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This video demonstrates the clinical application of the lung lavage technique for the treatment of Pulmonary Alveolar Proteinosis (PAP) (1,2).
The main indication for lung lavage in patients with PAP is the limitation of activities due to dyspnoea. The threshold could be lower for patients who work as heavy laborers, than those who have sedentary lifestyles (3). Some authors suggested that patients with a PaO2 less than 9.3 KPa (70 mmHg) or a P (A-a) O2 of more than 5.3 KPa on room air are more likely to progress, and hence require a whole lung lavage (4).
Since the disease description in 1958, there has been a “rule of thirds.” One third of patients have very mild disease and little tendency to progress, and therefore have no need for specific treatment. One third of patients have severe symptoms and incapacity that requires treatment. The last third have very severe and progressive incapacity. These patients may respond poorly to treatment, or show improvement only after prolonged treatment.
Anesthesia is performed via Total Intravenous Anesthesia (TIVA), using Propofol and Remifentanil with Rocuronium for muscle paralysis. A double lumen endobronchial tube (the largest size possible) is used, and its position is confirmed using flexible bronchoscopy. The patient is pre-oxygenation for 5 minutes to achieve denitrogenation. The target lung is isolated. The other lung is ventilated with 100% oxygen initially, and then the FiO2 is reduced to keep oxygen saturation (SaO2) above 90%.
Sterile warm (37 °C) saline is instilled via standard connecting tubing into the target lung lumen in 1L aliquots. Once the fluid column is seen in the endotracheal tube connector, fluid administration is stopped, and trained physiotherapists give manual chest vibration and chest percussions for 5 minutes. The saline is then drained out by gravity. The initial saline specimen is sent for biochemical and microbiological analysis. The effluent fluid will display a decreasing lipoprotein load as the procedure progresses. When the effluent returns are clear, the therapeutic endpoint has been reached (Figure 1). Finally, all the effluent fluids are sucked out using the suction catheter. Approximately 40 liters of warm saline should be ready for treatment (Figure 2). The right lung will take relatively more saline as compared to the left. The whole procedure will take between 3 to 4 hours.
- 30 – 40 liters of ‘warm’ saline (37 °C)
- ‘Long’ suction catheters that will go through the long double lumen tube
- Suction bottles (Figure 2)
- Appropriate physiotherapy bed to improve the chest vibrations (total care sport Hill-Rom bed)
Tips and Pitfalls
- More than one physiotherapist is recommended, as this is a long procedure and can get tiring for a lone physiotherapist.
- Maintain PEEP to ventilated lung to prevent spillage throughout the procedure.
- Temperature monitoring is needed. Patients can become hypothermic because this is a prolonged procedure, and large volumes of fluid are instilled into the adjacent vascular compartment.
Confirmation of a good lavage end-result is evident in a gradual decline in the turbidity within successive bottles. The surgeon should stop the procedure once the effluent becomes clear, signifying the target therapeutic end point has been reached (Figure 1). During follow-up, the best indication of improvement is the patient’s clinical picture and an improvement in NYHA class. Chest radiography and lung function test will also confirm improvement.
- Borie R, Danel C, Debray M-P, Taille C, Dombret M-C, Aubier M, Epaude R, Crestani B. Pulmonary alveolar proteinosis. Eur Respir Rev 2011;20:98–107
- Beccaria M, Luisetti M, Rodi G, Corsico A, Zoia MC, Colato S, Pochetti P, Braschi A, Pozzi E, Cerveri E. Long term durable benefit after whole lung lavage in pulmonary alveolar proteinosis. Eur Respir J 2004;23:526-531.
- Shah PL, Hansell D, Lawson PR, Reid KB, Morgan C. Pulmonary alveolar proteinosis: Clinical aspects and current concepts on pathogenesis. Thorax 2000;55:67–77
- Kariman K, Kylstra JL, and Spock A. Pulmonary alveolar proteinosis: Prospective clinical experience in 23 patients for 15 years. Lung 1984;162:223–231.