Pulmonary hemorrhage (PH) is a critical condition in children involving bleeding into the alveoli and airways of the lungs.
Pulmonary hemorrhage is characterized by acute bleeding from the lung, originating from the upper respiratory tract, trachea, and alveoli.
In infants, Pulmonary hemorrhage (PH) is a severe condition marked by bleeding into the lungs, often evident as fresh, bloody fluid emanating from the endotracheal tube (ETT) or lower respiratory tract.
Massive Pulmonary Hemorrhage: This involves bleeding affecting at least two lobes of the lungs, indicating a significant event.
Histological Definition: Diagnosed by the presence of red blood cells (RBCs) within the alveolar spaces or interstitium of the lung tissue.
The onset of pulmonary hemorrhage is typically signaled by a productive cough containing blood (hemoptysis) and a deterioration in oxygenation, potentially leading to cyanosis.
Infectious:
Viral: Common culprits include Respiratory syncytial virus (RSV), influenza, and parainfluenza.
Bacterial: Examples include Mycoplasma pneumoniae and Chlamydia pneumoniae.
Other: Less common viral causes can be Adenovirus and rhinovirus.
Non-infectious:
Idiopathic: Occurring without an identifiable cause, sometimes linked to Goodpasture’s syndrome, an autoimmune disease.
Trauma: Can result from chest trauma or blunt force injury.
Vascular abnormalities: Conditions like pulmonary arteriovenous malformations and pulmonary hypertension can predispose to hemorrhage.
Coagulation disorders: Underlying bleeding disorders such as hemophilia and von Willebrand disease increase risk.
Drug–induced: Certain medications like aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can contribute.
Maternal Risk Factors:
Pregnancy-related complications: Conditions like Preeclampsia/Eclampsia (Pregnancy-induced hypertension) and Toxemia increase risk.
Infection during pregnancy.
Bleeding Disorders: Such as Hemophilia and von Willebrand disease in the mother.
Medications: Maternal use of anticonvulsants, antitubercular drugs, and Vitamin K antagonists.
Lack of antenatal steroids: In cases of preterm labor, the absence of these steroids can compromise the infant’s lung strength.
Infant Risk Factors:
Prematurity: This is the most significant risk factor.
Low Birth Weight: Infants weighing less than 1000 grams are at substantially higher risk.
Intrauterine Growth Restriction (IUGR): Limited fetal growth in the womb.
Respiratory Problems:
Hypoxia (low oxygen levels).
Asphyxia (lack of oxygen).
Respiratory Distress Syndrome (RDS).
Meconium Aspiration.
Pneumothorax (collapsed lung).
Surfactant Treatment.
Sepsis: A serious bloodstream infection.
Mechanical Ventilation: The process itself can cause irritation to the delicate lung tissue.
Patent Ductus Arteriosus (PDA), Heart Failure: Underlying cardiovascular complications.
Disseminated Intravascular Coagulation (DIC), Coagulopathy: Existing bleeding disorders.
Multiple Births, Male Sex: These are identified as increased risk factors.
Hypothermia: An abnormally low body temperature.
Polycythemia: An unusually high red blood cell count.
Erythroblastosis Fetalis: Blood incompatibility between mother and fetus.
Extracorporeal Membrane Support: The need for this indicates severe respiratory distress.
Previous Use of Blood Products: Can elevate the risk of bleeding complications.
Hypoplastic Lung Disease: Underdeveloped lungs make infants more vulnerable.
Bleeding from Airways: Observable oozing of blood from the nose, mouth, or ETT.
Secretions: Characterized by frothy, pink-tinged secretions, followed by fresh, bloody secretions.
Rapid Clinical Deterioration:
Increased work of breathing, indicating the body’s struggle for oxygen.
Bradycardia (slow heart rate), a concerning sign of compromise.
Apnea (cessation of breathing), a critical emergency.
Cyanosis (blue discoloration of the skin), signifying severe oxygen deprivation.
Hypotension (low blood pressure), reflecting circulatory instability.
Pallor (paleness), indicating reduced blood flow.
Poor systemic perfusion (inadequate blood flow) to vital organs.
Signs of Infection or Congestive Heart Failure: May include fever, cough, wheezing, edema (swelling), hepatosplenomegaly (enlarged liver and spleen), and heart murmur.
Lung Auscultation: Examination with a stethoscope may reveal decreased breath sounds and crepitations (crackling sounds).
Respiratory distress: Evident by difficulty breathing, rapid breathing, wheezing, and coughing.
Hemoptysis: Coughing up blood, ranging from streaks of blood to frank (obvious) blood.
Hypoxia: Demonstrated by low blood oxygen levels, leading to cyanosis.
Fever: May be present if the pulmonary hemorrhage is secondary to an infection.
Chest pain: Possible if the underlying cause is trauma or a vascular abnormality.
Respiratory failure: Severe cases can progress to respiratory failure, necessitating mechanical ventilation.
Anemia: Ongoing bleeding leads to a decrease in hematocrit (HCT) levels, resulting in anemia.
Identifying pulmonary hemorrhage involves assessing symptoms and employing various diagnostic tools:
History and physical examination: A thorough medical history and physical assessment are crucial for evaluating the severity of the condition.
Common Laboratory Investigations:
Blood tests: To check for infection, coagulation disorders, Platelets count, and other contributing factors. This typically includes a Complete Blood Count (CBC).
Coagulation studies: To assess blood clotting ability, including Prothrombin time (normal range: 11-13.5 seconds), thrombin time (normal range: 14-19 seconds), and activated partial thromboplastin time (normal range: 30-40 seconds).
Pulmonary function tests: May show a restrictive pattern, indicated by an elevated DLCO (diffusion capacity of the lungs for Carbon Monoxide), and often have low exhalation of Nitric Oxide.
Radiographic Imaging:
Chest X-ray: Used to detect patchy alveolar opacification, showing infiltrates and atelectasis (collapsed lung) consistent with pulmonary hemorrhage.
CT chest: May be used to assess the extent of the disease in seemingly normal areas of the lung.
Bronchoscopy: A flexible tube with a camera is inserted into the airways to directly visualize the lungs and obtain samples for further analysis.
Serologic tests: Performed to identify specific underlying disorders.
Echocardiography: May be necessary if mitral stenosis (narrowing of the mitral valve) is suspected.
Lung or renal biopsy: Often considered when a cause is unclear or the disease progresses rapidly. Samples typically show blood along with numerous siderophages (iron-containing cells) and erythrocytes (red blood cells); lavage fluid remains hemorrhagic or becomes intensely hemorrhagic after repeated sampling.
Aims:
To reduce and stop the bleeding within the lungs.
To identify the underlying cause of the hemorrhage.
To improve gaseous exchange, ensuring adequate oxygenation.
To alleviate respiratory distress.
Treatment for Pulmonary Hemorrhage is tailored to the underlying cause and severity, encompassing supportive care and specific therapies.
Supportive care: Includes oxygen therapy, mechanical ventilation, and careful fluid management.
Antibiotics: Administered for confirmed or suspected bacterial infections.
Antivirals: Used in cases of viral infections.
Corticosteroids: To reduce inflammation in certain conditions.
Plasmapheresis: A procedure to remove harmful antibodies from the blood, used in autoimmune disorders like Goodpasture’s syndrome.
Surgery: May be required to repair vascular abnormalities or remove blood clots.
Airway Management: Secure a patent airway to ensure it is open and clear. Intubation might be necessary to facilitate mechanical ventilation. Gentle suctioning is crucial to minimize further airway trauma.
Oxygenation: Provide supplemental oxygen to maintain adequate oxygen saturation levels.
Hemodynamic Support:
Volume Expansion: Address hypovolemia (low blood volume) with intravenous fluids. Colloids like Albumin may be used to improve vascular volume and hemodynamic stability.
Inotropes: Administer medications such as dopamine or dobutamine to improve cardiac output and blood pressure if needed. Inotropes work by increasing the force of heart muscle contractions.
Packed Red Blood Cells (PRBCs): Transfuse PRBCs to correct anemia and maintain an adequate hematocrit level.
Acidosis Correction:
Identify and address the underlying causes of acidosis, such as hypovolemia, hypoxia, and low cardiac output.
Administer sodium bicarbonate intravenously if necessary.
Emergency Measures:
Suctioning the airway immediately and continuously until the bleeding is controlled.
Increasing oxygen support to the maximum feasible level.
Initiating mechanical ventilation in cases of massive pulmonary hemorrhage.
Packed Red Blood Cells: Continued administration to correct blood volume and hematocrit levels, addressing hypovolemia, hypoxia, and low cardiac output.
Rescue Surfactant: Consider a single dose of surfactant after the infant is stabilized on mechanical ventilation. Blood inhibits surfactant function, but further research is needed to fully confirm the benefit.
Endotracheal Epinephrine: Administering epinephrine via the endotracheal tube or nebulized form might be considered in certain situations, though its effectiveness is not definitively established.
Hemocoagulase: A novel treatment derived from Brazilian snake venom, it has a thromboplastin-like effect that promotes blood clotting by converting prothrombin to thrombin and fibrinogen to fibrin. Dosing is typically 0.5 KU (Klobusitzky Units) every 4-6 hours until the hemorrhage stops.
Activated Recombinant Factor VIIa (rFVIIa): This medication activates the extrinsic coagulation pathway and binds to tissue factor, helping to seal sites of vascular injury. It may be used in conjunction with platelet administration for enhanced effectiveness. The typical dosage is 50 mcg/kg twice daily for 2–3 days.
Low-molecular-weight Heparin: Studies suggest this drug can improve patient outcomes in neonatal pulmonary hemorrhage by enhancing pulmonary and coagulation function and reducing the occurrence of complications.
Diuretics and steroids: May also be beneficial in certain cases.
Respiratory Complications:
Respiratory Distress: Blood accumulation in the alveoli leads to tachypnea (rapid breathing), retractions (drawing in of the chest), and cyanosis.
Hypoxemia: Impaired gas exchange due to blood in the alveoli results in low blood oxygen levels.
Pneumothorax: Pressure from blood in the lungs can cause a collapsed lung.
Atelectasis: Blood in the alveoli can lead to the collapse of lung tissue.
Bronchospasm: Irritation from blood in the airways may trigger bronchial constriction.
Acute Respiratory Distress Syndrome (ARDS): Severe pulmonary hemorrhage can progress to this life-threatening condition characterized by widespread lung inflammation and impaired gas exchange.
Circulatory Complications:
Hypovolemia: Blood loss into the lungs can cause low blood volume, leading to hypotension, shock, and organ dysfunction.
Cardiac Dysfunction: Severe hypovolemia can impair heart function, resulting in decreased cardiac output and heart failure.
Cerebral Edema: Hypotension and hypoxemia can cause brain swelling, potentially leading to neurological issues.
Other Complications:
Anemia: Significant blood loss results in reduced red blood cell count, compromising oxygen delivery.
Infection: Blood in the lungs can serve as a breeding ground for bacteria, increasing infection risk.
Neurological Damage: Severe hypoxemia or cerebral edema can cause long-term neurological impairment.
Long-Term Complications:
Chronic Lung Disease: Repeated episodes of pulmonary hemorrhage or severe ARDS can lead to lasting lung damage.
Developmental Delays: Severe hypoxemia or neurological damage can result in developmental delays.
The child is showing hemoptysis (coughing up blood), exhibiting rapid breathing (tachypnea), and experiencing respiratory distress which can be observed through nasal flaring and the use of accessory muscles for breathing.
Nursing Diagnosis:
Ineffective Airway Clearance related to bleeding within the lung tissues, as evidenced by the presence of hemoptysis and signs of respiratory distress.
Goals/Expected Outcomes:
The intended outcome is for the child to achieve and maintain a clear and open airway, demonstrating reduced respiratory distress, and experiencing no further episodes of coughing up blood.
Interventions:
Continuously assess the child’s respiratory status, paying close attention to respiratory rate, breathing effort, and oxygen saturation levels.
Position the child in a semi-upright (Semi-Fowler’s) or upright position to help promote easier breathing and lower the risk of aspiration.
Administer humidified oxygen as per medical orders to ensure adequate oxygenation levels are maintained.
Be prepared to assist with intubation or initiate mechanical ventilation should the child’s respiratory condition worsen.
Rationale:
Continuous respiratory monitoring is essential for detecting any changes in the child’s breathing status promptly, enabling timely interventions. An upright or semi-upright position is beneficial as it aids in optimal lung expansion and helps in clearing the airway. Humidified oxygen is administered to ease the breathing process and reduce the effort of breathing. In situations where respiratory status deteriorates significantly, mechanical ventilation may become necessary to ensure adequate oxygen supply and support.
Evaluation:
The effectiveness of interventions will be evaluated by observing if the child’s respiratory rate and breathing effort return to a normal range, if oxygen saturation remains consistently above 92%, and if episodes of hemoptysis are reduced or completely absent.
The child presents with pale skin, cold extremities (hands and feet), and exhibits a prolonged capillary refill time.
Nursing Diagnosis:
Ineffective Tissue Perfusion related to blood loss resulting from pulmonary hemorrhage, as indicated by pallor, cold extremities, and delayed capillary refill.
Goals/Expected Outcomes:
The goal is for the child to maintain adequate tissue perfusion, which will be evidenced by a normal capillary refill time, warm extremities, and stable vital signs.
Interventions:
Frequently monitor vital signs, including heart rate, blood pressure, and capillary refill time, initially every 15 to 30 minutes.
Administer intravenous fluids or blood products as prescribed by the healthcare provider to maintain adequate circulating blood volume and improve tissue perfusion.
Regularly monitor hemoglobin and hematocrit levels through laboratory blood tests.
Assess for signs and symptoms of hypovolemic shock and be prepared to initiate immediate emergency interventions if necessary.
Rationale:
Frequent monitoring of vital signs is crucial to accurately assess the child’s circulatory status and detect any deterioration. Administration of fluids and blood products helps to restore circulating volume, which is diminished due to hemorrhage, and thereby improves tissue perfusion. Monitoring hemoglobin and hematocrit levels provides essential data to guide decisions regarding blood transfusions and fluid therapy. Early detection of hypovolemic shock is vital to enable prompt, life-saving interventions.
Evaluation:
Evaluation of care will be based on whether the child’s capillary refill time improves to less than 2 seconds, if skin color and temperature normalize, and if vital signs stabilize within acceptable ranges.
The child is identified as being at risk for further bleeding due to underlying conditions such as coagulopathy or infection.
Nursing Diagnosis:
Risk for decreased tissue perfusion related to pulmonary hemorrhage and the presence of underlying health conditions that exacerbate bleeding risk.
Goals/Expected Outcomes:
The expected outcome is that the child will experience no further episodes of bleeding, as evidenced by stable hemoglobin levels and the absence of hemoptysis.
Interventions:
Monitor coagulation profiles (PT, PTT, INR) and platelet count on a regular basis to assess clotting function.
Administer prescribed anticoagulants or clotting factors as ordered to manage underlying coagulopathy and bleeding tendencies.
Avoid invasive procedures whenever possible and handle the child gently to minimize the risk of provoking further bleeding.
Educate parents about the signs and symptoms of bleeding to watch for and the importance of limiting the child’s physical activity.
Rationale:
Regular monitoring of coagulation profiles is essential to identify and address any coagulopathies that could increase bleeding risk. Administering anticoagulants or clotting factors helps to correct underlying coagulation abnormalities. Gentle handling and avoidance of invasive procedures help to prevent iatrogenic bleeding. Parental education is crucial for ensuring early detection of bleeding at home and adherence to activity restrictions that minimize bleeding risks.
Evaluation:
Evaluation will be based on the child remaining free from new bleeding episodes, maintaining stable coagulation profiles within normal limits, and showing no clinical signs of increased bleeding tendency.
The child is exhibiting anxiety and restlessness, likely stemming from difficulty breathing and fear related to bleeding.
Nursing Diagnosis:
Anxiety related to respiratory distress and fear of bleeding, as evidenced by restlessness and verbal expressions of fear or worry.
Goals/Expected Outcomes:
The desired outcome is for the child to demonstrate reduced anxiety, which will be evidenced by calm behavior and verbalizing feelings of being more relaxed and less anxious.
Interventions:
Provide a calm and reassuring presence to help reduce the child’s anxiety levels.
Use age-appropriate communication techniques to explain medical procedures and care to both the child and their family to foster understanding and reduce fear.
Encourage the presence of a parent or caregiver at the bedside to provide comfort, security, and emotional support.
Administer prescribed anxiolytic medications if the child’s anxiety remains severe despite non-pharmacological interventions.
Rationale:
A calm and reassuring presence from healthcare providers can significantly alleviate fear and anxiety in children. Age-appropriate explanations help to improve understanding and promote cooperation with care. Parental or caregiver presence offers essential emotional support and reassurance to the child. In cases of severe anxiety that is not relieved by other measures, anxiolytic medication may be necessary to help the child cope and facilitate care.
Evaluation:
Evaluation will be based on observing if the child appears more relaxed, if restlessness is reduced, and if the child verbally expresses feeling less anxious or fearful.
The child is identified as being at risk for infection due to potential aspiration of blood and compromised lung function.
Nursing Diagnosis:
Risk for Infection related to potential aspiration of blood and compromised lung function increasing susceptibility to pathogens.
Goals/Expected Outcomes:
The goal is for the child to remain free from infection, as evidenced by maintaining a normal body temperature and absence of any clinical signs of infection.
Interventions:
Monitor for any signs and symptoms of infection, including fever, elevated white blood cell (WBC) count, and changes in respiratory status that might indicate infection.
Maintain strict aseptic technique during all medical procedures and nursing interventions to minimize pathogen introduction.
Administer prophylactic antibiotics as prescribed by the physician to prevent potential secondary infections.
Educate parents on the importance of hand hygiene and infection prevention measures to be implemented at home after discharge.
Rationale:
Early detection and prompt treatment of infection are critical to preventing serious complications in vulnerable children. Strict aseptic technique is paramount in reducing the risk of introducing pathogens. Prophylactic antibiotics may be indicated to lower the risk of secondary infections, especially in compromised patients. Parental education is essential to ensure consistent adherence to infection prevention practices at home.
Evaluation:
Evaluation will be based on the child exhibiting a normal body temperature, a normal white blood cell count on laboratory tests, and no clinical indications of infection both during hospitalization and after discharge.