Three cases of diffuse alveolar hemorrhage with collagen-vascular disease treated by airway pressure-release ventilation as supportive management

Abstract

    Diffuse alveolar hemorrhage (DAH) is a rare pulmonary complication of collagen-vascular diseases. DAH patients develop severe hypoxemia caused by wide alveolar collapse. DAH that originates in vasculitis is generally treated with the immunosuppressive agent; for instance, mPSL pulse therapy and/or cyclophosphamide. However, it takes a couple of days for the effects to appear. Mechanical ventilation is used to support these patients until the treatment takes effect. Most of the ventilation used during conventional management of these patients may be directed at recruitable and probably more healthy units, resulting in their overdistension, which is thought to be one of the causes of ventilator-associated lung injury. We make APRV (airway pressure-release ventilation) for DAH as a supportive management.
    Here, we report three cases with DAH; a 36-year-old woman with systemic lupus erythematosus, a 46-year-old woman with anti neutrophil cytoplasm autoantibodies-related vasculitis, and a 72-year-old woman with rheumatoid vasculitis and severe vasculitis. They were treated with the immunosuppressive agent and APRV. Their DAH resolved by 25～30 mmH₂O peek pressure of APRV in a short period. In our experience, APRV ameliorated pulmonary hemorrhaging. However, subcutaneous emphysema and pneumomediastinum were caused by the high Peek pressure in two cases. Therefore, these prompted us to pay attention to the setting of APRV pressure.