Pulmonary hemorrhage (PH), defined as extravasations of blood into airways and/or lung parenchyma
Pulmonary haemorrhage is an acute bleeding from the lung, from the upper respiratory tract, the trachea, and the alveoli. The onset of pulmonary hemorrhage is characterized by productive cough with blood (hemoptysis) and worsening of oxygenation leading to cyanosis.
Causes
- Infant prematurity is the factor most commonly associated with pulmonary hemorrhage.
- Toxemia of pregnancy
- Maternal cocaine use
- Erythroblastosis Fetalis
- Breech delivery
- Hypothermia
- Infection
- Infant respiratory distress syndrome (IRDS)
- Extracorporeal membrane oxygenation (ECMO)
- Coagulopathy
- Surfactant therapy
Risk Factors of Pulmonary Hemorrhage
The common risk factors that increase the chance of pulmonary hemorrhage include:
- Males are affected more often
- Intrauterine growth restriction or IUGR
- Patent Ductus Arteriosus
Clinical features
- Diffused alveolar bleeding either alone or together with eye lesions, rashes, hepatosplenomegaly
- Coughing associated with blood discharge, dyspnea, and fever.
- Sub-acute or acute condition results in a complete respiratory failure which may require mechanical ventilation otherwise can be fatal.
- Hemoptysis is a common symptom but not observed in one-third of the patients because of increase in alveolar volume.
- Continuous bleeding with decreased hematocrit (HCT) level resulting in anemia
- Recurrent episodes of this disease lead to diffusion of alveolar infiltrate, collagen deposition in insignificant airways, organizing pneumonia, and fibrosis
Diagnosis of Pulmonary Hemorrhage
The common method of identifying the disease symptoms as well as the progression includes the following:
- Common Laboratory Investigations: These include:
- Platelets count
- Broncho-alveolar lavage
- Complete Blood Count or CBC
- Coagulation studies (Prothrombin time n-11-13.5 sec), thrombin time n- 14-19 sec, activated partial thromboplastin n- 30-40 sec)
- Pulmonary function tests including elevated DLCO (diffusion capacity of the lungs for Carbonmonoxide), usually restrictive is greater than an obstructive pattern with the low exhalation of Nitric Oxide.
- Radiographic Imaging: The radiographic diagnosis includes –
- Chest X-ray for detecting patchy alveolar opacification
- CT chest for detecting spreading of the disease in normal areas
- HRCT (high resolution CT) pattern varies with the beginning of the hemorrhage.
- Serologic tests are performed to find out the exact underlying disorders.
- Echocardiography may also require if there is mitral stenosis.
- Lung or renal biopsy is often done when a cause is undetectable or if the progression of the disease is very fast. Specimens usually show blood along with numerous siderophages and erythrocytes; lavage fluid characteristically remains hemorrhagic or becomes highly hemorrhagic just after consecutive sampling.
Management
Aims
- To decrease and stop the bleeding in the lungs.
- To identify the underlying cause.
- To improve gaseous exchange.
- To improve distress
Emergency Measures
- Through or by suctioning the airway initially until the bleeding subsides.
- By increasing oxygen support.
- Mechanical ventilation should be given in massive pulmonary hemorrhage.
Continuous Management
- Packed Red Blood Cells to correct blood volume and hematocrit levels.
- Through administering blood, this will correct hypovolemia, hypoxia and also correct low cardiac output.
- Identifying and treating the cause
- Rescue surfactant by using a single dose of surfactant after the infant has been stabilized on the ventilator.
Pharmacology Management
- Hemocoagulase: Is a new treatment method discovered from a brazilian snake’s venom. It has a thromboplastin-like effect that coverts prothrombin to thrombin and fibrinogen to fibrin. Its measured in KU(Klobusitzky Units) and dose os 0.5KU every 4-6 hours until hemorrhage is stopped.
- Activated Recombinant Factor VIIa (rFVIIa): This drug works by activating the extrinsic pathway and binds to tissue factor which will eventually bind and seal sites with vascular injury. For effectiveness o this drug, platelets can be administered too. The dosage is 50mg/kg twice daily for 2 – 3 days.
- Low-molecular-weight Heparin: This drug is found to provide better patient outcome for neonatal pulmonary hemorrhage as it does improve the pulmonary function and coagulation function and reduce the incidence of getting complications.
- Diuretics and steroids can also be helpful.
We need complications
Some of the potential complications include:
Respiratory Distress: Pulmonary hemorrhage can lead to difficulty breathing and respiratory distress. The presence of blood in the lungs can obstruct the airways and compromise the exchange of oxygen and carbon dioxide, resulting in shortness of breath and rapid breathing.
Hypoxia: Hypoxia occurs when there is a decrease in the oxygen supply to the body’s tissues. In cases of severe pulmonary hemorrhage, the exchange of oxygen in the lungs may be impaired, leading to decreased oxygen levels in the blood and tissues.
Anemia: Prolonged or significant pulmonary bleeding can lead to anemia, a condition characterized by a deficiency of red blood cells or hemoglobin in the blood. Anemia can cause fatigue, weakness, and other symptoms related to reduced oxygen-carrying capacity.
Respiratory Failure: In severe cases, pulmonary hemorrhage can lead to respiratory failure, where the lungs are unable to adequately perform their function of oxygenating the blood and removing carbon dioxide. This can be life-threatening and requires immediate medical intervention.
Infection: Blood in the lungs provides an ideal environment for the growth of bacteria, increasing the risk of developing infections such as pneumonia. Infections can further exacerbate respiratory symptoms and worsen the overall condition.
Hemoptysis: Hemoptysis refers to the coughing up of blood from the respiratory tract. Pulmonary hemorrhage can cause hemoptysis, which is often a distressing symptom for the patient.
Respiratory Distress Syndrome: In some cases, pulmonary hemorrhage can trigger acute respiratory distress syndrome (ARDS), a severe lung condition characterized by inflammation and fluid accumulation in the lungs. ARDS can result in respiratory failure and may require intensive care support.
Organ Dysfunction: Severe pulmonary hemorrhage can lead to systemic effects, affecting other organs and systems in the body. This can result in multi-organ dysfunction, particularly if the underlying cause of the bleeding is not promptly addressed.
What is the pathophysiology of pulmonary hemorrhage?
Pulmonary hemorrhage in newborns involves a disruption in the delicate balance between the integrity of blood vessels and the blood clotting mechanisms within the lungs. This disruption leads to the escape of blood from the vascular system into the lung tissue or airways. The pathophysiology of this process can be described in the following steps:
Vascular Fragility and Immaturity: The blood vessels within the lungs of newborns are still developing and are more fragile compared to those in older individuals. This vascular fragility is particularly pronounced in premature newborns, as their lung tissues and blood vessels are not fully matured. The underdeveloped blood vessels have weaker walls that are more prone to damage and rupture.
Inflammation and Injury: Various factors, such as birth trauma, asphyxia, infections, or exposure to maternal risk factors, can trigger inflammation and injury to the lung tissues. Inflammation disrupts the normal structure of blood vessel walls, making them more susceptible to damage.
Increased Vascular Pressure: Conditions like respiratory distress syndrome (RDS) or transient tachypnea of the newborn (TTN) can cause increased pressure within the blood vessels of the lungs. Elevated pressure stresses the fragile vessel walls, making them more likely to leak or rupture.
Disruption of Coagulation and Fibrinolysis: The intricate balance between the coagulation (blood clotting) and fibrinolysis (clot dissolution) systems within the lung’s blood vessels can be disturbed in pulmonary hemorrhage. Imbalances in these systems can lead to impaired clot formation and weakened ability to control bleeding, contributing to the escape of blood into lung tissue.
Alveolar-Capillary Barrier Dysfunction: The barrier between the tiny air sacs (alveoli) and adjacent capillaries in the lungs can be compromised. This barrier normally prevents the movement of blood cells and fluids from the capillaries into the alveoli. When disrupted, this barrier allows blood components to enter the alveoli, leading to bleeding and potentially compromising gas exchange.
Hypoxia and Respiratory Distress: Pulmonary hemorrhage can lead to impaired gas exchange in the affected areas of the lungs. The presence of blood and compromised alveoli reduces the surface area available for oxygen and carbon dioxide exchange. This can result in hypoxia (low oxygen levels) and respiratory distress, further exacerbating the newborn’s condition.
Clinical Manifestations: The accumulation of blood within the lungs can manifest as hemoptysis (coughing up blood), increased respiratory rate, cyanosis (bluish skin discoloration due to poor oxygenation), and signs of respiratory distress.
Could you please help us with the nurses diagnosis
Impaired Gas Exchange: This nursing diagnosis is relevant because pulmonary hemorrhage can lead to inadequate oxygenation of the blood and impaired carbon dioxide elimination. Nurses must monitor the patient’s oxygen saturation, respiratory rate, and breath sounds and implement interventions to improve gas exchange, such as administering supplemental oxygen or assisting with mechanical ventilation if necessary.
Risk for Infection: Patients with pulmonary hemorrhage are at an increased risk of developing respiratory infections due to compromised lung function and potential exposure to pathogens during the hospital stay. Nurses should closely monitor for signs of infection, maintain strict hand hygiene, and follow infection control protocols.
Ineffective Airway Clearance: Hemoptysis (coughing up blood) can result in airway obstruction and compromised respiratory function. Nursing care may involve providing airway clearance techniques, such as suctioning, to maintain a patent airway and ensure effective breathing.
Anxiety: Patients experiencing pulmonary hemorrhage may feel anxious and frightened due to the severity of their condition and the fear of choking on blood. Nurses can address anxiety through therapeutic communication, relaxation techniques, and providing emotional support.
Risk for Excessive Bleeding: Pulmonary hemorrhage can lead to significant blood loss, increasing the patient’s risk of anemia and further complications. Nurses should monitor vital signs and hemoglobin levels, administer blood products as ordered, and take precautions to prevent falls or injuries that could exacerbate bleeding.
What could be there likely nursing interventions for pulmonary haemorrhage