Remember the patient who's case I just posted?
Ok maybe she doesn't have DAH; here are three x rays you tell me what you think.
Day 1 of solumedrol
Day 3 of solumedrol
Day 5 of solumedrol
On the other hand, her oxygen requirements are still high but the PEEP is down to 10 and the FiO2 is about 60-65%.
For what it's worth, the BAL grew some Candida and another yeast not identified. I'm not sure what this means if anything.
I guess this could be ARDS (with blood in BAL?), but I want to put the current presentation together with her 2004 CT showing fibrosis.
Any thoughts now?
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Since there is no response to steroids, i think that the patient has masive blood aspiration secondary to traumatic intubation which resulted in ARDS thus complicating whatever process she had going on before which looks like IPF radiologically.
My plan will be to continue to support her and try to wean her of the vent if possible and then get an open lung biopsy.
I just wanna repeat the question i asked earlier: is there a way to differentiate between blood aspiration and DAH by doing a BAL, because i think that both will give a bloody BAL?
On bronch, the airways had no blood. The blood was only in the alveoli (BAL). Thus I think it is DAH unresponsive to solumedrol. I think plasmapharesis is the next step.
I know of no way to definitively differentiate between local aspiration of blood and DAH. However, I'd think that diffuse aspiration from a traumatic intubation or from a laryngeal tear would present with evidence of blood in the larger airways.
My suspicion for vasculitic disease with DAH persists--the CXR's do seem to show some clearing with the Solumedrol (although it's hard to tell if that is just technique). I'm not sure if plasmaphersis is beneficial for DAH outside of Goodpasture's. My only other thought is to consider non-bacterial infection, such as HSV pneumonitis or PCP, although those possibilites signify the land of rapidly diminishing returns. I think the only possibility for a definitive answer here is a surgical biopsy; unfortunately that may not happen outside of a post-mortem.
By the way, I'm assuming the urine sediment was negative?
I agree with Jeff H on the limitations of plasmapheresis. You could consider adding Cytoxan if Cxs negative and the Pt is on good broad ABTx coverage.
Re: Obeid's comment, the classic description is thata with blood in the airways (e.g. aspiration) with each saline push the BAL tends to get clearer (if you are wedged, in theory you are only sampling that segment and the blood from the airways will be "washed out"). Conversely, with DAH, with each progressive BAL there will be more blood.
It is often much harder to get this clean results when bronch'ing someone on high PEEP and FiO2 on the vent...
I may have missed but did you post anything on cardiac Fxn?
The urine sediment was no WBC 9 RBC, no protein.
The cardiac workup echo in recent past normal. Current presentation, echo not repeated but EKG ok, trop negative.
Ok about the plasmapharesis. I would like the open lung, if the PEEP was just a little lower I would feel more comfortable, but I think there's not much choice. I would feel better with a biopsy prior to empirc cytoxan for a condition without any diagnosis.
As for HSV etc, nothing came out of the bronch but I don't think this was specifically sent. Maybe I can try to add that on.
I'm glad to see you think the cxr's are a bit improved. I thought so too - although it sure ain't a dramatic change
UPDATE:
HEMOSIDERIN IS NEGATIVE! WTF? I swear the BAL was bloody. Makes no sense. Anyway, I think she really really needs a biopsy.
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