Diffuse Alveolar Hemorrhage (DAH): Current Approach and Treatment

Abstract

Diffuse alveolar hemorrhage (DAH) is a rare life-threatening condition. The presentations are hemoptysis, anemia, diffuse lung infiltration, and acute hypoxemic respiratory failure. However, one-third of patients don’t have hemoptysis and need sequential bronchoalveolar lavage to demonstrate bleeding in 3 bottles of bronchoalveolar lavage fluids. The most common cause of DAH is capillaritis from ANCA-associated vasculitis (e.g., granulomatosis with polyangiitis and microscopic polyangiitis) and connective tissue disease (systemic lupus erythematosus, SLE). The treatment for ANCA-associated vasculitis is pulse methylprednisolone plus cyclophosphamide and maintenance with immunosuppressive drugs.  The study showed rituximab plus pulse methylprednisolone was not inferior to cyclophosphamide plus pulse methylprednisolone for induction of remission in severe ANCA-associated vasculitis. For connective tissue disease (e.g., SLE) with DAH responded well with high dose corticosteroid, however precaution superinfection with bacteria and fungus and suggestion empirical antibiotic at initial. Anti-glomerular basement membrane disease is a cause in bland pulmonary hemorrhage group and the treatment is plasmapheresis to remove anti-GBM antibodies plus pulse methylprednisolone. In refractory DAH cases from SLE and Anti-glomerular basement membrane disease, rituximab and recombinant-activated human factor VII may be use to stop bleeding. If DAH from diffuse alveolar damage (DAD) usually from sepsis, treatment infection together with support ventilation and oxygenation.