Chapter 133: Pulmonary Hemorrhage

Massive pulmonary hemorrhage · Risk factors (PDA, surfactant, asphyxia, coagulopathy) · Clinical presentation · Management (ventilation, blood products, epinephrine, HFOV)
🫁 Key fact: Occurs in ~10% of extremely preterm infants; associated with large PDA, surfactant therapy, and high mortality.

🫁 Pulmonary Hemorrhage in Newborns: Core Concepts

📊 Incidence
~10% of extremely preterm infants. Massive hemorrhage in 1-4/1000 live births; 75% weigh <2500g.
⚠️ Risk factors
Large PDA (pulmonary overcirculation), surfactant therapy (1-5% of treated infants), asphyxia, RDS, thrombocytopenia, DIC, cold injury, inborn errors of ammonia.
🩺 Clinical presentation
Sudden deterioration: fresh blood in ETT, hypotension, worsening oxygenation, pulmonary edema, often concurrent IVH.
📷 CXR findings
Bilateral alveolar infiltrates, consolidation, may mimic RDS or pulmonary edema.
⚕️ Management
Endotracheal suction, increase PEEP/mean airway pressure, HFOV, blood transfusion, treat coagulopathy, epinephrine intratracheally, consider PDA closure.
📈 Outcome
High mortality (40-60% in massive hemorrhage). Survivors at risk for BPD and neurodevelopmental impairment.
⚡ Prevention: Prophylactic indomethacin in ELBW infants reduces pulmonary hemorrhage and severe IVH. Early PDA closure may decrease risk.

🔍 Approach to newborn with suspected pulmonary hemorrhage

1
Recognize at-risk infants – Extremely preterm, large PDA, recent surfactant, asphyxia, coagulopathy, ECMO, or after indomethacin/ibuprofen.
2
Identify clinical signs – Sudden onset of bloody secretions from ETT, worsening oxygenation, hypotension, bradycardia, pulmonary edema.
3
Differentiate from other causes – Upper airway bleeding (NG trauma), pulmonary edema without blood, hemorrhagic pneumonitis.
4
Evaluate for associated conditions – Cranial ultrasound for IVH (often concurrent), echocardiogram for PDA, coagulation studies (DIC, thrombocytopenia).
5
Initiate resuscitation – Secure airway, suction, increase PEEP, volume resuscitation, treat coagulopathy, consider HFOV.

📋 Stepwise management of massive pulmonary hemorrhage in a neonate

1
Airway management & oxygenation – Endotracheal suction to clear blood. Increase PEEP (6-10 cmH2O) to tamponade bleeding. Consider intratracheal epinephrine (1:10,000, 0.5-1 mL).
2
Hemodynamic support – Volume resuscitation (10-20 mL/kg normal saline or blood). Treat hypotension with dopamine or epinephrine. Transfuse PRBCs to maintain hemoglobin.
3
Correct coagulopathy – Give fresh frozen plasma (10-15 mL/kg) and platelets (10-20 mL/kg) if DIC or thrombocytopenia. Vitamin K if deficiency.
4
Ventilatory support escalation – High-frequency oscillatory ventilation (HFOV) to maintain lung recruitment with lower tidal volumes. High mean airway pressure may control bleeding.
5
Address underlying cause – Echocardiogram to assess PDA. If hemodynamically significant, consider PDA closure (medical or surgical) after stabilization.
6
Post-hemorrhage surfactant – Exogenous surfactant may improve compliance because blood inactivates surfactant; can be given after bleeding controlled.
📌 Key prevention: Prophylactic indomethacin in ELBW infants (<1000 g) reduces pulmonary hemorrhage by decreasing PDA and IVH.

🧠 Rapid reflex prompts – Pulmonary Hemorrhage

📌 Most common risk factor for pulmonary hemorrhage in preterm?
Hemodynamically significant patent ductus arteriosus (PDA) with pulmonary overcirculation.
📌 How does surfactant increase pulmonary hemorrhage risk?
Rapid improvement in compliance can lead to increased pulmonary blood flow if PDA present.
📌 Immediate intervention for massive pulmonary hemorrhage?
Increase PEEP, suction blood, volume resuscitation, correct coagulopathy, consider HFOV.
📌 Prevention of pulmonary hemorrhage in ELBW?
Prophylactic indomethacin (reduces PDA and severe IVH).
📌 What is the role of surfactant after pulmonary hemorrhage?
Blood inactivates surfactant; replacement may improve compliance.
📌 What other organ bleed is often associated?
Intraventricular hemorrhage (IVH) – concurrent in many cases.