606 SECTION V Pediatric Critical Care Pulmonary bleeding is best managed by intubating the left main stem bron chus with a cuffed endotracheal tube and inflating the cuff of the tube Utilization of a[.]
606 S E C T I O N V Pediatric Critical Care: Pulmonary • BOX 52.6 Treatment of Pulmonary Hemorrhage General • • • • • • • Admission to pediatric intensive care unit Positioning (intermittent Trendelenburg) Oxygen supplementation Mechanical ventilation (positive end-expiratory pressure) Hemodynamic monitoring Hemostasis replacement therapy Endobronchial tamponade (Fogarty catheter, cuffed endotracheal tube) Specific Immune • • • • • Corticosteroids Other immunosuppressive agents (azathioprine, cyclophosphamide) Plasmapheresis (Goodpasture syndrome) Bilateral nephrectomy Deferoxamine, milk-free diet Focal • Surgical resection • Selective embolization of bronchial vessels bleeding is best managed by intubating the left main stem bronchus with a cuffed endotracheal tube and inflating the cuff of the tube Utilization of a double-lumen or Carlens-type endotracheal tube may also be helpful in isolating the bleeding segment However, the diameter of these tubes precludes their use in smaller children, and proper positioning may prove difficult.244,269 Rigid bronchoscopy is the best means of identifying the source and type of bleeding, but it also has therapeutic applications.269–271 The rigid scope readily establishes an adequate airway and can be used for large-volume isotonic saline solution lavage and for suctioning large volumes of blood Fiberoptic bronchoscopy should be reserved for diagnostic purposes, including definitive identification of the bronchopulmonary segments involved and BAL BAL provides useful information by permitting culture of the lavage for bacteria, fungi, mycobacteria, and viruses and quantitative assessment of the hemosiderin content of the alveolar lavage Interpreting the presence or absence of hemosiderin-laden macrophages should be done cautiously because macrophages may not appear for up to 48 hours following an acute episode of bleeding and usually disappear by weeks Specific Despite the different etiologies in the category of immune-mediated PH, the response to corticosteroid therapy is swift (within 24–48 hours) as assessed by transfusion requirements, hemoglobin concentration, hemoptysis, and absence of new infiltrates.255 Although controlled clinical trials have not been performed to validate this temporal relationship suggestive of therapeutic benefit, the risk of administering a short course of high-dose corticosteroids in this setting is low Hence, the corticosteroids adrenocorticotropic hormone (10–25 U/day), methylprednisolone (2–4 mg/kg per day), or hydrocortisone (4 mg/kg per day) should be administered early in a patient with an acute, life-threatening episode of immune-mediated PH Once remission is achieved, corticosteroids should be tapered until they are discontinued or symptoms recur In cases of inadequate response to corticosteroids alone, other immunosuppressive agents (e.g., azathioprine, cyclophosphamide, chlorambucil) have been administered with some success in persons with the immune-mediated PH syndromes.272 Azathioprine (1.2–5.0 mg/kg per day) with prednisone (5–20 mg every hours) is a typical treatment combination Cyclophosphamide is the drug of choice for treatment of patients with Wegener granulomatosis.273 Once a specific diagnosis is made for the various etiologies of immune-mediated PH, directed therapies are available, including immunosuppression and plasmapheresis These therapies are beyond the scope of this chapter and are discussed in the literature.273–275 Administration of IV vasopressin to a patient with massive hemoptysis may temporarily control the bleeding Surgical resection of a bleeding focus remains the procedure of choice if feasible Severe bleeding at the time of resection resulting in single-lung ventilation increased the mortality rate from 12% to 25% in one series Pulmonary embolectomy should be considered for patients with an acute large embolus, especially if fibrinolysis is contraindicated.246,276,277 For focal PH resulting from increased bronchial circulation, selective embolization or occlusion of bronchial vessels with glass microspheres, small pledgets of absorbable gelatin sponge or polyvinyl alcohol sponge may provide temporary hemostasis Embolization should be considered in the unstable or poor surgical candidate with focal PH Complications of embolization include inadvertent CNS or coronary artery occlusion and transverse myelitis with resulting paraplegia Summary PH that does not occur in the familiar setting of trauma or infection can be classified according to extent of pulmonary involvement (i.e., diffuse or focal) PH occurs most commonly during the neonatal period as a result of diffuse nonimmune mechanisms PH in the neonate is a preterminal complication of severe disorders of the cardiovascular and respiratory systems The best initial approach to diagnosis and specific therapy in the older child is determining the extent of extrapulmonary organ involvement Diseases that lead to focal hemorrhage are more likely to 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