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International Journal of Molecular... Jan 2021Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or systemic autoimmune disorders. Pathologic... (Review)
Review
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or systemic autoimmune disorders. Pathologic findings show pulmonary capillaritis, bland hemorrhage, diffuse alveolar damage, and hemosiderin-laden macrophages, but in the majority of cases, pathogenesis remains unclear. Despite the severity and high mortality, the current treatment options for DAH remain empirical. Systemic treatment to control inflammatory activity including high-dose corticosteroids, cyclophosphamide, and rituximab and supportive care have been applied, but largely unsuccessful in critical cases. Activated recombinant factor VII (FVIIa) can achieve rapid local hemostasis and has been administered either systemically or intrapulmonary for the treatment of DAH. However, there is no randomized controlled study to evaluate the efficacy and safety, and the use of FVIIa for DAH remains open to debate. This review discusses the pathogenesis, diverse etiologies causing DAH, diagnosis, and treatments focusing on hemostasis using FVIIa. In addition, the risks and benefits of the off-label use of FVIIa in pediatric patients will be discussed in detail.
Topics: Adrenal Cortex Hormones; Cyclophosphamide; Factor VIIa; Hemorrhage; Hemostasis; Humans; Inflammation; Lung Diseases; Pulmonary Alveoli; Recombinant Proteins; Rituximab
PubMed: 33466873
DOI: 10.3390/ijms22020793 -
Current Opinion in Pulmonary Medicine Jul 2016Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article,... (Review)
Review
PURPOSE OF REVIEW
Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema.
RECENT FINDINGS
Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study.
SUMMARY
Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.
Topics: Hematoma; Hemorrhage; Hemothorax; Humans; Incidence; Pleural Diseases; Pneumothorax; Pressure; Pulmonary Edema; Risk Factors; Thoracentesis; Thoracic Wall
PubMed: 27093476
DOI: 10.1097/MCP.0000000000000285 -
International Heart Journal Sep 2018Hemoptysis is a rare complication of acute aortic dissection. A 77-year-old woman was admitted to our department with epigastralgia and hemoptysis. Computed tomography...
Hemoptysis is a rare complication of acute aortic dissection. A 77-year-old woman was admitted to our department with epigastralgia and hemoptysis. Computed tomography showed Stanford A acute aortic dissection and massive posterior mediastinal hematoma which extended along the right pulmonary artery. Hemoptysis is a lethal sign of aortic dissection, therefore, emergency ascending aortic replacement was performed with a good clinical outcome.
Topics: Acute Disease; Aged; Aortic Dissection; Aorta; Female; Hematoma; Hemoptysis; Humans; Mediastinal Diseases; Pulmonary Artery; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 30158389
DOI: 10.1536/ihj.18-263 -
Revue Des Maladies Respiratoires Apr 2015Alveolar hemorrhage occurs relatively rarely and is a therapeutic emergency because it can quickly lead to acute respiratory failure, which can be fatal. Hemoptysis... (Review)
Review
Alveolar hemorrhage occurs relatively rarely and is a therapeutic emergency because it can quickly lead to acute respiratory failure, which can be fatal. Hemoptysis associated with anemia and pulmonary infiltrates suggest the diagnosis of alveolar hemorrhage, but may be absent in one third of cases including patients in respiratory distress. The diagnosis of alveolar hemorrhage is based on the findings of a bronchoalveolar lavage. The causes are numerous. It is important to identify alveolar hemorrhage due to sepsis, then separate an autoimmune cause (vasculitis associated with antineutrophil cytoplasmic antibody, connective tissue disease and Goodpasture's syndrome) with the search for autoantibodies and biopsies from readily accessible organs, from a non-immune cause, performing echocardiography. Lung biopsy should be necessary only in exceptional cases. If the hemorrhage has an immune cause, treatment with steroids and cyclophosphamide may be started. The indications for treatment with rituximab are beginning to be established (forms that are not severe and refractory forms). The benefit of plasma exchange is unquestionable in Goodpasture's syndrome. In patients with an immune disease that can lead to an alveolar hemorrhage, removing any source of infection is the first priority.
Topics: Diagnosis, Differential; Hemorrhage; Humans; Lung Diseases; Pulmonary Alveoli
PubMed: 25891303
DOI: 10.1016/j.rmr.2014.11.066 -
The Indian Journal of Chest Diseases &... 2016Pulmonary vasculitis is an uncommon disease. Patients present with unexplained haemoptysis, pulmonary infiltrates and constitutional symptoms. Pulmonary vasculitis often... (Review)
Review
Pulmonary vasculitis is an uncommon disease. Patients present with unexplained haemoptysis, pulmonary infiltrates and constitutional symptoms. Pulmonary vasculitis often goes undiagnosed due to lack of awareness and the disease is often mis-diagnosed as tuberculosis in India. Delayed or missed diagnosis leads to disease progression to a catastrophic event like diffuse alveolar haemorrhage which carries a high mortality. The outcome of appropriately treated cases, on the contrary, is good with excellent long-term survival. The present narrative review attempts to provide an overview of pulmonary vasculitis as it is seen in India.
Topics: Hemorrhage; Humans; India; Lung; Lung Diseases; Vasculitis
PubMed: 30182673
DOI: No ID Found -
Lung Apr 2021Diffuse alveolar hemorrhage (DAH) is a rare condition with reported mortality ranging between 20 and 100%. There are many etiologies of DAH. Cardiac diseases are likely... (Review)
Review
Diffuse alveolar hemorrhage (DAH) is a rare condition with reported mortality ranging between 20 and 100%. There are many etiologies of DAH. Cardiac diseases are likely underreported causes of DAH. Heart failure and mitral valve diseases are the most common cardiac causes of DAH. The DAH results from pulmonary venous hypertension leading to stress failure of the pulmonary capillaries. There is also a contribution of the bronchial circulation. The Alveolar-capillary membrane or blood-gas barrier is an extremely thin structure that allows rapid and passive diffusion of oxygen from the inhaled air to the pulmonary capillaries while preventing pulmonary edema and DAH with chronic elevation of the transmural hydrostatic pressure. The purpose of this manuscript is to inform the clinician about this rare cause of DAH, which may be overlooked unless specifically sought after. We also discuss the pathophysiologic aspects of DAH and the safety mechanisms in place to prevent such occurrences.
Topics: Heart Diseases; Hemorrhage; Humans; Lung Diseases; Pulmonary Alveoli
PubMed: 33709230
DOI: 10.1007/s00408-021-00433-x -
The Lancet. Neurology Nov 2023Optimisation of brain oxygenation might improve neurological outcome after traumatic brain injury. The OXY-TC trial explored the superiority of a strategy combining... (Randomized Controlled Trial)
Randomized Controlled Trial
Intracranial pressure monitoring with and without brain tissue oxygen pressure monitoring for severe traumatic brain injury in France (OXY-TC): an open-label, randomised controlled superiority trial.
BACKGROUND
Optimisation of brain oxygenation might improve neurological outcome after traumatic brain injury. The OXY-TC trial explored the superiority of a strategy combining intracranial pressure and brain tissue oxygen pressure (PbtO) monitoring over a strategy of intracranial pressure monitoring only to reduce the proportion of patients with poor neurological outcome at 6 months.
METHODS
We did an open-label, randomised controlled superiority trial at 25 French tertiary referral centres. Within 16 h of brain injury, patients with severe traumatic brain injury (aged 18-75 years) were randomly assigned via a website to be managed during the first 5 days of admission to the intensive care unit either by intracranial pressure monitoring only or by both intracranial pressure and PbtO monitoring. Randomisation was stratified by age and centre. The study was open label due to the visibility of the intervention, but the statisticians and outcome assessors were masked to group allocation. The therapeutic objectives were to maintain intracranial pressure of 20 mm Hg or lower, and to keep PbtO (for those in the dual-monitoring group) above 20 mm Hg, at all times. The primary outcome was the proportion of patients with an extended Glasgow Outcome Scale (GOSE) score of 1-4 (death to upper severe disability) at 6 months after injury. The primary analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew consent or had protocol violations. This trial is registered with ClinicalTrials.gov, NCT02754063, and is completed.
FINDINGS
Between June 15, 2016, and April 17, 2021, 318 patients were randomly assigned to receive either intracranial pressure monitoring only (n=160) or both intracranial pressure and PbtO monitoring (n=158). 27 individuals with protocol violations were not included in the modified intention-to-treat analysis. Thus, the primary outcome was analysed for 144 patients in the intracranial pressure only group and 147 patients in the intracranial pressure and PbtO group. Compared with intracranial pressure monitoring only, intracranial pressure and PbtO monitoring did not reduce the proportion of patients with GOSE score 1-4 (51% [95% CI 43-60] in the intracranial pressure monitoring only group vs 52% [43-60] in the intracranial pressure and PbtO monitoring group; odds ratio 1·0 [95% CI 0·6-1·7]; p=0·95). Two (1%) of 144 participants in the intracranial pressure only group and 12 (8%) of 147 participants in the intracranial pressure and PbtO group had catheter dysfunction (p=0.011). Six patients (4%) in the intracranial pressure and PbtO group had an intracrebral haematoma related to the catheter, compared with none in the intracranial pressure only group (p=0.030). No significant difference in deaths was found between the two groups at 12 months after injury. At 12 months, 33 deaths had occurred in the intracranial pressure group: 25 (76%) were attributable to the brain trauma, six (18%) were end-of-life decisions, and two (6%) due to sepsis. 34 deaths had occured in the intracranial pressure and PbtO group at 12 months: 25 (74%) were attributable to the brain trauma, six (18%) were end-of-life decisions, one (3%) due to pulmonary embolism, one (3%) due to haemorrhagic shock, and one (3%) due to cardiac arrest.
INTERPRETATION
After severe non-penetrating traumatic brain injury, intracranial pressure and PbtO monitoring did not reduce the proportion of patients with poor neurological outcome at 6 months. Technical failures related to intracerebral catheter and intracerebral haematoma were more frequent in the intracranial pressure and PbtO group. Further research is needed to assess whether a targeted approach to multimodal brain monitoring could be useful in subgroups of patients with severe traumatic brain injury-eg, those with high intracranial pressure on admission.
FUNDING
The French National Program for Clinical Research, La Fondation des Gueules Cassées, and Integra Lifesciences.
Topics: Humans; Oxygen; Intracranial Pressure; Brain Injuries, Traumatic; Brain; France; Hematoma; Death
PubMed: 37863590
DOI: 10.1016/S1474-4422(23)00290-9 -
Journal of Thrombosis and Haemostasis :... Jul 2017Advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use, and... (Review)
Review
Advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use, and well standardized. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-dimer measurement, and imaging tests-predominantly computed tomography pulmonary angiography. These diagnostic algorithms allow safe and cost-effective diagnosis for most patients with suspected PE. In this review, we summarize signs and symptoms of PE, current existing evidence for PE diagnosis, and focus on the challenge of diagnosing PE in special patient populations, such as pregnant women, or patients with a prior VTE. We also discuss novel imaging tests for PE diagnosis and highlight some of the additional challenges that might require adjustments to current diagnostic strategies, such as the reduced clinical suspicion threshold, resulting in a lower proportion of PE among suspected patients as well as the overdiagnosis of subsegmental PE.
Topics: Acute Disease; Algorithms; Computed Tomography Angiography; Cost-Benefit Analysis; Dyspnea; Female; Fibrin Fibrinogen Degradation Products; Hematology; Hemorrhage; Humans; Lung; Magnetic Resonance Angiography; Male; Pregnancy; Probability; Pulmonary Alveoli; Pulmonary Embolism; Radionuclide Imaging; Reproducibility of Results; Tomography, X-Ray Computed
PubMed: 28671347
DOI: 10.1111/jth.13694 -
Medicina Clinica Sep 2018
Topics: Adult; Air; Hematoma; Humans; Lung Diseases; Lung Injury; Male; Thoracic Injuries; Tomography, X-Ray Computed; Wounds, Nonpenetrating
PubMed: 29246563
DOI: 10.1016/j.medcli.2017.09.028 -
Pediatric Rheumatology Online Journal Nov 2019Henoch-Schönlein Purpura (HSP) is the most common vasculitis of childhood and affects the small blood vessels. Pulmonary involvement is a rare complication of HSP and... (Review)
Review
BACKGROUND
Henoch-Schönlein Purpura (HSP) is the most common vasculitis of childhood and affects the small blood vessels. Pulmonary involvement is a rare complication of HSP and diffuse alveolar hemorrhage (DAH) is the most frequent clinical presentation. Little is known about the real incidence of lung involvement during HSP in the pediatric age and about its diagnosis, management and outcome.
METHODS
In order to discuss the main clinical findings and the diagnosis and management of lung involvement in children with HSP, we performed a review of the literature of the last 40 years.
RESULTS
We identified 23 pediatric cases of HSP with lung involvement. DAH was the most frequent clinical presentation of the disease. Although it can be identified by chest x-ray (CXR), bronchoalveolar lavage (BAL) is the gold standard for diagnosis. Pulse methylprednisolone is the first-line of therapy in children with DAH. An immunosuppressive regimen consisting of cyclophosphamide or azathioprine plus corticosteroids is required when respiratory failure occurs. Four of the twenty-three patients died, while 18 children had a resolution of the pulmonary involvement.
CONCLUSIONS
DAH is a life-threatening complication of HSP. Prompt diagnosis and adequate treatment are essential in order to achieve the best outcome.
Topics: Child; Hemoptysis; Hemorrhage; Humans; IgA Vasculitis; Kidney; Lung; Lung Diseases
PubMed: 31752918
DOI: 10.1186/s12969-019-0381-y