Treatment of Pulmonary Bleed in Preterm Infants
Immediately increase positive end-expiratory pressure (PEEP) to higher levels (8-10 cm H₂O or greater), administer surfactant replacement therapy, provide blood component therapy as needed, and consider intratracheal epinephrine if bleeding is massive—this combination approach has demonstrated the strongest survival benefit in preterm infants with pulmonary hemorrhage. 1, 2
Immediate Ventilatory Management
The single most critical intervention is increasing PEEP to higher levels, as this directly correlates with survival in massive pulmonary hemorrhage 2. After adjusting for confounding factors, higher PEEP levels showed the strongest association with reduced mortality in a 2021 retrospective analysis of 51 preterm infants with massive pulmonary hemorrhage 2.
Specific Ventilator Strategy:
- Increase PEEP immediately to 8-10 cm H₂O or higher, as survivors consistently had higher PEEP levels compared to non-survivors 2
- Consider high-frequency oscillatory ventilation (HFOV) when hypoxia or respiratory acidosis persists despite conventional mechanical ventilation with optimized PEEP 1
- Maintain adequate mean airway pressure to prevent alveolar collapse and reduce ongoing hemorrhage 1, 2
The mechanism is straightforward: higher PEEP tamponades bleeding vessels, maintains alveolar recruitment, and prevents the hemorrhagic fluid from spreading throughout the lung 2.
Surfactant Replacement Therapy
Administer surfactant replacement immediately when secondary respiratory distress syndrome develops following pulmonary hemorrhage, as blood inactivates endogenous surfactant 3, 1. A 2013 study demonstrated that surfactant supplementation in preterm infants with pulmonary hemorrhage produced:
- Statistically significant improvement in alveolar-arterial oxygen difference (AaDO₂) and oxygenation index (OI) within 2-4 hours post-hemorrhage 1
- Reduced duration of high oxygen requirement (FiO₂ >40%) compared to those not receiving surfactant 1
- Improved lung function in 66.6% of cases who developed secondary RDS following hemorrhage 1
The rationale is clear: blood in the alveoli inhibits surfactant function, creating a secondary surfactant deficiency state that requires replacement 3, 1.
Hemostatic Interventions
Intratracheal Epinephrine
Spray or irrigate the trachea with epinephrine for massive pulmonary hemorrhage with active bleeding 1. This local vasoconstrictor effect helps control hemorrhage at the source 1.
Blood Component Therapy
Transfuse blood products aggressively to correct:
- Anemia from blood loss 1, 4
- Coagulopathy, which is a major risk factor (OR 6.56) for massive pulmonary hemorrhage 2, 4
- Thrombocytopenia if present 4
Emerging Hemostatic Agents
Hemocoagulase administration in addition to mechanical ventilation significantly reduced mortality from 75% to 39.3% in a 2005 randomized study of 48 newborns 5. This agent also shortened:
Recombinant activated factor VII and antifibrinolytics show promise but require further investigation before routine use 4.
Supportive Care Measures
Oxygen Management
- Titrate FiO₂ to maintain adequate oxygenation while avoiding hyperoxia 6, 7
- Monitor pre-ductal oxygen saturation continuously via pulse oximetry on the right hand/wrist 6, 7
- Target saturations of 85-95% for preterm infants 6
Cardiovascular Support
Evaluate and treat hemodynamically significant patent ductus arteriosus (hsPDA) urgently, as PDA is the strongest predictor of massive pulmonary hemorrhage (OR 11.4) 2, 4. The left-to-right shunt increases pulmonary blood flow and capillary pressure, precipitating hemorrhage 2, 4.
Temperature Management
Maintain normothermia (36.5-37.5°C), as hypothermia shows dose-dependent increases in mortality in preterm infants 3, 7.
Predictive Risk Stratification
The combination of patent ductus arteriosus plus coagulopathy has 68.9-70.4% positive predictive value for massive pulmonary hemorrhage 2. When both conditions are present:
- Implement preventive strategies including early PDA closure consideration 2, 4
- Correct coagulopathy proactively with vitamin K, fresh frozen plasma, or specific factor replacement 2, 4
- Increase monitoring intensity for early detection 2
Critical Pitfalls to Avoid
Do not maintain low PEEP levels (5 cm H₂O or less) during active pulmonary hemorrhage, as this is associated with mortality 2. The 2021 study clearly demonstrated that survivors had significantly higher PEEP compared to non-survivors 2.
Do not delay surfactant administration when secondary RDS develops, as blood rapidly inactivates surfactant and the window for effective intervention is narrow 3, 1.
Do not overlook coagulopathy correction, as this is both a major risk factor (OR 6.56) and a treatable contributor to ongoing hemorrhage 2, 4.
Do not use conventional mechanical ventilation alone when oxygenation or ventilation remains inadequate—escalate to HFOV promptly 1.
Outcome Expectations
With aggressive implementation of this treatment strategy, mortality can be reduced to 10.7-39.3% compared to historical rates of 40-75% with mechanical ventilation alone 1, 5. However, survivors remain at high risk for:
- Bronchopulmonary dysplasia (53.6% in hemorrhage group vs 17.2% in controls) 8
- Prolonged mechanical ventilation 8
- Retinopathy of prematurity 8
- Long-term neurodevelopmental impairment 4
These infants require intensive follow-up and early intervention for respiratory and developmental complications 8.