Posts: 3,675,934
Threads: 734,342
Joined:
Sep 2021
Reputation:
5
A 44-year-old woman is hospitalized because of respiratory failure. She has had flu-like symptoms with arthralgias, low-grade fever, cough, and rare hemoptysis for 2 months. Respiratory failure developed during the past 48 hours. Three days ago a chest radiograph revealed bibasilar alveolar infiltrates. Physiology revealed an FVC 85% of predicted, FEV1 88% of predicted, and a DLCO of 120%. On physical examination there is no exanthem. Loud end-inspiratory bilateral crackles are heard. Mild anemia is present. The PaO2 is 48 mm Hg, and the PaCO2 is 29 mm Hg. The current chest radiograph shows extensive bilateral infiltrative lesions. Intravenous therapy with appropriate antibiotics for overwhelming community-acquired pneumonia is begun; 24 hours later respiratory failure continues.
Which of the following is the best management option for this patient?
A Surgical lung biopsy
B Corticosteroids
C Bronchoscopy with bronchoalveolar lavage
D High-resolution computed tomography of the chest
Posts: 3,675,934
Threads: 734,342
Joined:
Sep 2021
Reputation:
5
Answer and Critique (Correct Answer = C)
Diffuse alveolar hemorrhage (DAH) is a clinical syndrome characterized by dyspnea and diffuse alveolar infiltrates. It can be the initial manifestation of various disorders, including primary or secondary pulmonary vasculitis, drug reactions, coagulation disorders, and infection. DAH should be considered in patients with unexplained diffuse alveolar infiltrates and respiratory failure, particularly in a patient with new-onset renal insufficiency or with a known connective tissue disease. Up to one third of patients with DAH do not have hemoptysis. Diagnosis is made with bronchoalveolar lavage, as serial samplings showing a persistently bloody fluid. Cultures for infectious organisms can be collected at the same time. Pulmonary-renal syndrome (the combination of DAH and glomerulonephritis) should be sought after in all patients, and most patients with the syndrome have a primary small-vessel vasculitis or Goodpasture's syndrome.
Although surgical lung biopsy would be definitive, the diagnosis can be made in a less invasive manner. Treatment with corticosteroids would be inappropriate before determining the mechanism of this patient's respiratory failure. An HRCT would be helpful in defining the radiographic pattern of disease and can be particularly useful in specific clinical settings; however in this situation the expected pattern of diffuse ground glass opacities with occasional consolidation is nonspecific and would not preclude additional evaluation.
Key Points
* Diffuse alveolar hemorrhage is characterized by dyspnea and diffuse alveolar infiltrates; it can be the initial manifestation of primary or secondary pulmonary vasculitis, drug reactions, coagulation disorders, and infection.
* The diagnosis of diffuse alveolar hemorrhage is made with bronchoalveolar lavage, with serial samplings showing a persistently bloody fluid.
Posts: 3,675,934
Threads: 734,342
Joined:
Sep 2021
Reputation:
5
DIFFUSE ALVEOLLAR AIRWAY ......BRONCOSCOPY
