Bronchopulmonary lavage: effects on oxygenation and hemodynamics

Pulmonary alveolar proteinosis: an overview for internists and hospital physicians

Pulmonary alveolar proteinosis (PAP) is a rare diffuse lung disease characterized by abnormal accumulation of surfactant-associated phospholipoproteinaceous material in the pulmonary alveoli. The clinical findings of slow-onset dyspnea or dyspnea on exertion and persistent dry cough are nonspecific; radiographic findings of "bat-wing configuration" and "crazy paving" appearance in high-resolution computed tomography are suggestive, but not diagnostic of PAP. The current gold standard of PAP diagnosis involves histopathological examination of alveolar specimens obtained from bronchoalveolar lavage and transbronchial lung biopsy. The characteristic histopathological features are intraalveolar periodic acid Schiff (PAS)-positive eosinophilic homogeneous material with well-preserved architecture ofalveolar septa. The current standard medical treatment of PAP involves the physical removal of the surfactant-associated phospholipoproteinaceous alveolar deposit by whole lung lavage, which causes clinical and radiological improvement in a majority of patients. Some patients have been successfully treated with recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF).

The Combination of Inhaled Nitric Oxide and Pulmonary Artery Balloon Inflation Improves Oxygenation During Whole-Lung Lavage

We present a case in which the use of inhaled nitric oxide associated with temporary partial unilateral pulmonary artery occlusion further improved oxygenation during whole-lung lavage. This is the first case in the literature describing the simultaneous use of these two modalities.

Pulmonary alveolar proteinosis: progress in the first 44 years

Pulmonary alveolar proteinosis is a rare clinical syndrome that was first described in 1958. Subsequently, over 240 case reports and small series have described at least 410 cases in the literature. Characterized by the alveolar accumulation of surfactant components with minimal interstitial inflammation or fibrosis, pulmonary alveolar proteinosis has a variable clinical course ranging from spontaneous resolution to death with pneumonia or respiratory failure. The most effective proven treatment--whole lung lavage--was described soon after the first recognition of this disease. In the last 8 years, there has been rapid progress toward elucidation of the molecular mechanisms underlying both the congenital and acquired forms of pulmonary alveolar proteinosis, following serendipitous discoveries in gene-targeted mice lacking granulocyte-macrophage colony-stimulating factor (GM-CSF). Impairment of surfactant clearance by alveolar macrophages as a result of inhibition of the action of GM-CSF by blocking autoantibodies may underlie many acquired cases, whereas congenital disease is most commonly attributable to mutations in surfactant protein genes but may also be caused by GM-CSF receptor defects. Therapy with GM-CSF has shown promise in approximately half of those acquired cases treated, but it is unsuccessful in congenital forms of the disease, consistent with the known differences in disease pathogenesis.

Whole lung lavage

After more than 35 years of evolution, whole lung lavage is an efficient and safe technique. Furthermore, it can be a pleasant experience because it consists of performing general anesthesia without a surgeon being in the operating room. Whole lung lavage can be adapted to many patients and diseases; however, more research must be done to confirm the new indications.

One-lung flooding for video-assisted thoracoscopic surgery in animal experiments on pigs--oxygenation and intrapulmonary shunt

Unilateral flooding of the lung after intubation with a double-lumen tube makes intraoperative sonography of the lung during video-assisted thoracoscopic surgery possible. After flooding with 15 ml/kg, the arterial partial oxygen pressure (with FiO2=1.0) is higher than that in total atelectasis by about 100 mmHg, while it is only slightly less than that during bilateral lung ventilation. Compared to total atelectasis, lung flooding reduces the pulmonary right-to-left shunt volume. The pulmonary function normalizes within 8 h after the operation.

Lung flooding--a new method for complete lung sonography

A sonographic examination of the lung has so far been impossible because of sound reflection. In conjunction with video-assisted thoracoscopic surgery, lung sonography would be helpful to make up for the lack of direct palpation. Animal experiments with pigs were performed to find out whether lung sonography becomes possible following bronchoalveolar flooding with a suitable liquid. The lung was filled with whole electrolyte solution through the left leg of a double-lumen endotracheal tube after resorption atelectasis (method 1) or compressive atelectasis (method 2). As an alternative, liquid perfluorocarbon was used (method 3). Under atelectasis, the lung thus flooded was investigated by ultrasound applied transpleurally and endobronchially. The first results proved that lung flooding is possible if certain prerequisites are fulfilled. Perfluorocarbon flooding led to total sound absorption which prevented sonography, whereas flooding with whole electrolyte solution made complete lung sonography possible, making visible the intrapulmonary vessels, bronchi and peribronchial lymphatic nodes. Measurements proved that the unilateral flooding caused no significant changes in the arterial and central venous pressure nor in transcutaneous oxygen saturation.