• Diffuse alveolar hemorrhage syndromes 
  • bleeding into alveolar spaces of the lungs due to disruption of the alveolar-capillary basement membrane 
  • hemoptysis can be present as the presenting symptom but also possible to have considerable DAH without any hemoptysis or Hct drop
  • 3 histopathologic patters
    • Pulmonary capillaritis - neutrophilic infiltration of the alveolar septa, seen in systemic vasculitides, anti-GBM/Goodpasture's disease, rheumatic diseases, and with certain drugs
    • Bland pulmonary hemorrhage - hemorrhage without inflammation or destruction, seen with elevated LVEDP, bleeding disorders, and systemic anticoagulation
    • Diffuse alveolar damage - edema of the alveolar septa with hyaline membrane formation, underlying lesion of ARDS
  
  
  
  

  Posted 11/30/16 10:09:27 AM by Anna Krigel

• Diagnostic evaluation of DAH
  • Can tell blood from another consolidating process on imaging using DLCO (an increase above 100% of predicted is sensitive marker for DAH)
  • Sequential bronchoalveolar lavage - preferred method for diagnosis of DAH
    • instill and retrieve 3 sequential aliquots of 50 to 60 ml sterile saline into a subsegmental bronchus where opacities are seen on imaging
    • alveolar hemorrhage confirmed when lavage aliquots are progressively more hemorrhagic
  
  

  Posted 11/30/16 10:11:55 AM by Anna Krigel

• Treatment of DAH with capillaritis due to systemic vasculitis
  • Glucocorticoids - initiated promptly, typically IV pulse methyprednisolone
  • Additional immunosuppressive therapy with cyclophosphamide or rituximab
  • Plasmapheresis
  
  

  Posted 11/30/16 10:47:36 AM by Anna Krigel

• For further reading...

  Rituximab vs Cyclophosphamide for ANCA-associated Vasculitis (RAVE Trial NEJM)
  Plasmapheresis Therapy for DAH in Patients with Small Vessel Vasculitis (Am J Kidney Dis)
  ECMO in the Management of DAH (ASAIO Journal 2015)
  
  

  Posted 11/30/16 11:06:10 AM by Anna Krigel

Created by Christopher Kelly

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