Critical Care: Critical Care |

Alveolar Proteinosis in Extremis: A Critical Case Treated With Whole Lung Lavage Without Extracorporeal Membrane Oxygenation FREE TO VIEW

Wen-Liang Guo, MD; Shi-Yue Li, MD
Author and Funding Information

State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A142. doi:10.1016/j.chest.2016.02.148
Text Size: A A A
Published online

SESSION TITLE: Critical Care

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Pulmonary alveolar proteinosis (PAP) is a syndrome arising from altered surfactant homeostasis. Pathophysiologically, the major changes involve impaired pulmonary diffusion and ventilation/perfusion mismatch, which may result in respiratory failure[1]. Whole lung lavage (WLL) is considered the standard treatment for progressive PAP leading to respiratory compromise[2]. In very rare cases where the patient has developed critical respiratory failure and can not tolerate single-lung ventilation, extracorporeal membrane oxygenation (ECMO) may be required to facilitate WLL[2-3]. This may bring up a question whether ECMO or hyperbaric conditions are always essential for WLL in PAP patients with critical respiratory failure. We present a life-threatening case of PAP requiring mechanical ventilation in which the patient was successfully managed by bilateral WLL under single lung ventilation alone. ECMO was nevertheless set up beforehand.

CASE PRESENTATION: A 39-year-old patient with PAP and severe life-threatening respiratory failure, with an oxygen index of 51 when under mechanical ventilation, who was successfully treated with bilateral whole lung lavage without extracorporeal oxygenation

DISCUSSION: Nearly 80 cases of WLL have been performed for treatment of PAP in our institution. According to our previous observations, the oxygen saturation was not dramatically reduced in single-lung ventilation compared with that in the ventilation of both lungs; moreover, the oxygen saturation may show some increase after a certain duration of lung lavage with constant setting of the ventilator. We found that ventilation/perfusion could change at any time despite no change in diffusion of the ventilated lung. When the lung on one side is lavaged and the other ventilated, pulmonary vasoconstriction due to a chemoreceptor reflex in the lavaged lung, reduces perfusion of the lavaged lung and improves the ventilation/perfusion[4], which can counteract the reduction in oxygen saturation due to decreased diffusion area with single-lung ventilation. Additionally, intrapulmonic pressure increases when lavage fluid is introduced into the bronchus and alveoli, leading to pulmonary capillary contraction and shunting of pulmonary blood flow through the ventilated lung[5-6], which also counteracts the lowering oxygen saturation. This conform wtih previous studies[7-8].

CONCLUSIONS: In summary, the observation in this case and many others suggests a potential treatment protocol by which a patient with severe respiratory failure due to PAP can complete bilateral WLL under single-lung ventilation without ECMO. Despite reduced diffusion area with single-lung ventilation, oxygen saturation can be maintained in a safe range through improved ventilation/perfusion during WLL. Last but not least, ECMO must be prepared beforehand.

Reference #1: [1] Rogers RM, Levin DC, Gray BA, et al: Physiologic effects of bronchopulmonary lavage in alveolar proteinosis. Am Rev Respir Dis 1978;118:255-264.

DISCLOSURE: The following authors have nothing to disclose: Wen-Liang Guo, Shi-Yue Li

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543