Definition

• Acute onset of bleeding from trachea or ETT or from the larynx and mouth in a non-intubated baby associated with cardiorespiratory deterioration and changes on chest X-ray

• Significant pulmonary haemorrhage is most likely to represent haemorrhagic pulmonary oedema. Differentiate from minor traumatic haemorrhage following endotracheal suction

Risk factors

• Prematurity (higher risk if <32 weeks’ gestation)
• Respiratory distress syndrome (RDS)
• Large patent ductus arteriosus (PDA)
• Excessive use of volume (>20 mL/kg) in first 24–48 hr in babies ≤28 weeks’ gestation
• Coagulopathy
• Sepsis
• IUGR
• Grade 3 hypoxic ischaemic encephalopathy (HIE)

Symptoms and signs

• Apnoeas, gasping respirations, desaturations
• Tachycardia >160 bpm, bradycardia, hypotension, shock, PDA, signs of heart failure
• Widespread crepitations, reduced air entry
• Pink/red frothy expectorate, or frank blood from oropharynx or ETT if intubated 

Investigations

• Blood gas (expect hypoxia and hypercapnia with mixed acidosis)
• FBC, clotting
• Chest X-ray (usually shows classic white-out with only air bronchogram visible but may be less striking and resemble RDS)

• Basic resuscitation, ABC

Respiratory

• Intubate and ventilate 
  
  • if already intubated do not remove ETT unless blocked – may be very difficult to reintubate
• Sedate and give muscle relaxant
• PEEP 6–8 cm H₂O, even higher PEEP of 10–12 cm H₂O sometimes required to control haemorrhage
• PIP to be guided by chest expansion and blood gases
• Long inspiratory times (0.5 sec may be needed)
• Cautious endotracheal suction of haemorrhagic fluid (try to avoid but consider in extreme cases to reduce risk of ETT blockage)
• Ensure adequate humidification
• Chest physiotherapy contraindicated until active bleeding stopped and platelets >50 (see Chest physiotherapy (percussion) guideline)
• Establish arterial access 

Fluid management

• If hypovolaemic, restore circulating volume over 30 min with 10 mL/kg sodium chloride 0.9% or Group O RhD negative packed cells if crystalloid bolus already given. Beware of overloading (added volume can be detrimental to LV failure)
• If not hypovolaemic and evidence of LV failure, give furosemide 1 mg/kg IV
• Correct acidosis (see Neonatal Formulary)
• If PDA present, restrict fluids to 60–80 mL/kg/day in acute phase 
• Further blood transfusion, vitamin K administration and FFP to be guided by Hb concentration, PT and APTT (see Transfusion of red blood cells and Coagulopathy guidelines). Coagulopathy is not usually seen before pulmonary haemorrhage but DIC can occur afterwards

Hypotension/cardiac dysfunction

• If still hypotensive or evidence of cardiac dysfunction after fluid resuscitation, treat hypotension with inotropes (see Hypotension guideline)

Infection

• Request septic screen and start antibiotics

Once baby stable

• Update parents
• Document event in case notes
• Consider single extra dose of surfactant in babies with severe hypoxaemia or oxygenation index >20
• If PDA suspected, arrange echocardiogram (see Patent ductus arteriosus guideline)
• Perform cranial ultrasound scan to exclude intracranial haemorrhage as this is often associated with pulmonary haemorrhage and may influence management (see Cranial ultrasound scans guideline)