What is the management for an extreme preterm neonate with endotracheal bleeding?

Management of Endotracheal Bleeding in Extreme Preterm Neonates

Perform flexible bronchoscopy through the endotracheal tube to remove blood clots and mucus plugs causing airway obstruction, while simultaneously optimizing ventilator settings and addressing underlying coagulopathy. 1

Immediate Airway Management

Direct Visualization and Therapeutic Intervention

• Use flexible bronchoscopy through the existing endotracheal tube to directly visualize the source of bleeding and therapeutically remove blood clots or mucus plugs. 1 This is the primary therapeutic maneuver for restoring airway patency in neonates with endotracheal bleeding.
• Flexible bronchoscopes as small as 2.2 mm outer diameter can be passed through neonatal endotracheal tubes to evaluate tube position, assess airway patency, and perform therapeutic suctioning. 1
• The improved suction channels in newer neonatal bronchoscopes allow for effective aspiration of blood and mucus plugs that may be causing atelectasis. 1

Suctioning Technique

• Perform gentle endotracheal suctioning to maintain airway patency, but recognize this is a temporizing measure until bronchoscopy can be performed. 1
• Use shallow dry suctioning rather than deep suctioning with saline lavage, as both methods are equally effective for material removal and dry suctioning causes less trauma. 2
• Be aware that endotracheal suctioning can cause transient bacteremia in ventilated newborns, particularly when respiratory tract colonization is present. 3

Ventilator Management

Immediate Adjustments

• Increase FiO2 to 100% if the infant is experiencing significant desaturation from blood in the airway. 1 This is recommended whenever there is cardiovascular compromise or significant respiratory distress.
• Rapidly adjust ventilator settings after blood removal, as clearance of airway obstruction can cause sudden improvements in lung compliance and functional residual capacity. 1
• Monitor closely for pneumothorax or air leak, as rapid changes in lung mechanics following clot removal increase this risk. 1

Positioning of Endotracheal Tube

• Verify endotracheal tube position using exhaled CO2 detection, which remains the most reliable confirmation method. 1, 4 A prompt increase in heart rate after repositioning indicates successful tube placement and lung aeration.
• Ensure the tube is not malpositioned or causing trauma that could be contributing to bleeding. 1

Addressing Underlying Coagulopathy

Assess for Hemorrhagic Disease of the Newborn

• Immediately check prothrombin time and consider empiric vitamin K administration while awaiting results. 5 A prompt response (shortening of PT in 2-4 hours) is diagnostic of hemorrhagic disease of the newborn.
• Administer vitamin K1 1 mg subcutaneously or intramuscularly for treatment of suspected hemorrhagic disease. 5 Higher doses may be necessary if the mother received oral anticoagulants.
• If bleeding is excessive, consider whole blood or component therapy in addition to vitamin K, as transfusion corrects the immediate problem while vitamin K addresses the underlying disorder. 5

Transfusion Thresholds

• For extreme preterm neonates on respiratory support in the first postnatal week, maintain hemoglobin ≥11 g/dL. 1 This threshold decreases to 10 g/dL in week 2 and 9 g/dL in week 3 or later.
• Transfuse packed red blood cells if hemoglobin falls below these thresholds, as blood loss from endotracheal bleeding combined with baseline anemia can compromise cerebral oxygenation. 1

Consider Other Coagulation Disorders

• Evaluate for specific factor deficiencies or acquired coagulopathy related to sepsis, liver dysfunction, or disseminated intravascular coagulation. 6
• Factor concentrates may be indicated for specific diagnosed deficiencies, though their use in neonates is often off-label. 6

Identify and Treat the Bleeding Source

Trauma-Related Causes

• Assess whether recent intubation, tube manipulation, or aggressive suctioning caused mucosal trauma. 1
• Preterm infants have fragile airway mucosa that is particularly susceptible to trauma from endotracheal tubes and suctioning. 1
• If trauma is identified on bronchoscopy, minimize further manipulation and allow time for mucosal healing while maintaining gentle suctioning technique. 1

Blood Aspiration

• Consider whether the infant aspirated blood from maternal sources (vaginal bleeding, placental hemorrhage) during delivery. 7
• Blood aspiration can cause acute respiratory failure and persistent pulmonary hypertension requiring mechanical ventilation and potentially surfactant administration. 7
• If blood aspiration is suspected, consider surfactant administration (particularly if respiratory status is deteriorating) and monitor for development of persistent pulmonary hypertension. 7

Pulmonary Hemorrhage

• If frank pulmonary hemorrhage is occurring (not just blood-tinged secretions), consider surfactant administration as surfactant inactivation may be contributing to respiratory deterioration. 1
• Surfactant rescue therapy has shown improved gas exchange in neonates with pulmonary hemorrhage, though evidence is limited. 1

Monitoring and Supportive Care

Continuous Assessment

• Monitor heart rate continuously as the primary indicator of adequate oxygenation and ventilation. 1 A declining heart rate indicates worsening respiratory status requiring immediate intervention.
• Use pulse oximetry to guide oxygen supplementation, recognizing that preterm infants normally have gradual rise in oxygen saturation over the first 10 minutes of life. 1
• Assess for signs of air leak (pneumothorax, pulmonary interstitial emphysema) which can occur after rapid changes in airway patency. 1

Temperature Control

• Maintain strict thermoregulation as extreme preterm infants are highly susceptible to hypothermia, which can worsen coagulopathy. 1
• All resuscitation and bronchoscopy procedures can be performed while maintaining temperature-controlling interventions. 1

Common Pitfalls to Avoid

• Do not perform deep suctioning with saline lavage, as this provides no advantage over gentle dry suctioning and may cause additional trauma. 2
• Do not delay bronchoscopy if blood clots are suspected to be causing significant airway obstruction or atelectasis, as therapeutic removal is often necessary. 1
• Do not assume bleeding will resolve spontaneously without addressing potential coagulopathy—always check coagulation studies and consider vitamin K. 5
• Do not forget to adjust ventilator settings immediately after clearing blood from the airway, as sudden improvement in compliance can lead to volutrauma. 1
• Do not overlook maternal factors that may have led to blood aspiration during delivery. 7