Anaesthesia for serial whole-lung lavage in a patient with severe pulmonary alveolar proteinosis: a case report

Anesthetic Challenges During Whole Lung Lavage: A Case Report

Pulmonary alveolar proteinosis is an uncommon lung disease characterized by the accumulation of surfactant in the lungs. Treatment is done by whole lung lavage. One-lung ventilation in diseased lungs is a challenge to anesthesiologists due to the rapid desaturation and hemodynamic fluctuations encountered during the procedure. A 24-year-old female, a known patient of pulmonary alveolar proteinosis, who had undergone previous lung lavage presented with a dry cough and shortness of breath. Our management of the case included complete lung isolation with a double-lumen tube (DLT), one-lung ventilation, and an appropriate hemodynamic management strategy during the procedure.

Pulmonary Alveolar Proteinosis: A Case of Profound Hypoxemia in a Previously Healthy Teenager

ABSTRACT

The profoundly hypoxemic child presents an interesting set of diagnostic and management challenges in the pediatric emergency department. While common pathologies including pneumonia, asthma, bronchiolitis, and pneumothoraces are managed using evidence-based algorithms, more enigmatic pathologies may present the treating physician with less diagnostic and therapeutic clarity. We present the case of a profoundly hypoxemic 16-year-old girl who presented in minimal distress, with oxyhemoglobin saturation of 63% on room air.

Whole-Lung Lavage-a Narrative Review of Anesthetic Management

Pulmonary alveolar proteinosis is a rare disease characterized by progressive accumulation of lipoprotein material in the alveoli as a result of a dysfunction in surfactant clearance. The whole-lung lavage procedure is considered the current standard of care and consists of the sequential lavage of both lungs for mechanical removal of residual material in the alveoli. However, a lack of standardization has resulted in different procedural techniques among institutions. Even though whole-lung lavage is considered to be a safe procedure, unforeseen complications might occur, and proper knowledge of physiologic implications may allow clinicians to establish the appropriate therapy. This review provides an insight into the underlying physiology of the disease, the technical details of the procedure from an anesthesiologist's perspective, and discussion of potential intraoperative complications.

Anaesthetic considerations for whole lung lavage for pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis (PAP) is an uncommon lung disease characterized by excessive accumulation of pulmonary surfactant that usually requires treatment with whole-lung lavage. A 47-year-old female presented with history of dry cough and breathlessness for past 6months. Chest radiograph demonstrated bilateral alveolar shadows and high resolution computerized tomography thorax showed crazy paving pattern. Broncho-alveolar lavage (BAL) and transbronchial lung biopsy confirmed a diagnosis of PAP. Due to worsening hypoxemia and respiratory failure, wholelung lavage was planned and performed. Anaesthetic management involved integrated use of pre-oxygenation, complete lung isolation, one-lung ventilation with optimal positive end-expiratory pressure, vigilant use of positional manoeuvres, and use of recruitment manoeuvres for the lavaged lung. We have discussed valuable strategies for the anaesthetic management of patients undergoing this multifaceted procedure in a case of severe PAP.

FUNDING

None declared.

Whole-lung lavage in a patient with pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis (PAP) is a rare syndrome in which phospholipoproteinaceous matter accumulates in the alveoli leading to compromised gas exchange. Whole-lung lavage is considered the gold standard for severe autoimmune PAP and offers favorable long-term outcomes. In this case report, we describe the perioperative management and procedural specifics of a patient undergoing WLL for PAP in which an anesthesiologist serves as the proceduralist and a separate anesthesiologist provides anesthesia care for the patient.

Monitoring whole-lung lavage using lung ultrasound: The changing phases of the lung

Lung ultrasound (LUS) has been proven to yield valuable information for lung and pleural pathology. It is well validated for assessing extravascular lung water. It can also be used to monitor stages of controlled lung de-aeration in whole lung lavage (WLL) which is the treatment for Pulmonary Alveolar Protienosis (PAP),characterized by abnormal surfactant in the alveoli affecting gas exchange .LUS can help decide the point of termination of lung flooding. A 55 year old lady with biopsy proven pulmonary alveolar proteinosis presented with respiratory failure. WLL was planned. LUS was used to study the stages of lung flooding as previously described for ARDS model.6 areas screened based on six areas that are normally examined like upper zone, mid zone and lower zone showed alveolar interstitial pattern. One lung ventilation (OLV) was done and isolation of lavage lung was confirmed which was seen as lung collapse (lung pulse) on LUS. Saline infusion resulted in increase in B lines followed by tissue like pattern with fluid bronchogram on LUS(alveolar flooding) in all the areas. During the lavage of the second lung, appearance of alveolar flooding pattern resulted in termination of saline infusion. The use of LUS in monitoring WLL reduced amount of saline used for lavage, pick up complications like pleural effusion and spillage.

Anaesthetic, procedure and complications management of serial whole-lung lavage in an obese patient with pulmonary alveolar proteinosis: case report

BACKGROUND AND OBJECTIVES

The first case of Pulmonary Alveolar Proteinosis (PAP) was described by Rose in 1958, but it is still a rare disorder. PAP is characterized by deposition of lipoproteinaceous material secondary to abnormal processing of surfactant by macrophages. Patients may suffer from progressive dyspnea and cough that at times is accompanied by worsening hypoxia and its course can vary from progressive deterioration to spontaneous improvement. Many therapies have been used to treat PAP including antibiotics, postural drainage, and intermittent positive pressure breathing with aerosolized Acetylcysteine, heparin and saline. At present, the mainstay of treatment is whole lung lavage (WLL). Although generally well tolerated, WLL can be associated with some complications.

CASE REPORT

We report a case of severe PAP through the anaesthetic, procedure and complications management of pulmonary alveolar proteinosis in one patient who has undergone multiple, alternating, single-lung lavages over the past seven years, the last three in our hospital, with improvements in her symptoms following each therapy.

Treatment of Acute Silicoproteinosis by Whole-Lung Lavage

Acute silicoproteinosis is a rare disease that occurs following a heavy inhalational exposure to silica dusts. Clinically, it resembles pulmonary alveolar proteinosis (PAP); silica exposure is thought to be a cause of secondary PAP. We describe a patient with biopsy-confirmed acute silicoproteinosis whose course was complicated by acute hypoxemic respiratory failure requiring mechanical ventilation. Without clinical improvement despite antibiotic and steroid treatment, the patient was scheduled for whole-lung lavage under general anesthesia. Anesthetic challenges included double-lumen tube placement and single-lung ventilation in a hypoxic patient, facilitating lung lavage, and protecting the contralateral lung from catastrophic spillage.

Effective use of bronchial blockers in lung isolation surgery: an analysis of 130 cases

BACKGROUND

One-lung ventilation (OLV) is necessary for selected surgical settings and medical conditions. Different methods have been described and used to isolate 1 lung, including the double-lumen endotracheal tube (DLT) and a variety of bronchial blockers (BBs). This selection is often based on the preferences and experiences of the anesthesiologist and surgeon. Complications associated with OLV isolation tubes have been previously described, but complications specifically associated with the Cohen BB (CBB) (Cook Medical, Bloomington, IN) have not been investigated. The purpose of this retrospective review was to determine the incidence of vocal cord injury, tracheobronchial injury, and hoarseness in adult patients who underwent OLV with the CBB.

METHODS

We reviewed electronic anesthesia records, operative dictation, and inpatient progress notes to collect information about vocal cord injury, bronchial injury, hoarseness, and sore throat for adults who underwent surgical and diagnostic procedures requiring OLV. Secondary endpoints were types of surgical procedures, degree of difficulty with orotracheal intubation, ability of the patient to tolerate extubation in the operating room, and whether the thoracic surgeon deemed the lung separation adequate. P<0.05 was considered significant.

RESULTS

Of 130 patients, 113 underwent OLV with a CBB, and 17 patients underwent OLV with a DLT. The thoracic surgeon deemed the lung isolation adequate in all cases. Airway injury occurred in 2 patients with a CBB and none with a DLT (P=0.86). Both airway injuries were attributed to surgical technique. Two cases of postoperative hoarseness occurred in the CBB group (P=0.86). One injury was attributed to vagus nerve transection, and the other injury was diagnosed as vocal cord paralysis of unknown etiology. In 1 case, orotracheal intubation with a DLT was unsuccessful because of intubation difficulty and required conversion to a regular endotracheal tube and CBB for successful lung isolation.

CONCLUSION

This study demonstrates that the use of CBB can be successful in a wide variety of thoracic operations, has minimal complications, eliminates the need for tracheal tube exchange when postoperative mechanical ventilation is required, and effectively isolates the lungs of critically ill patients.

An uncommon procedure for a rare ailment: massive bronchoalveolar lavage in a patient with pulmonary alveolar proteinosis

As a rare procedure, massive bronchoalveolar lavage (MBAL) is a large-volume lavage which necessitates general anesthesia and one-lung ventilation (OLV). During MBAL isotonic saline is instilled into one lung and drained through one lumen of a double-lumen tube. MBAL is the most effective treatment for symptomatic pulmonary alveolar proteinosis (PAP). A 27-year-old male with PAP was scheduled for therapeutic MBALs. After standard preoxygenation, monitoring and anesthesia induction, a double-lumen tube was placed. Tube position was verified by a fiberoptic bronchoscope. The internal jugular vein, radial and pulmonary arteries were cannulated. A temperature probe and foley catheter were inserted. The nonventilated lung was filled with 1000 mL saline and then drained in each session. The left and right lung were lavaged with an interval of 2 weeks. A total of 20 L saline was used in each MBAL without retention. MBALs were terminated after the effluent became clear. Duration of the left and right MBALs were 325 and 275 minutes, respectively. Despite increased shunt fraction, oxygenation was within acceptable limits during OLV. The trachea was extubated in the operating room uneventfully after each MBAL. The patient's clinical and laboratory findings were evidently improved. Consequently, if proper conditions are provided, MBAL is safe and beneficial despite its risks and the long duration.

Pulmonary alveolar proteinosis and successful therapy with combined lavage procedures: Case reports

Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by the accumulation of lipoproteinaceous material within alveolar spaces. Whole-lung lavage (WLL) has been the most common therapeutic intervention for this disorder. However, patients presenting with PAP are usually hypoxemic or in poor clinical condition, and WLL may be impossible to perform. In such cases, multiple segmental lavage (MSL) may be advocated as a first-choice therapy prior to WLL. Herein, we present two cases with idiopathic PAP treated successfully with both lavage techniques consecutively. After the MSL procedure, WLL was performed, and both patients showed a marked clinical and physiologic improvement. Therefore, for patients who are not good candidates for general anesthesia, we recommend MSL (or 'prewash') before WLL to produce an increase in the blood oxygen level for long-duration general anesthesia. In the surgical room, close monitoring and repositioning of the patient as well as maintenance and inspection of the correct tube position, and manual chest wall percussion are extremely important for the safety and success of the procedure.

A case report of pulmonary alveolar proteinosis

This is a case of pulmonary alveolar proteinosis that presented in an inner city hospital in Birmingham, UK. The patient was a previously well 42-year-old man, who went on to experience unusual cerebral complications of the disease. The presentation, imaging findings and diagnostic histology findings are described. Pulmonary alveolar proteinosis is a rare but important diagnosis. Characteristic high-resolution CT findings include diffuse ground glass density with superimposed interlobular septal thickening, which is described as the "crazy paving" pattern. Diagnosis is made by bronchoalveolar lavage. Pathologically the disease is characterised by alveolar filling with a lipid rich, proteinaceous material (positive to periodic acid-Schiff stain) while the lung interstitium remains relatively normal. Morbidity and mortality can be improved by treatment with whole lung lavage.