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Hemoptysis

Hemoptysisis the coughing up of blood or blood-stained sputum.

It is a manifestation of bleeding intothe lungs or conducting airways, and as a consequence, blood alsomay be found in tracheal secretions or aspirate.

Principal Causes of Hemoptysis

1. Neonates
   1. Airwaytrauma
   2. Pulmonary hemorrhage
   3. Bleeding disorders
2. Infants, children, and adolescents
   1. Trauma
   2. Pulmonary disorders
      1. Bronchitis
      2. Pneumonia
      3. Lung abscess
      4. Bronchiectasis including cystic fibrosis
      5. Foreign body
      6. Idiopathic pulmonary hemosiderosis
      7. Pulmonary hemosiderosis with cow milkhypersensitivity
      8. Vascular anomalies
         1. Pulmonaryarteriovenous malformation
         2. Hereditary hemorrhagic telangiectasia(Osler-Rondu-Weber disease)
      9. Neoplasm
   3. Cardiac disorders
   4. Goodpasture syndrome
   5. Vasculitis
   6. Bleeding disorders

Clinical Features and Diagnosis

Neonates

Airway Trauma

Aggressive suctioning of trachea and mucosalinjury from endotracheal tube may cause mild tracheal bleeding,which is usually self-limited.

Pulmonary Hemorrhage

Sudden onsetof blood-tinged fluid oozing from trachea or endotracheal tube usually signifiespulmonary hemorrhage.

Chest radiography shows diffuse scatteredinfiltrates in lung fields.

Predisposing factors for pulmonaryhemorrhage include prematurity, perinatal asphyxia, neonatal respiratorydistress syndrome, pneumonia, pulmonary edema, and septicemia. Thesedisorders are discussed in other chapters.

Bleeding Disorders

Pulmonary hemorrhage may occur in infantswho have bleeding disorders, particularly disseminated intravascularcoagulation. See Chap. 52, Purpuraand Bleeding.

Infants, Children, and Adolescents

Trauma

Injuriesto thorax may be blunt or penetrating. Automobile accidents aremost common cause of pulmonary compression injury.

Damage to bronchi, blood vessels, orlung parenchyma may cause bleeding and respiratory distress.

Rib fracture may lacerate lung parenchymaor pleura to produce bleeding.

History, physical exam, and chest radiographare often diagnostic.

Chest CT and bronchoscopy are usefulto determine location and extent of injury.

Pulmonary Disorders

Bronchitis

Persistent hacking cough that occurs withacute or chronic bronchitis can produce blood-tinged sputum.

Pneumonia

Productivecough and blood-streaked sputum ("rusty sputum")can occur with pneumonia caused by pyogenic organisms (S. pneumoniae,H. influenzae type b, group A Streptococcus, S. aureus). M. tuberculosisis another cause of blood-streaked sputum.

Fungal infection, especially aspergillosis,can produce parenchymal bleeding and erosion of major blood vessels.Viral pneumonia (influenza and varicella) are rare causes of hemoptysis.

See Chap.10, Cough.

Lung Abscess

Clinicalmanifestations of lung abscess include fever, cough with sputumproduction, and occasionally hemoptysis.

Chest radiography may be diagnostic,but chest CT usually demonstrates abscess.

See Chap.10, Cough.

Bronchiectasis Including Cystic Fibrosis

Common findingin bronchiectasis is blood-streaked sputum because of local inflammationand persistent coughing.

Cystic fibrosis is common cause ofbronchiectasis in pediatric population, and mild-to-massive bleedingcan occur.

Local inflammation with mucosal ulcerationthat erodes wall of enlarged or tortuous bronchial artery is usuallysource of massive bleeding in cystic fibrosis.

Foreign Body

Retained foreign bodies may cause airwayinflammation and bleeding. See Chap.10, Cough.

Idiopathic Pulmonary Hemosiderosis

Usuallyoccurs in early childhood.

Clinical manifestations include cough,dyspnea, hemoptysis, and wheezing. Pallor and fatigue occur withsignificant iron deficiency anemia.

Infiltrates resembling pneumonia butindicative of pulmonary hemorrhage may be seen on chest radiography.

Clinical findings and presence of hemosiderin-ladenmacrophages in gastric aspirate, sputum, or bronchoalveolar lavagefluid are diagnostic.

Pulmonary Hemosiderosis with Cow Milk Hypersensitivity

Pulmonaryhemorrhage may be associated with cow milk hypersensitivity in some cases.

These children have circulating immunoglobulinG antibodies against cow milk proteins, increased serum immunoglobulinE levels, and often peripheral eosinophilia.

Improvement usually occurs on dietfree of cow milk.

Vascular Anomalies

Pulmonary Arteriovenous Malformation

Communicationof pulmonary artery or arteries with variable number of pulmonary veins.

Bypass of pulmonary capillary bed leadsto arterial desaturation and cyanosis. Clubbing of fingers and toesand exercise intolerance are common. Systolic ejection or continuousmurmur may be heard on chest wall over malformation. If communicationis large, heart may be enlarged.

Chest radiography shows ≥1 opacitiesof variable size in 1 or both lung fields.

Cardiac catheterization and angiographyconfirm diagnosis.

Hereditary Hemorrhagic Telangiectasia (Osler-Rondu-WeberDisease)

Multipletelangiectasias occur on skin and mucosa of respiratory and GI tractsin this autosomal-dominant disorder. Face, lips, ears, and fingersare especially affected.

Spontaneous bleeding in respiratorytract can result in hemoptysis.

Clinical findings and positive familyhistory are diagnostic.

Most frequent form has been mappedto long arm of chromosome 9.

Neoplasm

Primarypulmonary neoplasms, unusual in childhood and adolescence, commonly causechronic cough or wheezing and often some degree of respiratory distress.Benign bronchial tumors include papillomas, hemangiomas, fibromas,and adenomas. Malignant tumors include bronchogenic carcinoma andvarious sarcomas.

Chest radiograph may show some degreeof atelectasis with an endobronchial lesion or a mass lesion ofthe pulmonary parenchyma.

Chest CT defines location and extentof lesion.

Bronchoscopy with biopsy may be diagnostic.Otherwise thoracoscopy or thoracotomy is necessary to obtain tissuefor histologic diagnosis.

Cardiac Disorders

Pulmonaryedema precipitated by cardiac failure may produce pink, frothy,blood-tinged fluid. See Chap.7, Cardiac Failure.

Other cardiovascular causes of hemoptysisare pulmonary atresia with ventricular septal defect (enlarged bronchialcirculation with thrombosis of small pulmonary arteries) and pulmonaryvascular disease.

Goodpasture Syndrome

Association of pulmonary hemorrhage and glomerulonephritiswith antiglomerular basement membrane antibody is called Goodpasturesyndrome. Renal biopsy shows evidence of proliferative glomerulonephritisand characteristic linear immunoglobulin G deposition along glomerularbasement membrane.

Vasculitis

Systemic vasculitis disorders (e.g., systemiclupus erythematosus, Wegener granulomatosis, and Henoch-Schönleinpurpura) also may be associated with pulmonary hemorrhage. See Chap. 28, Hematuria.

Bleeding Disorders

Various bleeding disorders can produce hemoptysisin children of any age; however, there is usually other evidenceof bleeding. See Chap. 52, Purpuraand Bleeding.

Diagnostic Approach

Age of Onset

In neonates,blood in tracheal aspirate signifies mucosal bleeding from aggressive suctioning,trauma from endotracheal tube, or pulmonary hemorrhage. With thelatter, there is usually a history of perinatal asphyxia, neonatalrespiratory distress syndrome, or septicemia.

In infants, children, and adolescents,blood in mouth or upper airway is most commonly due to epistaxis,gingivitis, tonsillitis, nasopharyngeal trauma, retching duringvomiting, or persistent cough. Most common causes of persistentcough and hemoptysis are bronchitis, bacterial pneumonia, and cystic fibrosis.

Evaluation

CBC, includingplatelet count, and chest radiography should be performed in anyindividual with hemoptysis. Depending on suspected diagnosis, otheruseful tests include tuberculin skin test, prothrombin and activatedpartial thromboplastin times, and sputum culture for bacteria, tuberclebacilli, and fungi.

With suspected heart disease, chestradiography, ECG, and 2-D echocardiography are often diagnostic.Sometimes cardiac catheterization and angiography are necessary.

Laryngoscopy and bronchoscopy helpdistinguish between upper and lower respiratory tract bleeding.Bronchoscopy may diagnose foreign body or bronchial tumor. Materialfrom this procedure may be collected for culture, acid-fast stain,cytology, and Prussian blue stain. The latter can demonstrate hemosiderin-ladenmacrophages, which are seen in hemosiderosis.

Chest CT helps locate and define extentof any respiratory tract or mediastinal mass. It also can diagnoseand define extent of bronchiectasis.

Angiography of bronchial and pulmonaryarteries may demonstrate site of focal, unilateral, massive bleeding.

Hemoptysis combined with other evidenceof bleeding usually signifies a bleeding disorder. Diagnostic approachto these disorders is discussed in Chap.52, Purpura and Bleeding.

References

1. Behrman RE, et al., eds. Nelson textbookof pediatrics, 16th ed. Philadelphia: WB Saunders, 2000.
2. Boat TF. Pulmonary hemorrhage and hemoptysis. In: ChernickV, Boat TF, eds. Kendig's disorders of the respiratorytract in children, 6th ed. Philadelphia: WB Saunders, 1998:623–633.
3. Fabian MC, Smitheringale A. Hemoptysis in children:the Hospital for Sick Children experience. J Otolaryngol 1996;25:44–45.
4. Haroutunian LM, Neill CA. Pulmonary complications ofcongenital heart disease: hemoptysis. Am Heart J 1972;84:540–559.
5. Online Mendelian Inheritance in Man (OMIM). McKusick-NathansInstitute for Genetic Medicine, Johns Hopkins University (Baltimore,MD) and National Center for Biotechnology Information, NationalLibrary of Medicine (Bethesda, MD), 2001. World Wide Web URL: http://www.ncbi.nlm.nih.gov/omim.
6. Pianosi P, Al-Sadoon H. Hemoptysis in children. PediatrRev 1996;17:344–348.
7. Rudolph, AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
8. Taussig LM, Landau LI, eds. Pediatric respiratory medicine.St. Louis: Mosby-Year Book, 1999.

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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