Infant presenting with pulmonary haemorrhage as a sequelae of accidental asphyxiation
Anupama Menon1* and Ema Kavaliunaite2
1 Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH
2Kings College Hospital, Department of Paediatric Respiratory Medicine, Denmark Hill, London, SE5 9RS
*Correspondence: Dr Anupama Menon, Respiratory Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH
Email: anupama_menon23@yahoo.co.in
Telephone number: +44 2085 346050
Fax number: +44 2078138514
Conflict of interest: None
Keywords: pulmonary haemorrhage; negative pressure pulmonary oedema; asphyxiation; intrathoracic pressure
Menon and Kavaliunaite
To the Editor,
Pulmonary haemorrhage, though a well-recognised entity is uncommon in paediatric population 1-3. It can present as an insidious and chronic course or as an acute life-threatening event1,2.There is no clear data on the incidence of pulmonary haemorrhage in children 1,2. Respiratory infections, cystic fibrosis and congenital heart diseases remain the leading causes 1,2. Less common causes identified are foreign body aspiration, upper airway bleeding, trauma (accidental, related to tracheostomy), suffocation (intentional or accidental), pulmonary hypertension or embolism or arteriovenous fistula, tumours, congenital lung malformations, primary hematologic bleeding, coeliac disease, Heiner’s syndrome (cow’s milk sensitivity), vasculitis and associated syndromes, idiopathic pulmonary haemorrhage of infancy, catamenial and factitious hemoptysis1,2 . Pulmonary haemorrhage is not only rare but poorly understood in infants3. Suffocation leading to airway obstruction and in turn, leading to oronasal and pulmonary haemorrhage in infants is poorly studied 3. Discrepancy and inconsistency in reporting these presentations also contribute to the poor understanding and availability of data3. McIntosh et al reported in a 10-year retrospective hospital study that the incidence of suffocation is 0.22/10 000 live births and 40% of them can progress to pulmonary haemorrhage 3.
We describe a 7-week-old male infant, who presented to Emergency Department after mother noted gurgling noises followed by blood from mouth and floppiness. The incident occurred when the infant, previously fit and well was breastfeeding in a sling strapped to mother while she was walking in a farm with the older siblings. The only relevant history was coryzal symptoms noted two weeks before this episode.
In view of further clinical deterioration with respiratory failure, hypotension and bradycardia, he required a brief period of cardiopulmonary resuscitation, intubation and hypovolemic correction with fluids, red blood cells (haemoglobin of 91 g/L) and plasma. Frank blood was noted at mouth, vocal cords, nostril and through nasogastric tube on insertion. On admission to intensive care, he needed high frequency oscillation ventilation for about 24 hours following which he was switched to conventional ventilation and then extubated after 3 days.
Investigations done included chest radiograph (Figure 1) that showed diffuse ground glass opacification. Echocardiogram, cranial ultrasound, ophthalmology assessment and coagulation studies were normal. CT chest with contrast was performed 6 days after admission and was normal. Vasculitic and septic screenings were negative. Respiratory viral screen was positive for rhinovirus but thought to be of minimal significance in this clinical context.
Safeguarding team were involved in view of the nature of presentation. However following review of events there were nil concerns raised. The patient recovered well with no neurological sequelae and was discharged home after 8 days of hospital stay. He remains well at 12 months follow up.