Diffuse alveolar hemorrhage

• Diffuse Alveolar Hemorrhage (DAH) is a life-threatening condition
• It is a subset of Pulmonary hemorrhage involving the microcirculation involving alveolar microvasculature
• Most commonly the result of systemic vasculitis [1]

• Hemoptysis ( may be initially absent in up 33% of DAH presentations [2]
• Anemia
• Diffuse lung infiltrates
• Acute hypoxemic respiratory failure

• Idiopathic small vessel vasculitis
  • Granulomatosis with polyangiitis (Wegener's)
  • Churg-Strauss syndrome
  • Microscopic polyangitis
• Primary immune complex-mediated vasculitis
  • Goodpasture syndrome
  • Henoch-Schonlein purpura
• Secondary vasculitis
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Mixed connective tissue disease
  • Polymyositis/Dermatomyositis
• Acute lung transplant rejection
• Drug induced (ie. chemotherapy, amiodarone, propylthiouracil)
• ARDS
• Multilobar Pneumonia
• Coagulopathy
• Pulmonic veno-occlusive disease
• Mitral stenosis

• Clinical suspicion with falling hematocrit
• Radiographic imaging consistent with bilateral infiltration (CXR, CT) - can be patchy, focal or diffuse
• Bronchoscopy with BAL showing sequentially increasing RBC counts

• Airway stabilization if large volume hemoptysis or problems with oxygenation/ventilation (>8.0 ETT preferable)
• IV corticosteroids - high dose Methylprednisolone Q6H[3]
• Bronchoscopy to obtain BAL and localize/address source of bleeding if localizable
• Management of Hemoptysis
  • Correct any coagulopathy
  • Consider nebulized TXA if massive[4]

• Typically requires upper level of care

• Hemoptysis

Life in the Fast Lane: Diffuse Alveolar Hemorrhage