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I. PROBLEM

A nurse informs you that an infant has bloody secretions from the endotracheal tube (ETT). Pulmonary hemorrhage is bleeding into the lungs. It is typically an acute, catastrophic, often life-threatening event that causes a sudden deterioration in the infant’s clinical condition and is characterized by fresh continuous bloody fluid from the ETT or lower respiratory tract. Histologically, it is defined as fresh hemorrhage in the alveolar spaces or interstitium of the lung. The incidence of pulmonary hemorrhage varies from 1 to 12 per 1000 live births. It can be as high as 50 per 1000 live births if high risk (eg, premature, intrauterine growth restriction [IUGR]). The mortality rate can be up to 50% in premature infants. Survivors of pulmonary hemorrhage require longer ventilator support, and many will develop bronchopulmonary dysplasia/chronic lung disease (60% of premature infants). Studies show an increased risk of death and survival with neurosensory impairment, increased incidence of cerebral palsy and cognitive delay, and an increased risk of seizures and periventricular leukomalacia at 18 months of age.

II. IMMEDIATE QUESTIONS

  1. Are any other signs abnormal? Typically, an infant with a pulmonary hemorrhage is a ventilated low birthweight infant, often from a multiple birth, and 2 to 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 with a pulmonary hemorrhage can have a sudden deterioration: hypoxic, severe retractions, 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 overtransfusion) 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 of the endotracheal blood? If the hematocrit (Hct) is close to the venous Hct, it represents a true hemorrhage, and the blood is usually from trauma or a bleeding diathesis. Aspiration of maternal blood will result in an Hct close to the venous Hct. If the Hct is 15 to 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 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? Major risk factors include IUGR, surfactant therapy, PDA, sepsis, and coagulopathy.

    1. Maternal risk factors. Breech delivery, maternal cocaine use, maternal hypertension during pregnancy, abruptio placentae, maternal antibiotic therapy, preeclampsia, possible previous pregnancy losses. Note that antenatal steroids may ...

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