Most children with pulmonary hemorrhage present with hemoptysis. It is important to rule out extrapulmonary sources of bleeding, including hematemesis and bleeding from the nasopharynx or mouth, as these are more common than true pulmonary hemorrhage. In addition to hemoptysis, the presenting signs and symptoms of pulmonary hemorrhage include cough, wheeze, shortness of breath, pallor, fatigue, cyanosis, and fever. Episodic pulmonary hemorrhage frequently manifests as recurrent respiratory symptoms associated with pulmonary infiltrates on chest radiographs. Symptomatic airway hemorrhage may result in significant hemoptysis with few radiographic changes, whereas alveolar bleeding often causes profound respiratory symptoms, hypoxemia, diffuse infiltrates on radiographs, and minimal hemoptysis. Some patients experience a localized bubbling sensation in the chest, which may be helpful in differentiating local from diffuse sources of pulmonary bleeding. Physical examination findings may include locally or diffusely decreased breath sounds, cyanosis, and crackles on auscultation.
The differential diagnosis of pulmonary hemorrhage includes alveolar and airway bleeding. The causes of alveolar (capillary) bleeding include: idiopathic pulmonary hemosiderosis; diffuse alveolitis (capillaritis) secondary to autoimmune disease; clotting disorders; venoocclusive disease; diffuse alveolar injury; and cardiac conditions associated with elevated pulmonary venous and capillary pressures (Table 136-2).Rarely, a previously well infant will present with life-threatening acute alveolar hemorrhage. Often no cause is found, and, once the acute episode resolves, the infant returns to normal. Most of these infants never have a second bleeding episode. Hemoptysis can have cardiovascular, pulmonary, or immunologic causes (see Table 136-2).
It is important to perform a thorough upper airway examination to rule out epistaxis. Sometimes this requires nasopharyngoscopy. If extrapulmonary sources of bleeding havebeen excluded, then a chest radiograph, CT angiogram ofthe chest, bronchoscopy, echocardiogram, and evaluationfor rheumatologic/autoimmune diseases, especially Good-pasture disease, granulomatosis with polyangiitis, Henoch-Schönlein purpura, and systemic lupus erythematosus, should be considered.
The management of acute episodes of pulmonary bleeding includes the administration of supplemental O2, blood transfusions, and, often with acute alveolar hemorrhages, mechanical ventilation with PEEP to tamponade the bleeding. Attempts should be made to identify the cause of the bleeding. Treatment is directed toward the underlying disorders and providing supportive care. In bronchial arterial bleeding, arteriography with vessel embolization has been shown to be successful.
Pulmonary embolism is rare in children. When it occurs, it is often associated with indwelling central venous catheters,
Respiratory distress syndrome Bronchogenic cyst Sequestration Pneumonia (bacterial, mycobacterial, fungal, or parasitic) Cystic fibrosis Tracheobronchitis Bronchiectasis Lung abscess Tumor (adenoma, carcinoid, hemangioma, metastasis) Foreign body retention Contusion—trauma oral contraceptives, or hypercoagulable states. In adolescents, trauma, obesity, abortion, and malignancy may lead to deep vein thromboses (DVTs) and pulmonary embolism.