Hemoptysis in Children

Hemoptysis in Children

A child spewing bright red blood across the room will likely grab your attention, and potentially ruin your day. Fortunately, it is a rare event, but it is the life-threatening rare event that we must remain vigilant for! The post-tonsillectomy hemorrhage gets a lot of “publicity,” but let’s not overlook other reasons a child may turn into a hemorrhagic faucet. This week, let’s review Hemoptysis in Children:

Hemoptysis: Basics

  • Hemoptysis = Coughing up blood or bloody sputum (the lungs are the source of bleeding)
  • Rare, but potentially life-threatening. [Simon, 2017]
  • Most often it is self-limited. [Naum, 2019]
  • The lungs have 2 separate blood supplies: [Singh, 2013]
    • Pulmonary Arteries – account for ~99% of blood supply; low pressure
    • Bronchial Arteries – provide blood to the airway structures; high pressure
    • The two systems are connected at the thin-walled anastomoses of the vasa vasorum.
  • “Grading” of hemoptysis:
    • Difficult to determine.
    • Not universally agreed upon. [Naum, 2019]
      • “Scant:” < 5 mL of blood loss
      • Mild-Moderate: 6 – 240 mL of blood loss
      • Massive: > 240 mL of blood loss or > 8mL/kg/Day; “You know it when you see it!”

Hemoptysis vs Hematemesis

  • Determining where the bleeding is coming from is often challenging.
    • Young children often swallow the expectorated blood before coughing it out. [Abu-Kishk, 2012]
    • Vomiting may also be associated with coughing episodes (post-tussive emesis) and vice versa.
  • Some potential distinguishing features:
    • pH:
      • Hemoptysis is typically alkaline
      • Hematemesis is often acidic
    • Color:
      • Hemoptysis tends to be pink or red
      • Hematemesis tends to be dark red or brown (if brisk , may be bright red)
    • Other Appearances:
      • Hemoptysis tends to be frothy; Hematemesis is usually not.
      • Hemoptysis often mixed with sputum; Hematemesis may have food particles
  • History Matters:
    • Since expectorated blood can be swallowed and then induce vomiting, and vomited blood can be trigger coughing too, how the material appears may be less than helpful.
    • Try to discern whether prior to the production of blood there was:
      • Nausea/vomiting – favors GI source
      • Cough/gagging/choking – favors pulmonary source
      • Past Medical History of lung or GI / hepatic pathology also helpful.

Hemoptysis: Possible Causes

  • Infectious (Pneumonia, Bronchitis, Lung Abscess) [Simon, 2017; Abu-Kishk, 2012]
    • The most common (~40%) cause of hemoptysis in children.
    • Pneumonia may be bacterial, viral, fungal, or parasitic.
    • Don’t forget about tuberculosis.
  • Local Trauma (Aspirated Foreign Body, Pulmonary Contusion, Iatrogenic) [Singh, 2013; Abu-Kishk, 2012]
    • Foreign bodies can lead to direct trauma, but local inflammatory process caused by organic material can also cause bleeding.
    • Always take parental concerns for possible choking on object seriously!
  • Congenital Heart Disease [Simon, 2017; Singh, 2013; Abu-Kishk, 2012]
  • Vascular
  • Bronchiectasis [Singh, 2013; Abu-Kishk, 2012]
    • Particularly problematic in patients with Cystic Fibrosis.
    • May be from prior aspiration, prior infection, or ciliary dyskinesia.
  • Cancers [Simon, 2017; Abu-Kishk, 2012]
    • Fortunately, this is rare in children… but…
    • Bronchial Carcinoid and Bronchial Adenoma do occur. [Singh, 2013]
  • Idiopathic (~12% of cases) [Simon, 2017; Abu-Kishk, 2012]

Hemoptysis: Management

  • STABILIZE FIRST! ABCs as always!
    • Massive Hemoptysis will make videoscopic laryngoscopy very challenging (if not impossible – blood on camera lens makes visualization difficult)
    • Have lots of suctioning ready and in hand.
    • Have all options ready and in arms reach.
    • Use High PEEP once mechanically ventilated. [Naum, 2019]
    • Give PRBCs … consider Massive Transfusion Protocol… and TXA!
  • If stable now, (that your lucky stars) anticipate impending disaster! [Simon, 2017]
    • Obtain Labs:
      • Type and Cross
      • CBC with Diff
      • Coagulation Studies
      • Liver Function Tests (if concern for hepatic etiology of bleeding)
    • Obtain an Image:
      • Chest X-ray is the screening tool of choice. [Singh, 2013]
        • May show pneumonia (most common etiology), or mass.
        • May define affected side… if massive hemoptysis, place the affected side DOWN and oxygenate the good lung. [Naum, 2019]
        • May be normal… and will be in ~33% of cases.
      • Chest CT may be required, but only if patient stable and/or airway protected. [Simon, 2017]
      • Bronchoscopy will be the means to determine etiology if not determined by other modalities.

Moral of the Morsel

  • Remain vigilant! It is likely related to a pulmonary infection… but…
  • Check the pH! It may help distinguish between GI and Pulmonary source!
  • Check that CXR! It is the preferred screening tool and may show the cause!
  • Gravity Works! – Use it to your advantage. Place affected side DOWN so you can oxygenate the good side.

References

Naum R1, Speed B2. Hemoptysis in Pediatric Patients. Cureus. 2019 Mar 23;11(3):e4305. PMID: 31183285. [PubMed] [Read by QxMD]
Qiu L1,2, Zan Y1,2, Zhong L1,2, Liu H1,2, Tao Q1, Chen L1,2. Foreign body aspiration as a cause of cryptogenic hemoptysis in a child: A case report. Medicine (Baltimore). 2018 May;97(20):e10715. PMID: 29768339. [PubMed] [Read by QxMD]
Zaidi SJ1, Schweig L1, Patel D1, Javois A1, Akhter J2. A novel approach to the diagnosis and treatment of hemoptysis in infants: A case series. Pediatr Pulmonol. 2018 Nov;53(11):1504-1509. PMID: 30226294. [PubMed] [Read by QxMD]
Simon DR1, Aronoff SC1, Del Vecchio MT1. Etiologies of hemoptysis in children: A systematic review of 171 patients. Pediatr Pulmonol. 2017 Feb;52(2):255-259. PMID: 27575742. [PubMed] [Read by QxMD]
Singh D1, Bhalla AS1, Veedu PT1, Arora A1. Imaging evaluation of hemoptysis in children. World J Clin Pediatr. 2013 Nov 8;2(4):54-64. PMID: 25254175. [PubMed] [Read by QxMD]
Abu-Kishk I1, Klin B, Eshel G. Hemoptysis in children: a single institutional experience. Pediatr Emerg Care. 2012 Nov;28(11):1206-10. PMID: 23114250. [PubMed] [Read by QxMD]
Dine AP1, Werner SL. Pediatric hemoptysis with pulmonary hemorrhage and respiratory failure. Am J Emerg Med. 2008 Jun;26(5):639. PMID: 18534322. [PubMed] [Read by QxMD]
Batra PS1, Holinger LD. Etiology and management of pediatric hemoptysis. Arch Otolaryngol Head Neck Surg. 2001 Apr;127(4):377-82. PMID: 11296044. [PubMed] [Read by QxMD]
Coss-Bu JA1, Sachdeva RC, Bricker JT, Harrison GM, Jefferson LS. Hemoptysis: a 10-year retrospective study. Pediatrics. 1997 Sep;100(3):E7. PMID: 9271622. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. Great Blog..
    All the information that you shared with us that is very helpful and useful for us. Thank You

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