Immediate Management of Pulmonary Hemorrhage in Preterm Infants
Immediately increase positive end-expiratory pressure (PEEP) and escalate to high-frequency oscillatory ventilation (HFOV) if oxygenation does not improve rapidly, while simultaneously administering intratracheal epinephrine and preparing for surfactant therapy. 1, 2
Initial Stabilization Steps
Ventilatory Support (First Priority)
- Increase PEEP immediately to 6-8 cm H₂O using conventional mechanical ventilation (CMV) to tamponade bleeding and maintain alveolar recruitment 3, 1
- Escalate to HFOV within 2-4 hours if hypoxia (FiO₂ >60%) or respiratory acidosis persists despite optimized CMV settings 1, 2
- Avoid bag-mask ventilation or low-pressure strategies—these infants require higher pressures than standard resuscitation (20-25 cm H₂O may be insufficient) 3
Intratracheal Epinephrine Administration
- Spray or irrigate epinephrine (1:10,000 dilution) directly into the trachea via endotracheal tube immediately upon diagnosis 1, 2
- This provides local vasoconstriction and helps control active bleeding 1
Secondary Interventions (Within First Hour)
Surfactant Therapy
- Administer exogenous surfactant if secondary respiratory distress syndrome (RDS) develops following the hemorrhage, which occurs in approximately 67% of cases 1
- Surfactant therapy significantly improves alveolar-arterial oxygen difference (AaDO₂) and oxygenation index (OI) within 2-4 hours post-hemorrhage 1
- Reduces duration of high oxygen requirement (FiO₂ >40%) 1
- All five studies using surfactant as primary treatment showed effectiveness in improving oxygenation and preventing recurrence, with no association with increased mortality 2
Blood Product Therapy
- Transfuse packed red blood cells if hemoglobin drops significantly or hemodynamic instability occurs 1, 2
- Correct coagulopathy with fresh frozen plasma and platelets if thrombocytopenia or clotting abnormalities are present 2
- Administer vitamin K if not previously given or if coagulopathy suspected 2
Hemodynamic Management
Patent Ductus Arteriosus (PDA) Assessment
- Obtain urgent echocardiography to evaluate for hemodynamically significant PDA, which is strongly associated with pulmonary hemorrhage 4, 5
- Consider indomethacin or ibuprofen for PDA closure if hemodynamically significant 4
Cardiovascular Support
- Initiate vasopressors/inotropes if hypotension persists despite volume resuscitation 2
- Monitor for left ventricular diastolic dysfunction, which contributes to hemorrhage pathophysiology 4
Diagnostic Confirmation (Concurrent with Treatment)
- Obtain chest X-ray immediately to document bilateral infiltrates and rule out pneumothorax 3
- Chest imaging should be completed within 48 hours of presentation 3
- Visualize frank blood below the larynx during intubation or suctioning to confirm diagnosis 3
Critical Pitfalls to Avoid
- Do not delay HFOV escalation—waiting beyond 2-4 hours with persistent hypoxia increases mortality 1
- Do not withhold surfactant based on prior administration; secondary RDS is common and requires repeat dosing 1
- Do not assume adequate ventilation with standard settings—these infants require higher PEEP and mean airway pressures than typical RDS 3, 1
- Do not overlook PDA—failure to address hemodynamically significant PDA leads to recurrent hemorrhage 4, 5
Monitoring Parameters
- Continuous pulse oximetry and arterial blood gases every 1-2 hours initially 1
- Serial hemoglobin/hematocrit every 4-6 hours for first 24 hours 1
- Coagulation studies (PT, PTT, fibrinogen, platelets) at presentation and as needed 2
- Echocardiography within first 24 hours and repeat if clinical deterioration 4