74: Pulmonary Hemorrhage

I. PROBLEM

Grossly bloody secretions are seen in the endotracheal tube (ETT). The incidence of pulmonary hemorrhage varies from 0.8 to 12 per 1000 live births. It can be as high as 50 per 1000 live births if high risk. The mortality rate can be as high as 50%. Survivors of pulmonary hemorrhage require longer ventilator support, and many will develop bronchopulmonary dysplasia/chronic lung disease. Others survivors may have an increase in cerebral palsy, cognitive delay, seizures, and periventricular leukomalacia. Most cases of pulmonary hemorrhage are secondary to hemorrhagic pulmonary edema and not a true bleed.

II. IMMEDIATE QUESTIONS

1. Are any other signs 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-minute Apgar scores. The infant has a sudden deterioration: hypoxic, severe retractions, and may experience associated pallor, shock, apnea, bradycardia, and cyanosis.

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

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

4. What is the hematocrit (Hct) of the endotracheal 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).

5. Has there been a recent procedure or has suctioning just taken place? Was surfactant recently given? Vigorous suctioning, traumatic intubation, or chest tube insertion may be a cause. Surfactant can also be associated.

6. Did the mother or infant have any risk factors for pulmonary hemorrhage?

   1. Maternal risk factors. Breech delivery, maternal cocaine use, maternal hypertension during pregnancy, abruptio placentae, maternal antibiotic therapy, preeclampsia, possible previous pregnancy losses. (Antenatal steroids may be protective.)

   2. Infant. Prematurity is the most common factor. Others include respiratory problems (hypoxia, asphyxia, respiratory distress syndrome [RDS], meconium aspiration, pneumothorax, surfactant treatment, or any need for ventilator support), mechanical ventilation, PDA with left to right shunting, disseminated intravascular coagulation (DIC), cold injury, oxygen toxicity, urea cycle defects, multiple births, male sex, infections/sepsis, coagulopathy, hypothermia, polycythemia, intrauterine growth restriction, erythroblastosis fetalis, extracorporeal membrane oxygenation/extracorporeal life support, toxemia of pregnancy, surfactant therapy.

   3. Infant near term or term. Hypotension, requirement of positive pressure ventilation in the delivery room, meconium aspiration.

7. Did the infant receive indomethacin? Prophylactic indomethacin reduces the rate of early serious ...