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  1. Problem. Grossly bloody secretions are seen in the endotracheal tube (ETT). The incidence of pulmonary hemorrhage varies from 0.8–12 per 1000 live births. It has been reported in >11% of infants with a birthweight <1500 g who were treated with surfactant and in 5–7% low birthweight infants with respiratory distress syndrome (RDS). It occurs most commonly in acutely ill infants on mechanical ventilation between 2 and 4 days of age. The mortality rate is higher immediately after pulmonary hemorrhage and can be as high as 50%.

  2. Immediate questions

      1. Are any other signs or symptoms abnormal? Typically, an infant with pulmonary hemorrhage is a ventilated low birthweight infant, often from a multiple birth, and 2–4 days old (usually in the first week of life). Late gestation infants with pulmonary hemorrhage usually have low 1 and 5 min APGAR scores. The infant has a sudden deterioration in respiratory status. The infant becomes hypoxic, has severe retractions, and may experience associated pallor, shock, apnea, bradycardia, and cyanosis.

      1. Is the infant hypoxic? Has a blood transfusion recently been given? Hypoxia or hypervolemia (usually caused by overtransfusion) may cause an acute rise in the pulmonary capillary pressure and lead to pulmonary hemorrhage.

      1. Is bleeding occurring from other sites? If there is bleeding from multiple sites, coagulopathy may be present, and coagulation studies should be obtained. Volume replacement with colloid or blood products may be needed.

      1. What is the hematocrit (Hct) of the tracheal blood? If the Hct is close to the venous Hct, it represents a true hemorrhage, and the blood is usually from trauma, aspiration of maternal blood, or bleeding diathesis. If the Hct is 15–20 percentage points lower than the venous Hct, the bleeding is likely hemorrhagic edema fluid. This is seen with the majority of cases of pulmonary hemorrhage (such as those secondary to patent ductus arteriosus [PDA], surfactant therapy, and left-sided heart failure; others discussed later).

  3. Differential diagnosis

      1. Direct trauma. Trauma to the airway may be a result of nasotracheal or endotracheal intubation. Vigorous suctioning can also cause tissue trauma. Lung trauma during chest tube insertion can cause hemorrhage.

      1. Aspiration of gastric or maternal blood is often seen after cesarean delivery. The majority of blood is usually obtained from the nasogastric tube, but blood may be seen in the ETT.

      1. Coagulopathy may be due to sepsis or due to congenital factors. The role of coagulation abnormalities is unclear as a cause of pulmonary hemorrhage or if it just exacerbates it.

      1. Other disorders associated with pulmonary hemorrhage

          1. Hypoxia/Asphyxia. Acute left ventricular failure due to asphyxia is a very important factor in pulmonary hemorrhage.

          1. Hypervolemia as the result of overtransfusion or fluid overload.

          1. Congenital heart disease/Congestive heart failure (especially in pulmonary edema caused by PDA).

          1. Pulmonary related. Respiratory distress syndrome, pulmonary interstitial emphysema, pneumothorax, meconium aspiration, and pneumonia (caused by Gram-negative organisms).

          1. Surfactant administration. Pulmonary hemorrhage occurred within hours of surfactant therapy and may be related to a rapid increase in pulmonary blood flow (PBF) because of improved lung function. The increased PBF may cause hemorrhagic pulmonary edema. Reports show a significant relationship between pulmonary hemorrhage and a clinical PDA in surfactant-treated infants. Recent data indicates rescue surfactant therapy did not increase the risk of pulmonary hemorrhage, but prophylactic surfactant did.

          1. Mechanical ventilation or oxygen therapy/toxicity.

          1. Hematologic disorders. Severe Rh incompatibility, thrombocytopenia, ...

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