Total lung lavage for pulmonary alveolar proteinosis in an infant without the use of cardiopulmonary bypass

Anesthetic techniques to facilitate lung lavage for pulmonary alveolar proteinosis in children-new airway techniques and a review of the literature

Pediatric patients with pulmonary alveolar proteinosis require whole lung lavage to clear the accumulation of lipoproteinaceous material within the alveoli, to maintain respiratory function. Anesthesia for this presents a challenge due to preexisting respiratory failure, and the small diameter and length of the pediatric airway, which is often unable to accommodate existing one-lung isolation and ventilation equipment. Novel techniques to facilitate lung lavage on seven occasions are described and placed in the context of the existing literature to date.

Whole-lung lavage in infants and children with pulmonary alveolar proteinosis

BACKGROUND

Pulmonary alveolar proteinosis (PAP) is a rare alveolar filling syndrome where the mainstay of treatment is therapeutic whole-lung lavage (WLL). WLL techniques used in adults have to be modified for children because of their small-diameter airways.

AIM

To describe a technique for WLL adapted for small children.

METHODS

We describe a WLL technique that combines safe single-lung ventilation with the use of an age-appropriate endotracheal tube and selective occlusion of the other main bronchus with a balloon catheter through which the lavage is performed. Effectiveness measured by change in oxygen requirements and adverse effects was noted.

RESULTS

We performed 64 WLL procedures in four children (age 13 months to 7 years; body weight 4.7-14 kg). Two children had idiopathic and two had secondary PAP. At referral, all children had dyspnoea at rest and required continuous oxygen supplementation. Two patients showed significantly decreased oxygen demands and radiological improvement after WLL. Two patients showed no significant response. The only adverse effect observed was transient hypoxemia. Complications comprised fluid leak at the balloon (4), balloon rupture (1), and pneumothorax (1).

CONCLUSIONS

This technique for WLL combining single-lung ventilation with an endotracheal tube and lung exclusion for lavage with a balloon catheter can be safely and effectively performed in small children with PAP.

Pulmonary alveolar proteinosis in China: a systematic review of 241 cases

BACKGROUND AND OBJECTIVE

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease. It was first described in China in 1965, and more cases have been reported subsequently. A systematic review was performed on 241 cases of PAP in China and progress in the diagnosis and treatment of this disease is discussed.

METHODS

The Chinese biological and medical databases from 1965 to 2006 were searched and 241 cases with complete clinical and pathological data were identified. The clinical characteristics of the disease were summarized and longitudinal comparisons were made of diagnostic and treatment methods over time.

RESULTS

The morbidity associated with PAP has increased in recent years. The clinical manifestations were non-specific. Progressive dyspnoea, cough and sputum were the most common symptoms. The percentage of patients undergoing CT examination has increased over the years. The combination of bronchoscopic biopsy and bronchoalveolar lavage (BAL) was usually sufficient to establish the diagnosis. Treatment was reported for a total of 142 cases. BAL and whole lung lavage were both effective and were only required once by most patients.

CONCLUSIONS

The demographic characteristics and clinical manifestations of PAP patients in China are largely consistent with previous reports. Morbidity has increased dramatically in recent years, mainly due to the broad application of bronchoscopy since 1995. CT is very important for diagnosis of the disease. The long-term effects of treatment by whole lung lavage and BAL are similar.

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.

Surfactant protein B deficiency: clinical, histological and molecular evaluation

Congenital alveolar proteinosis due to surfactant protein B deficiency is an inherited disease which results in severe respiratory failure in term infants soon after birth. The pathophysiologic basis of this disease is now known to be an inability to synthesise adequate quantities of normally functioning surfactant protein B. We report a male infant with fatal respiratory failure of neonatal onset, and histopathological features typical of those seen in congenital alveolar proteinosis. Molecular analysis of genomic DNA revealed two mutations, the 'common' 121ins2 mutation in exon 4, and a novel 2bp frameshift mutation in exon 5. We believe this is the first Australian case of surfactant protein B deficiency confirmed by molecular analysis.

Childhood pulmonary alveolar proteinosis. Extracorporeal membrane oxygenation with total cardiopulmonary support during bronchopulmonary lavage

Partial cardiopulmonary bypass with extracorporeal membrane oxygenation to allow bilateral bronchopulmonary lavage in pulmonary alveolar proteinosis has been described. However, this technique is complicated by a very low arterial PO2 and cardiovascular embarrassment. Total cardiopulmonary support avoids these problems and was successfully used in a 2 1/2-year-old girl.

Flexible fiberoptic bronchoscopy in children on extracorporeal membrane oxygenation

Bleeding is one of the most feared complications of veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO), and is also a potential complication of flexible fiberoptic bronchoscopy (FFB). We retrospectively reviewed 14 patients who underwent FFB procedures with bronchial washings (BW) and bronchoalveolar lavage (BAL) to evaluate the safety of this procedure in children on ECMO. Standard FFB with BAL/BW technique was used after stabilization on ECMO. Three patients underwent two procedures each, and one patient underwent three, for a total of 19 procedures. No significant complications, such as bleeding have occurred. Three patients required additional ECMO support shortly after FFB. After the 16 procedures done for atelectasis, seven patients improved radiographically, three had increased opacifications, and six were unchanged. The remaining three patients had suspected pulmonary infections, and in each, therapeutic decisions were guided by the BAL results. Lung compliance was unchanged or improved after 11 of 13 procedures. We conclude that FFB with BAL/BW in children on ECMO is safe and may benefit certain patients.

Partial and massive lung lavages in an infant with severe pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis is a rare disease of unknown etiology, characterized by progressive respiratory failure. Lung lavage has only been applied in a few children. A 6 month old boy suffering from severe pulmonary alveolar proteinosis was treated with three lung lavages. The first two were partial (or unilateral) lavages; a 3.5 mm flexible bronchoscope was introduced adjacent to a no. 3 cuffed endotracheal tube. This procedure allowed selective ventilation of one lung, and contralateral lung lavage. Respiratory improvement was observed during 1 week after the two procedures. At the third lavage we used partial veno-venous extracorporeal circulation because of severe respiratory failure. A significant improvement during the 5 following months was achieved. These results suggest that both partial and total lung lavage can be performed even in young infants and they may control the declining respiratory status in severe pulmonary alveolar proteinosis.

Congenital pulmonary alveolar proteinosis: failure of treatment with extracorporeal life support

Pulmonary alveolar proteinosis, a rare disease in neonates, is characterized by the accumulation of insoluble amorphous material within the alveoli. We describe two pairs of siblings with pulmonary alveolar proteinosis in two otherwise unaffected families. All four patients were term neonates in whom severe pulmonary failure developed within hours after birth; three had mature lung profiles. Radiographic lung markings were characterized by an early granular pattern followed by lung opacification. All patients were treated with extracorporeal life support for periods of 212 to 381 hours, but none survived. Life spans ranged from 16 to 190 days. We speculate that pulmonary alveolar proteinosis in neonates results from a genetic defect in surfactant processing that may not be amenable to conventional or unconventional therapies, including extracorporeal life support.

Pulmonary alveolar lipoproteinosis in a seven-year-old girl. A follow-up over six years

Alveolar lipoproteinosis is a rare disease in childhood, and its outcome is considered unfavourable compared to adults. We report on the spontaneous improvement of the disease over a six-year period in a child now 13 years of age. At the time of diagnosis the vital capacity was reduced to 65% of the mean predicted for her height, but deteriorated to 40% during the following year. A bronchoalveolar lavage was performed with small amounts of fluid but it did not immediately reverse the pulmonary alterations. Contrary to expectation, in the following years there was a continuous and gradual increase of the vital capacity to 70% of the mean predicted without specific therapy. This observation underlines the importance of an individual approach to prognosis in this disease and contributes to discussion of therapeutic procedures in the paediatric age group.

Pulmonary alveolar lipoproteinosis complicating juvenile dermatomyositis

A 9 year old boy with juvenile dermatomyositis developed pulmonary alveolar lipoproteinosis. This previously unreported association was treated successfully by bronchoalveolar lavage.