Intratracheal Budesonide Combined With Surfactant for Pulmonary Hemorrhage in a Preterm Neonate: A Case Report

Intratracheal budesonide combined with surfactant has been recently reported to be effective in the treatment of respiratory distress syndrome (RDS), acute respiratory distress syndrome (ARDS), and other conditions associated with reduced surfactant activity and lung inflammation. This report presents the first case of intratracheal budesonide using surfactant for acute pulmonary hemorrhage and severe respiratory failure in an extremely low birthweight infant. A 251 g preterm infant born at the 24th gestational week was intubated, received one dose of intratracheal surfactant for the treatment of RDS on her first day of life. The patient's respiratory condition was stable using assist/control mode ventilation with a fraction of inspired oxygen (FiO₂) of 0.28, and the oxygenation index (OI) was between 1 and 2 on her first day of life. However, she developed severe pulmonary hemorrhage at 30 hours after birth. Because pulmonary hemorrhage persisted and the maximum oxygenation index was 42.5 at 45 hours after birth, despite high-frequency oscillatory ventilation (HFOV) with high mean airway pressure and high concentration of inhaled oxygen (FiO₂=0.9), we administered intratracheal budesonide (0.25 mg/kg/dose) combined with surfactant (80 mg/kg/dose) at 54 hours of age. As a result, her respiratory conditions successfully improved, and the OI reduced stepwise to 19.5 at 56 hours of age and 5.3 at 66 hours of age. Respiratory acidosis also improved rapidly, and FiO₂ could be reduced to 0.4 within 24 hours of treatment. No pulmonary hemorrhage was observed after 62 hours of age. She no longer required any respiratory support or oxygen therapy at 136 days of age. This case suggests that intratracheal budesonide with surfactant can be a novel therapeutic option for acute respiratory failure due to pulmonary hemorrhage.