ALVEOLAR HEMORRHAGE SYNDROMES in Objective-C

Painting Quick Response Code in Objective-C ALVEOLAR HEMORRHAGE SYNDROMES

Diffuse alveolar hemorrhage may occur in a variety of immune and nonimmune disorders Hemoptysis, alveolar infiltrates on chest radiograph, anemia, dyspnea, and occasionally fever are characteristic Rapid clearing of diffuse lung infiltrates within 2 days is a clue to the diagnosis of diffuse alveolar hemorrhage Pulmonary hemorrhage can be associated with an increased DLCO Causes of immune alveolar hemorrhage have been classified as anti-basement membrane antibody disease (Goodpasture s syndrome), vasculitis and collagen vascular disease (systemic lupus erythematosus, Wegener s granulomatosis, systemic necrotizing vasculitis, and others), and pulmonary capillaritis associated with idiopathic rapidly progressive glomerulonephritis Nonimmune causes of diffuse hemorrhage include coagulopathy, mitral stenosis, necrotizing pulmonary infection, drugs (penicillamine), toxins (trimellitic anhydride), and idiopathic pulmonary hemosiderosis Goodpasture s syndrome is idiopathic recurrent alveolar hemorrhage and rapidly progressive glomerulonephritis The disease is mediated by anti-glomerular basement membrane antibodies Goodpasture s syndrome occurs mainly in men who are in their 30s and 40s Hemoptysis is the usual presenting symptom, but

impaired ability to clear oral secretions, and upper airway obstruction, producing inspiratory stridor Respiratory failure occurs in severe cases Early management (see also 37) includes the use of a high-humidity face mask with supplemental oxygen, gentle suctioning to evacuate oral secretions, elevation of the head 30 degrees to promote clearing of secretions, and topical epinephrine to reduce edema of the oropharyngeal mucous membrane Helium-oxygen gas mixtures (Heliox) may reduce labored breathing due to upper airway narrowing Close monitoring with arterial blood gases and later with oximetry is important Examination of the upper airway with a fiberoptic laryngoscope or bronchoscope is superior to routine physical examination Endotracheal intubation is often necessary to establish airway patency and is likely to be necessary in patients with deep facial burns or oropharyngeal or laryngeal edema Tracheotomy should be avoided if possible because of an increased risk of pneumonia and death from sepsis Chemical injury to the lung results from inhalation of toxic gases and products of combustion, including aldehydes and organic acids The site of lung injury depends on the solubility of the gases inhaled, the duration of exposure, and the size of inhaled particles that transport noxious gases to distal lung units Bronchorrhea and bronchospasm are seen early after exposure along with dyspnea, tachypnea, and tachycardia Labored breathing and cyanosis may follow Physical examination at this stage reveals diffuse wheezing and rhonchi Bronchiolar and alveolar edema (eg, ARDS) may develop within 1 2 days after exposure Sloughing of the bronchiolar mucosa may occur within 2 3 days, leading to airway obstruction, atelectasis, and worsening hypoxemia Bacterial colonization and pneumonia are common by 5 7 days after the exposure Treatment of smoke inhalation consists of supplemental oxygen, bronchodilators, suctioning of mucosal debris and mucopurulent secretions via an indwelling endotracheal tube, chest physical therapy to aid clearance of secretions, and adequate humidification of inspired gases Positive endexpiratory pressure (PEEP) has been advocated to treat bronchiolar edema Judicious fluid management and close monitoring for secondary bacterial infection with daily sputum Gram stains round out the management protocol The routine use of corticosteroids for chemical lung injury from smoke inhalation has been shown to be ineffective and may even be harmful Routine or prophylactic use of antibiotics is not recommended Patients who survive should be watched for the late development of bronchiolitis obliterans

Miller K et al Acute inhalation injury Emerg Med Clin North Am 2003 May;21(2):533 57 [PMID: 12793627] Sheridan R Specific therapies for inhalation injury Crit Care Med 2002 Mar;30(3):718 9 [PMID: 11990950]

Aspiration of inert material may cause asphyxia if the amount aspirated is massive and if cough is impaired, in which case immediate tracheobronchial suctioning is necessary Most patients suffer no serious sequelae from aspiration of inert material