Pulmonary

Hemorrhage

Dr. Habibur Rahim

Resident year 3, neonatology
BSMMU, Bangladesh
 Case scenario
• A 3 days old baby diagnosed as a case of preterm (30weeks)
very Low birth weight (1240 gm) with RDS, is on mechanical
ventilator. Duty nurse noticed that baby has bloody secretions
from the endotracheal tube during suctioning & desaturation.

• Diagnosis?
Pulmonary Hemorrhage
Contents
• Introduction
• Definition
• Incidence
• Risk factors
• Pathophysiology
• Diagnosis
• Management
• Prognosis
Introduction
• Pulmonary hemorrhage (PH) is a well-recognized condition in
term and preterm newborns that was first described as early as
1855.
• It is typically an acute, catastrophic, often life-threatening event
that causes a sudden deterioration in the infant’s clinical
condition.
• 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.
Berger TM, Allred EN, Van Marter LJ. Antecedents of clinically significant pulmonary hemorrhage
among newborn infants. J Perinatol. 2000;20(5):295–300
Introduction cont

• The mortality rate can be up to 50% in premature infants.

• It is present in 7-10% of neonatal autopsies and up to 80% of

VLBW infant autopsies.

• Pulmonary hemorrhage occurs most commonly in the first few

days after birth. Usually second to fourth day of life.
Introduction cont

• 6.4% among <30 weeks in a tertiary Hospital, Bangladesh.

Begum LN, Raj AY, Salam F (2016) Comparison Study of Very Low Birth Weight Infants at a Tertiary Care
Hospital, Dhaka: < 30 wks versus ≥30
J Pediatr Neonatal Care 2016, 5(1): 00165

• 5.33% in India
Mathur, K. Garg and S. Kumar. Respiratory Distress in Neonates with Special Reference to
Pneumonia. Indian Pediatrics 2002; 39:529-537
 Definition

• Pulmonary hemorrhage is bleeding into the lungs.

• Characterized by fresh continuous bloody fluid from the ETT
or lower respiratory tract.
• Massive pulmonary hemorrhage is a pulmonary hemorrhage
that involves at least 2 lobes of the lungs.
• Histologically, it is defined as presence of RBC in the
alveolar spaces or interstitium of the lung.
Maternal risk factors

• Pregnacy induced hypertention

• Toxemia
• Infection
• Bleeding disorders
• Medications : anticonvulsants, anti tubercular drugs, vitamin K
antagonists
• Lack of antenatal steroids in preterm labor
 Infant risk factors
• Prematurity - most common
• weight <1000gm
• IUGR
• Respiratory problems (hypoxia,
asphyxia, RDS, meconium
aspiration, pneumothorax,
surfactant treatment)
• sepsis
• mechanical ventilation
• PDA, heart failure
• DIC, Coagulopathy
• multiple births, male sex
• Hypothermia
• Polycythemia
• erythroblastosis fetalis
• extracorporeal membrane support
• previous use of blood products
• Urea cycle defects
• Oxygen toxicity
• Hypoplastic lung disease
• Neonatal pulmonary hemosiderosis
(rare)
• Airway hemangioma (rare)

Prophylactic indomethacin reduces the rate of early serious pulmonary hemorrhage by 35%
Pathophysiology

Hypoxia→ myocardial
failure →↑ pulmonary
vascular pressure →
pulmonary edema.
Pathophysiology…
Stress failure
Three major forces involved in the
process:
breakage of
(1) Circumferential tension in the capillaries
capillary wall secondary to capillary
transmural pressure.
(2) surface tension of the alveoli
that supports the bulging leaking of fluid
capillaries.
(3) longitudinal tension in the
alveoli, as a result of lung inflation.
 Pathophysiology….
PDA

↓Pulmonary vascular
resistance→ ↑ left-to-right
shunting PDA → ↑ Pulmonary
blood flow →pulmonary edema
→ ↑ capillary pressure →
↑ vascular permeability
 Pathophysiology cont
Recent evidence suggests that
intrauterine neutrophil activation
in preterm newborns with
respiratory distress syndrome.
Pathophysiology cont

Other possible theories include

• Surfactant dysfunction
• Lung damage
• Hypervolemia
• High alveolar surface tension
• Low concentration of plasma proteins
 Presentations

• Oozing of blood from the nose and mouth Or the

endotracheal tube.

• Frothy pink tinged secretions are common followed

by fresh bloody secretions .
 Presentations…

A rapid clinical deterioration and instability:

Increased work of breathing

Bradycardia
Apnea
Cyanosis
Hypotension
Pallor
Poor systemic perfusion
 Presentations…

• Presence of other bleeding sites and signs of pneumonia,

infection, or congestive heart failure.

• Peripheral edema, hepatosplenomegaly, and murmur of a PDA.

• Decreased breath sounds and crepitation.

 Lab investigations
• CBC: Thrombocytopenia may be seen. The Hct should be
checked to determine whether excessive blood loss has
occurred.
• Coagulation profile (PT, aPTT, d-dimers, fibrinogen level)
may reveal coagulation disorders.
• Arterial blood gas : severe hypoxia, hypercarbia, and a
metabolic acidosis.
 Lab investigations …

• Blood cultures: to evaluate sepsis

• Serum electrolytes.
• Blood glucose ↓
• S. Calcium: ↓
• Blood urea nitrogen and creatinine for renal function
• Apt test to determine either it is maternal blood
• Ammonia level to evaluate for urea cycle defects - Metabolic
workup
 Apt test
The test allows the clinician to determine
whether the blood originates from the
infant or from the mother.
• Place 5 mL water in each of 2 test tubes
• To first test tube add 5 drops of vaginal
blood
• To other add 5 drops of maternal (adult)
blood
• Add 6 drops 10% NaOH to each tube
• Observe for 2 minutes
• Maternal (adult) blood turns yellow-
green-brown;
• fetal blood stays pink.
Chest X ray
• Chest radiograph can be variable and nonspecific.
• Focal Hemorrhage: patchy, linear, ground-glass opacities;
nodular densities; or fluffy opacities
• Lobar Hemorrhage: consolidation
• Massive hemorrhage: complete whiteout with just an air
bronchogram visible or diffuse ground-glass opacities
• The chest radiograph can also be clear in an early
pulmonary hemorrhage.
pulmonary hemorrhage
Ultarsound of Chest
• lung consolidation with air bronchograms (83%)
• Shred sign (92 %) (sensitivity of 91% and a specificity of 100% )
• Pleural effusion (84%)
• Pleural line abnormalities and disappearing A lines (100%).

Echocardiogram to rule out PDA, assess ventricular function,

identify intravascular fluid overload
A. Shred sign irregular junction between
consolidated and aerated lung

B. Air boncogram Echogenic area which

present air within consolidated area

C. B lines is a longitudinal echogenic lines

found in early pneumonia from early
consolidation
 Differential diagnosis

• Direct trauma to the airway due to nasotracheal or

endotracheal intubation, vigorous suctioning, bag-and-mask
ventilation etc. Local trauma usually has a smaller amount of
bleeding with no clinical deterioration
• Aspiration of maternal blood
• Hemorrhagic pulmonary edema : The fluid is not whole
blood but a mixture of plasma and blood with a low Hct,
usually 15% to 20% below the expected venous Hct.
 Management outline

The goals of management mainly supportive

• To decrease and stop the hemorrhage

• To identify the underlying etiology

• To improve gas exchange and distress

 Management
Emergency measures
• Suction the airway initially until bleeding subsides
• Increase Oxygen support
• Mechanical ventilation shoud be given in massive pulmonary
hemorrhage
If already on a ventilator-
• ↑ mean airway pressure
• ↑ positive end-expiratory pressure to 6 to 8 cm H2O
• ↑ the inspiratory time
• ↑ the peak inspiratory pressure
 Management cont
Other support:

• correct the blood pressure with volume expansion (colloids) and

inotropes
• PRBC transfusion to correct blood volume and hematocrit
• Correct acidosis by correcting hypovolemia, hypoxia, and low
cardiac output.
• Treat any underlying disorder.
 Management cont
Other measures to consider if the preceding methods are not
effective (controversial)
• Endotracheal tube administration of epinephrine or nebulized
epinephrine
• Consider high-frequency ventilation
• Rescue surfactant. Consider using a single dose of surfactant
after the infant is stabilized on the ventilator.
American Academy of Pediatrics Committee on Fetus and Newborn states
that surfactant treatment is plausible because blood inhibits surfactant
function, but because of the lack of studies, the benefit has not been
establish
Cochrane review (2012) also didn’t recocmended due to lack of RCT
 Management cont

• High-frequency oscillatory ventilation combined with

pulmonary surfactant
• Diuretics
• Steroids
• Recombinant factor VIIa
• Hemocoagulase
• Low molecular weight heparin
• Extremely low birth weight infants with serious pulmonary hemorrhage
have an increased risk for poor long-term outcome.
• Prophylactic indomethacin reduces the rate of early serious pulmonary
hemorrhage, mainly through its action on patent ductus arteriosus.
• Prophylactic indomethacin is less effective after the first week of life
• additional treatment with low-molecular-weight heparin could provide a
better patient outcome for neonatal pulmonary hemorrhage with
unfractionated heparin treatment,

• as it could notably improve pulmonary function and coagulation function and

reduce the incidence of complications
 Activated recombinant factor VII (rFVIIa):

• It works by activating the extrinsic

pathway and binds to tissue factor which
ultimately will seal sites of vascular injury
• Effect is enhanced when platelets are co
administered
• Dosing: 50 mg/kg twice daily 3 hours apart for
2 to 3 days
• Cerebral venous thrombosis is a
potentialcomplication of high-dose that has
occurred in adults
 Hemocoagulase
• Hemocoagulase is a newer treatment
option
• Derived from Brazilian snake venom
• It has a thromboplastin-like effect that
convert prothrombin to thrombin
and fibrinogen to fibrin
• dose 0.5 Klobusitzky unit (KU) through
ETT every 4 to 6 hours until hemorrhage
stopped.
 Prognosis
• The prognosis is difficult to establish in part due to the difficulty
in establishing a clinical diagnosis for this condition.
• Pulmonary hemorrhage was thought to be uniformly fatal before
mechanical ventilation
• Survivors of pulmonary hemorrhage require longer ventilator
support.
• Develop bronchopulmonary dysplasia/chronic lung disease (60%
of premature infants).
• Increased incidence of cerebral palsy and cognitive delay,
• Increased risk of seizures and periventricular leukomalacia at 18
months of age.
 Take home messages

• Pulmonary hemorrhage is bleeding into the lungs which is

characterized by fresh continuous bloody fluid from the ETT or
lower respiratory tract.
• It is acute, catastrophic, often life-threatening event that causes
a sudden deterioration in the infant’s clinical condition
• Premature and high risk baby should be taken care off
exclusively.
• Early diagnosis and prompt management can reduce fatality
and long time disability.
Reference books
• Gomella
• Roberton
• Avery
• Gold smith
• Cloherty
Notes
• Article on antenatal cortico steroids
• Prophylectic indomethacin
• PDA and pulmonary hemorrhage
• P Hg and Surfectant
• Rescue surfactant
• Epinephrin in ET Tube
• High frequency ventilation
• Diuretics
• Steroid in PH
• Recombinant factor VIIa
• Hemocoagulase
• Vit K, FFP
 oxygenation index
The oxygenation index is a calculation used in intensive care medicine to measure
the fraction of inspired oxygen (FiO2) and its usage within the body.

A lower oxygenation index is better - this can be inferred by the equation itself. As the
oxygenation of a person improves, they will be able to achieve a higher PaO2 at a lower FiO2.
This would be reflected on the formula as a decrease in the numerator or an increase in the
denominator - thus lowering the OI. Typically an OI threshold is set for when a neonate
should be placed on ECMO, for example >40.
The shred sign
• The shred sign, also known as the fractal sign, is a static sonographic
sign of lung consolidation. Consolidated lung tissue appears as a
subpleural hypoechoic region that has an irregular (shredded) deep
border (fractal line) abutting normally aerated lung, which has
echogenic artifacts.