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]
  • Hypoplasia of pulmonary artery/veins
  • Primary Pulmonary Hypertension
  • Eisenmenger Syndrome
• Vascular
  • Pulmonary Embolism
  • AVM
• 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.
    • Large bore to deal with clots and volume!
    • One trick… do what Neonatologists used to do for sticky situations… use a Meconium Aspirator on an endotracheal tube.
  • 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