Pulmonary haemorrhage and haemoptysis — structured oral (viva)

Branch 1 — The emergency and first move

Examiner: "He is bleeding briskly from the lungs. What is your very first priority and why?" Candidate: My first priority is the airway and breathing, not stopping the source. In massive haemoptysis the immediate danger is asphyxiation from blood flooding the airway rather than exsanguination, so I would give high-flow oxygen, clear and protect the airway, and prepare to intubate while calling for senior and intensive-care help. Only once ventilation is secure would I move to locating and controlling the bleed. [1]

Branch 2 — Controlling the bleed

Examiner: "You have secured the airway. How do you now control the bleeding?" Candidate: I would support the circulation with intravenous access and blood for significant loss, and correct any coagulopathy or thrombocytopenia. If I know which lung is bleeding, I would position him bleeding-side down to protect the other lung. In cystic fibrosis the bleeding is typically from hypertrophied bronchial arteries, so I would escalate early to bronchial artery embolization, which is the key intervention when brisk haemoptysis does not settle with supportive measures. [1] [2]

Examiner: "Why embolization rather than surgery?" Candidate: Bronchial artery embolization targets the high-pressure bronchial circulation that drives most focal haemoptysis and controls bleeding while preserving lung tissue, which matters greatly in a child with chronic lung disease. Surgery is reserved for the rare uncontrollable or localised lesion when embolization fails. [2]

Branch 3 — A different child

Examiner: "Now consider a 3-year-old with an iron-refractory anaemia, breathlessness, and shifting infiltrates who has never coughed up blood. What is happening, and how do you prove it?" Candidate: This is the occult presentation of diffuse alveolar haemorrhage. Young children swallow rather than expectorate blood, so alveolar bleeding shows as an iron-deficiency anaemia with diffuse, shifting infiltrates. I would prove alveolar bleeding by demonstrating haemosiderin-laden macrophages on bronchoalveolar lavage, or on an early-morning gastric aspirate in a child who cannot expectorate. [4] [3]

Branch 4 — Cause and treatment

Examiner: "How do you decide what to treat, and with what?" Candidate: I would classify diffuse alveolar haemorrhage as immune or bland, because that decides treatment, and I would exclude capillaritis, vasculitis, cardiac disease, and cow milk hypersensitivity before calling it idiopathic. Corticosteroids are the mainstay for diffuse alveolar haemorrhage, given early and adequately, with a steroid-sparing immunosuppressant added for capillaritis and milk elimination used for Heiner syndrome. I would check urinalysis and renal function in every child to catch a pulmonary-renal syndrome, replace iron, and arrange multidisciplinary follow-up. [3] [4]