ECMO Rescue Therapy in Diffuse Alveolar Haemorrhage: A Case Report with Review of Literature

A Rare Case of Diffuse Alveolar Hemorrhage Caused by Fentanyl Inhalation

Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening pulmonary disorder characterized by blood accumulation in alveolar spaces, often associated with autoimmune diseases and infections. Drug-induced causes of DAH, including inhalation of substances like fentanyl, are emerging concerns. A 40-year-old male with bipolar disorder and polysubstance abuse presented with altered mental status and hemoptysis after inhaling an unknown substance. Physical examination revealed respiratory distress, pinpoint pupils, and severe hypoxemia. Naloxone administration improved his condition. The workup showed negative infection markers, positive fentanyl-specific urine test, and diffuse bilateral opacities on imaging. Bronchoalveolar lavage confirmed DAH with >20% hemosiderin-laden macrophages. Steroid treatment resulted in marked improvement. Drug-induced DAH, such as fentanyl inhalation, should be considered in patients with altered mental status and pulmonary symptoms following substance use. Comprehensive evaluation and targeted treatment are crucial for optimal outcomes.

The use of ECMO in pediatric granulomatosis with polyangiitis

BACKGROUND

Granulomatosis with polyangiitis (GPA) vasculitis with pulmonary-renal syndrome rarely presents in children and is associated with high mortality rates.

CASE PRESENTATION

We present the case of a 13-year-old male with newly diagnosed GPA vasculitis, treated with extracorporeal membrane oxygenation, continuous renal replacement therapy, plasmapheresis, rituximab, cyclophosphamide, and corticosteroids.

CONCLUSION

This case presentation demonstrates that ECMO can be used as a life supporting therapy in pediatric patients with pulmonary hemorrhage from ANCA vasculitis in conjunction with other therapies.

Diffuse alveolar hemorrhage as a life threatening manifestation of newly diagnosed granulomatosis with polyangiitis following COVID-19 infection - a case report

A case report of a patient with newly diagnosed granulomatosis with polyangiitis (GPA) after undergoing COVID-19 (Coronavirus Disease 2019) is discussed. GPA is one of the ANCA-associated vasculitis, which is characterized by the presence of autoantibodies against cytoplasmic enzymes neutrophils (Anti Neutrophil Cytoplasmatic Antibodies). It is a vasculitis that mainly affects small blood vessels, leading to damage to the kidneys, lungs, and upper respiratory tract, including the paranasal sinuses and orbits. This disease can result in an acute life-threatening condition. Such complications include diffuse alveolar hemorrhage (DAH), a condition characterized by blood leakage from the pulmonary vessels into the alveoli, often leading to acute vital signs and even respiratory failure. DAH can have many causes - autoimmune diseases including vasculitides as well as non-immunological causes. Early and adequate comprehensive therapy including immunosuppressive treatment (cyclophosphamide/rituximab and glucocorticoids) can be life-saving.

A novel therapeutic strategy using extracorporeal membrane oxygenation in patients with anti-neutrophil cytoplasmic antibodies-associated vasculitis: a case report and literature review

Diffuse alveolar hemorrhage (DAH) secondary to anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) often results in severe respiratory failure which requires emergent management. In patients who are resistant to traditional mechanical respiratory support, extracorporeal membrane oxygenation (ECMO) can be used to maintain gas exchange, thereby providing time for the administration of immunosuppressive therapy to control the inflammation. Herein, we report the application of ECMO to support an adult patient with AAV complicated by severe respiratory failure due to DAH. Similar cases in the literature were identified and discussed. The patient in our case study was successfully treated with ECMO in the acute phase and relieved by immunosuppressive therapy after withdrawal of ECMO. A search in the PubMed database revealed 32 similar cases with DAH, of which 11 cases were microscopic polyangiitis (MPA), 2 cases were eosinophilic granulomatosis with polyangiitis (EGPA), and 19 cases were granulomatosis with polyangiitis (GPA). These patients were all treated with ECMO. Therefore, to date, we identified 33 patients who were effectively treated with ECMO, including 13 (39.4%) males and 20 (60.6%) females, with a ratio of 1:1.54. The average age was 32.4±17.5 and 36.0±16.1 years for males and females, respectively (t=0.610, P=0.547). Most patients received ECMO on the first day of admission to the intensive care unit (ICU) and it appeared that early initiation of ECMO was associated with a shorter duration of ECMO. In general, complications of ECMO in these patients were mild and were not often seen in the clinical setting. This study suggested that early recognition of respiratory failure and referral for ECMO are vital to achieve a satisfactory outcome in AAV patients with DAH.

ECMO Rescues Patients With Acute Respiratory Failure Related to GPA

Granulomatosis with polyangiitis (GPA) is a subtype of anti-neutrophil cytoplasmic antibody-associated vasculitis with a wide range of clinical symptoms related to the systemic involvement of small blood vessels. The respiratory system is one of the most frequently involved, and life-threatening acute respiratory failure could occur due to diffusive alveolar hemorrhage and tracheal stenosis. When maximum mechanical ventilation is unable to maintain oxygenation, extracorporeal membrane oxygenation (ECMO) should be considered as the final respiratory supportive method, if available. Here we present a 32-year-old male patient with acute respiratory failure (ARF) related to GPA, who was rescued by winning time for accurate diagnosis and appropriate treatment. Additionally, we reviewed more than 60 GPA-related ARF cases on multiple online databases, summarized the clinical manifestations of these patients, and concluded that ECMO plays an important role in further respiratory support for ARF patients with GPA and assists in accurate and timely diagnosis and appropriate treatment, thus helping them recuperate.

A Case of Refractory Hypoxemic Respiratory Failure due to Antineutrophil Cytoplasmic Antibodies-associated Diffuse Alveolar Hemorrhage Rescued by Extracorporeal Membrane Oxygenation

Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening disease. Mortality is very high in those patients who require mechanical ventilation. Traditionally, active bleeding has been considered a contraindication for extracorporeal membrane oxygenation (ECMO) support. There is limited evidence for ECMO in DAH as rescue therapy. Herein, we describe a case of antineutrophil cytoplasmic antibodies-associated DAH with intractable hypoxemic respiratory failure. An appropriate ventilator strategy failed to improve her hypoxemia leading to imminent risk to her life. The patient was rescued with veno-venous ECMO targeting lower than usual range of anticoagulation. ECMO proved to be lifesaving in our patient who was initiated on prompt immunosuppressive therapy and plasmapheresis along with continuous veno-venous hemodiafiltration and hemodynamic support. We feel that ECMO could be considered as adjunctive therapy in severe hypoxemic respiratory failure associated with DAH after careful consideration of the risk of bleeding and a restrictive anticoagulation strategy.

How to cite this article: Goel MK, Chauhan M, Kumar A, Wadwa P, Maitra G, Talegaonkkar M, et al. A Case of Refractory Hypoxemic Respiratory Failure due to Antineutrophil Cytoplasmic Antibodies-associated Diffuse Alveolar Hemorrhage Rescued by Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(9):879–881.

The role of extra-corporeal membrane oxygenation (ECMO) in the treatment of diffuse alveolar haemorrhage secondary to ANCA-associated vasculitis: report of two cases and review of the literature

Diffuse alveolar haemorrhage (DAH) secondary to anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a rare life-threatening condition presenting with severe respiratory failure. The management of AAV-related DAH consists of remission induction immunosuppressive therapy, which requires time to be effective, with significant fatality rates despite appropriate treatment. Extracorporeal membrane oxygenation (ECMO) can support gas exchanges providing the time necessary for immunosuppressive treatment to control the underlying disease in cases refractory to the conventional ventilation techniques. Despite severe preexisting bleeding has been considered a relative contraindication, ECMO has proven to be life-saving in several cases of respiratory failure associated with pulmonary haemorrhage due to various causes, including AAV. We reviewed the clinical presentation and course of two patients affected by AAV-related DAH treated at our Institution between 2012 and 2017, whose management required the use of veno-venous ECMO. We reviewed the current literature on the role of ECMO in the support of these patients. In both patients, ECMO provided life support and allowed disease control, in combination with immunosuppressive treatment. Despite systemic anticoagulation, clinical improvement was achieved without exacerbation of the pulmonary bleeding. We performed a literature review, and summarized available data confirming the effectiveness and safety of ECMO in AAV-related DAH. ECMO has a life-saving role in the management of patients with severe respiratory failure due to ANCA-associated pulmonary capillaritis.

Massive hemoptysis successfully treated with extracorporeal membrane oxygenation and endobronchial thrombolysis

Extracorporeal membrane oxygenation has been used to treat refractory hypoxemia in numerous clinical scenarios. The fundamental principles for the management of massive hemoptysis patients include protecting the airway and healthy lung, locating the source of bleeding and controlling the hemorrhage. We report the case of a patient with acute respiratory failure associated with massive hemoptysis secondary to lung laceration during cardiac surgery. The use of extracorporeal membrane oxygenation allowed patient survival. However, due to the great difficulty in managing pulmonary clots after hemoptysis, it was necessary to use an unusual therapy involving endobronchial infusion of a thrombolytic agent as described in rare cases in the literature.

H1N1 Influenza Induced Acute Respiratory Distress Syndrome Rescued by Extracorporeal Membrane Oxygenation: a Case Report

Extracorporeal Membrane Oxygenation (ECMO) is now a recognized revolutionary technology, which has emerged as a life-saving therapeutic option for patients with potentially reversible severe respiratory failure who fail to respond positively with the conventional ventilation therapy. Severe acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality, and ECMO has been proven to increase the survival rates in these patients by improving the gas exchange and thus preventing the further hypoxia and catecholamine induced multi-organ damage. The authors present a case of H1N1 influenza related severe ARDS who was successfully rescued by the early use of ECMO. The authors recommend the early use of ECMO to be incorporated in the management of severe refractory ARDS caused due to a potentially reversible cause.

Rare cause of respiratory failure in a young woman: isolated diffuse alveolar haemorrhage requiring extracorporeal membrane oxygenation

A previously healthy 21-year-old young woman presented with worsening dyspnoea and haemoptysis. Imaging was suggestive of widespread pulmonary haemorrhage. There was no other organ system involvement in particular no evidence of renal involvement. Raised antimyeloperoxidase titres allowed diagnosis of isolated diffuse alveolar haemorrhage (DAH) secondary to microscopic polyangiitis (MPA). The patient rapidly deteriorated with worsening respiratory failure despite invasive mechanical ventilation and required extracorporeal membrane oxygenation (ECMO). This maintained the patient long enough to allow aggressive therapy in the form of immunosuppression and plasma exchange. She made a remarkable recovery and is asymptomatic 2 years on. Isolated DAH in the absence of renal disease is an atypical presentation of MPA and can lead to diagnostic uncertainty. A literature review reveals increasing reports of successful use of ECMO in severe DAH due to pulmonary vasculitis. Despite this, the need for systemic anticoagulation in the presence of pre-existing haemorrhage remains a challenging dilemma.