Use of Therapeutic Surfactant Lavage in a Preterm Infant with Massive Pulmonary Hemorrhage

Abstract

We report a case of a premature infant presenting with recurrent pulmonary hemorrhage in which we performed a therapeutic lavage with diluted surfactant after an acute episode of bleeding with severe intractable hypoxemia. Repeated small aliquots of diluted surfactant (10×2 mL) allowed rapid improvement in oxygenation and reduction of required mean airway pressures during high frequency oscillatory ventilation. This observation may suggest that surfactant lavage could be beneficial in massive pulmonary hemorrhage in infants. A randomized controlled trial might be needed to clarify the potential benefit of this therapeutic intervention on outcome of infants suffering from this life-threatening complication.

Less invasive surfactant administration versus endotracheal surfactant instillation followed by limited peak pressure ventilation in preterm infants with respiratory distress syndrome in China: study protocol for a randomized controlled trial

“…This condition is characterized by the presence of hemorrhagic fluid from the endotracheal tube, accompanied by a sudden respiratory distress and deterioration of clinical condition (increased parameters or MV therapy is required with 1 h of the occurrence of blood fluid). X-ray imaging suggests involvement of more than two lung lobes [14].…”

The Role of Surfactant Therapy in Nonrespiratory Distress Syndrome Conditions in Neonates

“…21,22 Pulmonary Hemorrhage Pulmonary hemorrhage and subsequent clinical respiratory deterioration is a phenomenon known to occur in the preterm infant population with RDS, with an incidence in the extremely low-birth-weight (ELBW; birth weight of < 1,000 g) infant population of approximately 10 to 16%. 23 Pulmonary hemorrhage occurs most often in the context of RDS treated with surfactant and concomitant patent ductus arteriosus.…”

“…The onset of pulmonary hemorrhage is often accompanied by deterioration in the clinical status, with worsening lung compliance thought to be due, in part, to surfactant inactivation by blood components. 23 The literature addressing the utility and efficacy of surfactant for pulmonary hemorrhage is limited, though older published case series found that the administration of surfactant following pulmonary hemorrhage improves respiratory status, as measured by oxygenation index (OI) and arterial/alveolar oxygen ratio. 24 A more recently conducted meta-analysis did not identify any RCTs examining the effect of surfactant administration for pulmonary hemorrhage that met inclusion criteria for analysis.…”

“…However, high quality clinical trials are needed before any conclusions can be drawn about its efficacy, or any recommendations made regarding its use in clinical practice. 23,24,26 Pulmonary Edema Similar to pulmonary hemorrhage, pulmonary edema (with or without a hemorrhagic component) of varying etiologies can precipitate respiratory failure in the neonate. Studies examining the utility of surfactant administration in improv-ing poor respiratory status due to pulmonary edema are few; furthermore, in the single study we identified, investigated hemorrhagic pulmonary edema, a milder phenotype that exists on the continuum of pulmonary hemorrhage.…”