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A4944 - Etiologies and Outcomes of Pulmonary Hemorrhage in Children: A Single Institutional Series
Author Block: A. George1, E. B. Hysinger1, C. A. Torres-Silva1, J. J. Brewington1, C. K. Hart2, A. de Alarcon2, J. W. Byrnes3, B. H. Goldstein3, D. T. Benscoter1; 1Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States, 2Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States, 3Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
Rationale. Many pediatric conditions are associated with the rare, potentially catastrophic complication of pulmonary hemorrhage. Flexible bronchoscopy is often performed for both diagnostic and therapeutic reasons for pulmonary hemorrhage. Our aim was to describe etiologies, interventions, and outcomes among children undergoing bronchoscopy for pulmonary hemorrhage in our institution.
Methods. We conducted a retrospective chart review of all patients who underwent flexible bronchoscopy at Cincinnati Children’s Hospital Medical Center for an indication of hemoptysis or pulmonary hemorrhage between 2010 and 2017. Positive bronchoscopic findings included the presence of active bleeding, blood clots, mucosal hemorrhage, bloody bronchoalveolar lavage fluid or an abundance of hemosiderin-laden macrophages on cytology. The primary outcome was survival at 12 months post-hemorrhage.
Results. The authors reviewed 100 flexible bronchoscopies performed on 67 patients. Fourteen patients underwent repeat bronchoscopy due to concern for recurrent bleeding. Bronchoscopic evidence of hemorrhage was noted on 71 procedures among 41 patients. The most common condition associated with bleeding was cardiac and/or vascular disease, accounting for 32% of patients with hemorrhage and 39% of procedures with hemorrhage. Other common etiologies included infection (22% of patients), tracheostomy-associated bleeding (12% of patients), rheumatologic disorders (12% of patients), and cystic fibrosis (5% of patients). Flexible bronchoscopy was often performed in conjunction with other procedures; 22 of 100 bronchoscopies were accompanied by microlaryngoscopy and bronchoscopy, 20 by cardiac catheterization, and 18 by esophagogastroduodenoscopy. There were a number of interventions prompted by bronchoscopic findings, including coil occlusions of collateral vessels (8 patients), increases in immune-modulating therapies (6 patients) and surgical airway interventions (5 patients). Therapeutic bronchoscopy with significant clot removal occurred in 25 cases among 18 patients. Twenty-three patients (56%) with bronchoscopic evidence of pulmonary hemorrhage required admission to the Intensive Care Unit (ICU) for respiratory failure on at least 1 occasion, and 9 of these patients (5 of whom had underlying congenital heart disease) died while hospitalized. All patients (18) who had bronchoscopic evidence of hemorrhage but did not require ICU-level care survived admission. One-year survival was 75.6% among all patients with evidence of bleeding on bronchoscopy or cytology.
Conclusion. Pulmonary hemorrhage most commonly occurred in patients with underlying cardiovascular disorders, a population which also experienced the highest mortality from airway bleeding. Admission to the ICU portended an increased risk for mortality. Bronchoscopy-confirmed bleeding often prompted further intervention, such as cardiac catheterization to treat hemodynamically-significant collateral vessels, thereby highlighting the importance of an interdisciplinary approach to pulmonary hemorrhage.