children who are clinically stable and the specific etiology of their hemoptysis is suspected, management is directed at the underlying cause. In situations of massive bleeding, rigid bronchoscopy is indicated so that topical vasoconstrictors can be applied to curtail the bleeding and, if needed, endobronchial tamponade can be performed.In rare cases, when bleeding persists, the responsible blood vessel needs to be embolized: bronchial arteriography is performed to identify the bleeding vessel, and, once identified, the vessel is then cannulated and embolized using an absorbable gel sponge, a coil, or polyvinyl alcohol particles. In 77% of cases, embolization results in immediate cessation of bleeding, as well as long-term control beyond 3 months in 45% of all cases.COMMENT: Drs Shnayder and Needleman mention that young children tend to swallow their sputum, the inference being that some cases of what really is hemoptysis go unrecognized. When bloody sputum from a hemorrhage in the lungs is swallowed, it can be a gastric irritant leading to vomiting; and the bloody vomitus can easily be misdiagnosed as hematemesis. Although both hemoptysis and hematemesis can be life-threatening, while the alarm bells go off it can be calming to remember that in children, both conditions, frightening as they are, most often are relatively benign and self-limited.