Life-Threatening Hemoptysis in a Pediatric Referral Center

Antifibrinolytic and Adjunct Hemostatic Agents: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

OBJECTIVES

To derive systematic-review informed, modified Delphi consensus regarding antifibrinolytic and adjunct hemostatic agents in neonates and children supported with extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE consensus conference.

DATA SOURCES

A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021.

STUDY SELECTION

Use of antifibrinolytics (epsilon-aminocaproic acid [EACA] or tranexamic acid), recombinant factor VII activated (rFVIIa), or topical hemostatic agents (THAs).

DATA EXTRACTION

Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Eleven references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form.

MEASUREMENTS AND MAIN RESULTS

Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One weak recommendation and three consensus statements are presented.

CONCLUSIONS

Evidence supporting recommendations for administration of antifibrinolytics (EACA or tranexamic acid), rFVIIa, and THAs were sparse and inconclusive. Much work remains to determine effective and safe usage strategies.

Exercise-Induced Pulmonary Hemorrhage in a Non-Athletic Child: Implications for Military Recruits

Hemoptysis is a rare presenting symptom in pediatric and young adult patients with a highly variable outcome ranging from an isolated mild occurrence to severe illness and death. Exercise-induced pulmonary hemorrhage (EIPH) has several reports in adult literature but has not previously been reported in pediatric patients. A 12-year-old female with a history of trisomy X (47, XXX), obesity, depression, anxiety, and obstructive sleep apnea presented to the pediatric pulmonology clinic after several episodes of hemoptysis. Spirometry, imaging, and laboratory evaluation for autoimmune vasculitides and other causes associated with pediatric hemoptysis did not reveal an etiology for the hemoptysis. A combined bronchoscopy with pediatric and adult providers revealed no airway lesions or sources of bleeding. EIPH is a diagnosis of exclusion. This patient was diagnosed with EIPH and had spontaneous resolution with improved fitness. Many military training and service activities are similar to those reported with EIPH. Trainees with various levels of aerobic fitness are at risk of developing EIPH. The hemoptysis evaluation is important for military providers given the range of severity in presentations, even though it is a rare occurrence. In addition to a novel presentation of EIPH, this case demonstrates the value of collaboration between pediatric and adult specialists in the Military Health System (MHS). Military care providers should be aware of this rare phenomenon in service members and trainees who are at risk during maximal aerobic effort.

Haemoptysis: is it really from the lungs? The well child who spits out blood

Blood appearing in a previously well child's mouth may have many sources, and it should not be assumed to be haemoptysis, that is, coming from the respiratory tract below the larynx. In addition to the lungs and lower airways, consider also the upper airways, the mouth, gastrointestinal tract and cardiovascular conditions. This article discusses the differential diagnosis and appropriate investigations.

Tranexamic Acid Use for Massive Hemoptysis in a Child: A Case Report

Massive hemoptysis is a rare life-threatening condition in children. Individuals with non-cystic fibrosis bronchiectasis may present with various degrees of hemoptysis. Therapeutic measures are mainly derived from studies involving adults or various case reports of children with cystic fibrosis. The standard management of massive hemoptysis is limited to invasive bronchoscopy, bronchial artery embolization, and surgical resection. Tranexamic acid (TXA) use is limited to non-massive hemoptysis or as an adjuvant and temporizing measure before definitive treatment. We report the potential use of TXA as an emergency treatment for massive hemoptysis in a 10-year-old boy with non-cystic fibrosis bronchiectasis and chronic infection. The use of systemic TXA (250 mg every eight hours for five days) successfully stopped active bleeding beginning from the first dose and altered the need for invasive interventions. Although he experienced another episode of massive hemoptysis because of pneumonia and pulmonary exacerbation, invasive measures were not required because he responded to systemic TXA immediately. Moreover, no further recurrence of hemoptysis was noted on cessation of TXA and throughout two years of regular follow-up. Therefore, TXA could be considered a non-invasive therapy for children with massive hemoptysis, especially in the absence of standard invasive therapies.