Suspected Severe Pulmonary Hemorrhage Clinical Pathway – ICU

Immediate Interventions to Control Hemorrhage

Ventilation Interventions
- Ensure largest trach/ETT for child size
- ENT consult if existing tracheostomy
- Maximize MAP, increase PEEP
- Consider HFOV
  - Nebulized medications cannot be delivered on HFOV
- Neuromuscular blockade

Medical Interventions
- Support circulation, PRBCs as indicated
- Correct any known coagulation—platelets, FFP, cryo
- Consider anticoagulation reversals
- Administer inhaled racemic epinephrine, caution if cardiac disease
- Consider steroids
- Hematopoietic stem cell transplant history
- Known immune-mediated cause of pulmonary hemorrhage
- Consider antibiotics if concern for infection

Pulmonary Hemorrhage Medical Management

Nebulized tranexamic acid (TXA) q6hr
Nebulized factor VII (rFVIIa) alternating with nebulized TXA, if:
- Inadequate hemorrhage control after 24 hrs of tranexamic acid
- or
- Massive Transfusion Protocol required
Consider systemic antifibrinolytic agents
- Aminocaproic acid or TXA
Consider
- Hematology consult
- Thromboelastography assay

History and Physical

Laboratory Studies
Imaging
Consult Pulmonary, Cardiology

Determine Etiology of Bleeding
Review Differential Diagnosis: Diffuse vs. Focal Hemorrhage

Suspect Diffuse Hemorrhage

Suspect Non-Cardiac Focal Hemorrhage

Suspect Cardiac Source of Hemorrhage

Medical Treatment/Escalation

Emergency Pulmonary consult for bronchoscopy
Consider CTA
Consult IR for vessel embolization as indicated
Medical Treatment/Escalation

Consult Cardiology for catheterization
Emergency Pulmonary consult for bronchoscopy
Consider Medical Treatment/Escalation
- Consult cardiology/cardiac critical care prior to medical treatment/escalation

Lung Isolation Techniques: identify affected lung and protect unaffected lung
- L side bleed R mainstem intubation
- R side bleed L blind technique with head rotated to R
Interventional Pulmonary/Anesthesia
- Fiberoptic guided selective intubation
- Dual lumen ETT with differential ventilation of bleeding/non-bleeding lung
- Bronchial blocker occlusion of hemorrhagic area
- Localized medication administration to hemorrhagic area

Ongoing Management
- Monitor blood loss, CBC q4hr
- Factor replacement as indicated
- PRBC as indicated

Post Acute Care
- Monitor for potential rebleeding
- De-escalate CBC − q6hr × 2, q12hr × 2, then daily
- Wean inhaled therapies per medication table
- Resume previous respiratory management

Posted: December 2025
Authors:
- G. Keim, MD
- N. Yeyha, MD
- A. Gipsman, MD
- J. Piccione, MD
- A. Corcoran, MD
- A. Wannes Daou, MD
- P. Phinizy, MD
- M. Josephson, MD
- J. Freedman, MD
- B. Bruins, MD
- C. Witmer, MD
- T. Olson, MD
- J. Weller, MD
- K. Resendiz, PharmD
- E. Faulkner, RT
Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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CICU/PICU Clinical Pathway for the Management of Suspected Severe Pulmonary Hemorrhage

Evidence