Pulmonary Hemorrhage

Massive pulmonary hemorrhage is a relatively uncommon, but catastrophic complication with a high
risk of morbidity and mortality . Some degree of pulmonary hemorrhage occurs in about 10% of
extremely preterm infants. However , massive pulmonary hemorrhage less common and can
be fatal. Autopsy demonstrates,massive pulmonary hemorrhage in 15% of neonates who die
in the 1st 2 wk of life. The reported incidence at autopsy varies from 1-4 per 1,000 live births.
Approximately 75% of affected patients weigh <2,500 g at

birth. Prophylactic indomethacin in ELBW infants reducesthe incidence of

pulmonary hemorrhage.

Most infants with pulmonary hemorrhage have had symptoms of

respiratory

distress that are indistinguishable from those of RDS. The onset may
occur at

birth or may be delayedseveral days. Hemorrhagic pulmonary edema is

the

source of blood in many cases and is associated with significant

ductal shunting

and high pulmonary blood flow or severe left-sided heart failure

resulting from

hypoxia. In severe cases, sudden cardiovascular collapse, poor lung

compliance,

profound cyanosis, and hypercapnia may be present. Radiographic

findingsare

varied and nonspecific, ranging from minor streaking or patchy infiltrates

to

massiveconsolidation.

The risk of pulmonary hemorrhage is increased in association

with acute

pulmonary infection, severe asphyxia, RDS, assistedventilation, PDA,

congenital heart disease,erythroblastosisfetalis, hemorrhagic disease of the

newborn, thrombocytopenia, inborn errors of ammonia metabolism, and

cold

injury . Pulmonary hemorrhage is the only severe complication in which

the rate
is incr eased with surfactant treatment. Pulmonary hemorrhage is
seen with all

surfactants; the incidence ranges from 1–5% of treated infants and is

higher with

natural surfactant. Bleeding is predominantly alveolarin approximately 65%

of

cases and interstitial in the rest. Bleeding into other organs is

observed at

autopsyof severely ill neonates, suggesting an additional

bleeding diathesis,

such as disseminated intravascular coagulation. Acute pulmonary hemorrhage

may rarely occur in previously healthy full-term infants. The cause is

unknown.

Pulmonary hemorrhage may manifest as hemoptysis or blood in

the nasopharynx

or airway with no evidence of upper respiratory or gastrointestinal

bleeding.

Patients present with acute, severe respiratory failure requiring mechanical

ventilation. Chest radiographs usually demonstrate bilateral alveolarinfiltrates.

The condition usually responds to intensive supportive treatment

(see Chapter

436 ).

T reatment of pulmonary hemorrhage includes blood replacement,

suctioning

to clear the airway , intratracheal administration of epinephrine, and

tamponade

with increased mean airway pressure (often requiring HFV). Although

surfactant

treatment has been associated with the development of pulmonary

hemorrhage,

administration of exogenous surfactant after the bleeding has

occurred can

improve lung ^compliance, because the presence of intraalveolar

blood and
protein can inactivate surfactant.