Hemoptysis The 5 Minute Pediatric Consult


	Hemoptysis

Helen Anita John-Kelly

Database
Differential Diagnosis
Data Gathering
Physical Examination
Laboratory Aids
Therapy
Bibliography

DATABASE

DEFINITION

Blood loss into the respiratory tract with amounts ranging from mild to massive which can cause hypoxia or exsanguination.

CAUSES

Bronchiectasis
Cavitary infections (e.g., tuberculosis, abscess, histoplasmosis)
Tumors (lymphomas)
Trauma (pulmonary contusion, bronchoscopy, airway manipulation)
Congenital heart disease with large collateral vessels
Foreign body aspiration
Pneumonia
Hemorrhagic diathesis including anticoagulant therapy
H-type tracheaesophageal fistula

PATHOPHYSIOLOGY

Related to the underlying pulmonary disease

EPIDEMIOLOGY

Large series of pediatric patients with massive hemoptysis have not been described.
Most instances of massive hemoptysis take place in older children.

COMPLICATIONS

Respiratory insufficiency
Hypovolemic shock

DIFFERENTIAL DIAGNOSIS

Infections: pneumonia, pulmonary abscess, tuberculosis
Pulmonary disease: cystic fibrosis, bronchiectasis, foreign body, arteriovenous malformation, congenital lung malformation, pulmonary emboli, pulmonary hemosiderosis
Cardiovascular disease
Collagen vascular disease: lupus, vasculitis, Goodpasture disease
Trauma
Coagulation disorder
Munchausen syndrome
Complications: anemia, pneumonia

DATA GATHERING

HISTORY

Familial history of pulmonary disease or bleeding disorder?
Exposure to environmental toxins?
Exposure to tuberculosis?
Drug use: cocaine, marijuana?

Question: Recurrent episodes of hemoptysis with significant spectrum production and cyst formation on chest x-ray?
Significance: Suggests a diagnosis of bronchiectasis.

Question: Acute pleuritic chest pain?
Significance: Raises the possibility of pulmonary embolism with infarction or some other pleurally based lesion. A pleural friction rub may be present.

PHYSICAL EXAMINATION

Finding: Pleural friction rub
Significance: May be associated with pulmonary embolism.

Finding: Pulmonary hypertension
Significance: Raise the diagnostic possibilities of primary pulmonary hypertension, mitral stenosis, and Eisenmenger syndrome.

Finding: Localized wheeze over a major lobar airway
Significance: Suggests an intramural lesion such as a foreign body or carcinoma.

Finding: Presence of a murmur over the lung fields
Significance: May suggest pulmonary arteriovenous malformation.

LABORATORY AIDS

Test: Complete blood count and reticulocyte count
Significance: May reveal the volume of blood loss and chronicity.

Test: Sputum and PPD
Significance: Tuberculosis is suspected.

Test: Drug screen
Significance: If appropriate.

Test: Chest x-ray both AP and lateral
Significance: May reveal pleural effusion, bronchiectasis, foreign bodies, or consolidation.

Test: Bronchoscopy
Significance: Usually performed to localize the site of bleeding and at times may be therapeutic (e.g., in foreign body removal).

Test: CT
Significance: May identify source of bleeding.

Test: Angiogram
Significance: Used to detect bleeding from arteriovascular malformation.

THERAPY

Initial management should follow the lines of Basic Life Support.
Support intravascular volume by packed red blood cells or fresh frozen plasma.
Methods used to stop localized bleeding include tamponade with balloon-tipped catheters, ice water lavage, catheter-directed umbilication, intravenous pitressin, and surgical resection. The last option is usually reserved for most difficult cases such as extensive collateralization of bronchial arteries or arteriovenous malformations not responsive to embolization.

PROGNOSIS

It depends on the etiology and the nature of hemoptysis. Immediate management of airway central decreases the morbidity and mortality.

ICD-9-CM 786.3

BIBLIOGRAPHY

Blumer JL. Pulmonary hemorrhage. Practical guide to pediatric intensive care, 3rd ed. 1991:359–361.

Cahill BC, Ingbar DH. Massive hemoptysis, assessment and management. Clin Chest Med 1994;15(1):147–167.

DiLeo MD, Gianoli GJ. Diagnosis and management of hemoptysis. LA State Med Soc 1994;146(4):115–118.

Thompson AB, Teschler H, Rennard SI. Pathogenesis, evaluation and therapy for massive hemoptysis. Clin Chest Med 1992;13(1):69–82.

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