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.