BAL in DAH

Q: Subsegmental bronchoscopy guided by chest X-ray in Diffuse Alveolar Hemorrhage (DAH) will yield? - select one

A) progressively less hemorrhagic output

B) progressively more hemorrhagic output

Answer: B

Many times hemoptysis may not be evident in DAH. Flexible bronchoscopy with sequential Broncho-Aleveloar Lavage (BAL) should be carried out. Depending on radiographic opacities, a fiberoptic bronchoscope is wedged into a subsegmental bronchus. Sequential BAL should be performed by instilling and retrieving three aliquots of 50 to 60 mL sterile saline from the suspected subsegmental bronchus. Alveolar hemorrhage is confirmed when lavage aliquots are progressively more hemorrhagic, a finding characteristic of DAH, irrespective of the cause.

Although hemosiderin-laden macrophages from Prussian blue staining is considered characteristic of DAH, it can also be found in diffuse alveolar damage (DAD) and idiopathic pulmonary fibrosis (IPF).

#procedures

#pulmonology

References:

1. De Lassence A, Fleury-Feith J, Escudier E, et al. Alveolar hemorrhage. Diagnostic criteria and results in 194 immunocompromised hosts. Am J Respir Crit Care Med 1995; 151:157.

2. Prasad P, Gupta A, Nath A, Hashim Z, Gupta M, Krishnani N, Khan A. Clinical characteristics of patients with diffuse alveolar hemorrhage diagnosed by cytological examination of 1000 bronchoalveolar lavage samples. Sarcoidosis Vasc Diffuse Lung Dis. 2023 Mar 28;40(1):e2023004. doi: 10.36141/svdld.v40i1.13413. PMID: 36975056; PMCID: PMC10099654.

3. Maldonado F, Parambil JG, Yi ES, Decker PA, Ryu JH. Haemosiderin-laden macrophages in the bronchoalveolar lavage fluid of patients with diffuse alveolar damage. Eur Respir J. 2009 Jun;33(6):1361-6. doi: 10.1183/09031936.00119108. Epub 2009 Jan 7. PMID: 19129275.