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 is 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 autopsyvaries from 1-4 per 1,000 live births. Approximately 75% of
affected patients weigh <2,500 g at birth. Prophylactic indomethacin in ELBW infants reduces the
incidence of pulmonary hemorrhage. Most infants with pulmonar hemorrhage have had symptoms of
respiratory distress that are indistinguishable from those of RDS. The onset may occur at birth or may be
delayed several 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. ducal In severe cases, sudden cardiovascular collapse, poor lung
compliance, profound cyanosis, and hypercapnia may be present. Radiographic findings are varied and
nonspecific, ranging from minor streaking or patchy infiltrates to massive consolidation.

The risk of pulmonary hemorrhage is increased in association with acute pulmonary infection, severe
asphyxia, RDS, assisted ventilation, PDA,

Congenital heart disease, erythroblastosis fetalis, 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 increased 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 alveolar in approximately 65% of cases and interstitial
in the rest. Bleeding into other organs is observed at autopsy of 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 alveolar infiltrates. The condition usually responds to
intensive supportive treatment

treatment 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 intra alveolar blood and protein can inactivate
surfactant.