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  Table of Contents 
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 62-65

Anesthetic management of bilateral pulmonary alveolar proteinosis for whole lung lavage

Department of Anesthesia, B. J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India

Date of Submission26-Nov-2019
Date of Decision09-Dec-2019
Date of Acceptance10-Dec-2019
Date of Web Publication13-Feb-2020

Correspondence Address:
Dr. Nilesh M Solanki
44-Devshrusti Bungalows-II, B/H Kena Bungalows, Motera Stadium Road, Motera, Sabarmati, Ahmedabad - 380 005, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_89_19

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Pulmonary alveolar proteinosis (PAP) is a rare lung diseases in which there is abnormal accumulation of lung surfactant in alveoli by lipoproteinaceous material. The standard method for management of such cases is whole lung lavage (WLL). We report a PAP patient for WLL under general anesthesia and discuss the anesthetic challenges and management strategies to maintain adequate lung isolation and oxygenation, implementation of lateral positions of the patient with prolonged procedure and hypothermia during the lung lavage.

Keywords: Double lumen tube, hypothermia, one lung ventilation, pulmonary alveolar proteinosis, whole lung lavage

How to cite this article:
Solanki NM, Shah SK, Jasoliya RH. Anesthetic management of bilateral pulmonary alveolar proteinosis for whole lung lavage. Indian Anaesth Forum 2020;21:62-5

How to cite this URL:
Solanki NM, Shah SK, Jasoliya RH. Anesthetic management of bilateral pulmonary alveolar proteinosis for whole lung lavage. Indian Anaesth Forum [serial online] 2020 [cited 2021 May 10];21:62-5. Available from: http://www.theiaforum.org/text.asp?2020/21/1/62/278207

  Introduction Top

Pulmonary alveolar proteinosis (PAP) was first diagnosed in 1958 by Rosen et al.[1] It is a rare disease of the lung. It may be congenital (2%), idiopathic (90%) or secondary (5%–10%). The granulocyte-monocyte colony-stimulating factor (GM-CSF) autoantibodies cause altered alveolar macrophage function and disrupt catabolism of normal surfactant, which causes deposition of lipoproteinaceous material in the alveolar spaces.[2] Secondary PAP can occur by lung infections (nocardiosis, pneuomocystitis jerovecii pneumonia), hematological malignancies and with inhalation of silica, titanium.

  Case Report Top

A 40-year-old male patient presented to our institute with complain of gradually progressive breathlessness on exertion and cough with scanty mucoid expectoration since 3 months. His occupation was to dig a well. Bronchoscopy was done for broncho-alveolar lavage and it was positive for periodic acid schiff stain. Clinical impression was of secondary PAP and the patient was posted for whole lung lavage (WLL).

His vitals showed pulse rate 90/min, normal temperature, respiratory rate 32/min, blood pressure 110/70 mm of Hg and SpO2 77% on room air. On chest auscultation, bilateral crepitations with decreased breath sounds were heard. Chest radiograph [Figure 1] showed bilateral alveolar infiltrates. High resolution computed tomography (HRCT) scan of thorax [Figure 2] showed diffuse ground glass densities in both lungs with interstitial septal thickening seen through it (Crazy paving pattern). During preoperative check-up haemogram, liver and renal function tests were found within normal limits. While the patient was on room air, the arterial blood gas (ABG) sample showed pH = 7.38, PaO2 = 63.7, PaCO2 = 36.6, HCO3 = 21.9.
Figure 1: Chest X-ray showed bilateral alveolar infiltrates

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Figure 2: High resolution computed tomography scan showed crazy paving pattern

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The right lung was affected more than left, so the lavage of right lung was carried out in the first sitting under general anesthesia. Preoxygenation was done for 5 min and his oxygen saturation increased to 100%. In addition to standard anesthesia monitoring, right radial artery was cannulated with 20-gauze cannula for invasive blood pressure monitoring. Glycopyrollate 0.004 mg/kg, ondensetron 0.15 mg/kg, fentanyl 1.5 μg/kg and dexamethasone 0.2 mg/kg were given intravenously as premedication. Anesthesia induction was done with propofol 2 mg/kg and succinylcholine 2 mg/kg. The left side 39 French Gauze double lumen endobroncheal tube was inserted with standard technique and bilateral equal air entry was confirmed after inflating the tracheal cuff. The bronchial cuff was inflated after tracheal side of tube, till air entry disappeared on tracheal side. A 2.8 mm fiberoptic bronchoscope (Olympus-Europe, BF TYPE XP60) was inserted through bronchial lumen to confirm the proper position of double lumen tube (DLT). The patient was made to turn on left lateral position to lavage the nondependent lung (right side). Anesthesia was maintained with oxygen, sevoflurane (1%–1.5%) and vecuronium bromide. Throughout the procedure the vitals were closely monitored.

Lavage involved 950–1000 ml aliquots of warmed normal saline, instilled into right lung using IV set tubing with a Y-shape connection over 8–9 min. During instillation, drainage tube which also connected with Y-piece was blocked [Figure 3]. Chest physiotherapy was performed to loosen the proteinaceous material for 4–5 min. Saline was then drained from the lung by gravity. Around 14 litre of warm normal saline was used during the procedure till the colour of drainage fluid became clear and 14 L of return fluid was collected from right lung. The oxygen saturation was dropped up to 96% but manageable and temperature decreased up to 96°F at the end of procedure as we did not use warmer.
Figure 3: Y-shape connection with infusion and drainage line

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At the end of the procedure left DLT was replaced with 8.5 portex cuffed single lumen endotracheal tube and suction was done through endotracheal tube and the patient was shifted to intensive care unit for postoperative ventilation. At the end of procedure the ABG showed pH = 7.364, PaO2 = 108.2, PaCO2 = 37.3, HCO3 = 21.2 on FiO2-0.5. Total time consumed during the procedure was around 4.5 h. The patient was extubated on next morning. After extubation the ABG showed PH = 7.5, PaO2 = 93.7, PaCO2 = 37.7, SaO2 95% on room air. Patient was comfortable with 94% SpO2 and respiratory rate of 16–18/min. Postprocedure chest radiograph and HRCT scan of thorax [Figure 4] and [Figure 5] showed improvement in the lung opacities.
Figure 4: Comparison of chest X-ray

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Figure 5: Postprocedure high resolution computed tomography scan of thorax

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The patient underwent left lung lavage after 1 month with 10 L of warm normal saline with same anaesthetic management using 39 Fr (left) DLT. This time we made the patient position right lateral and lavaged the nondependent lung without any adverse events.

  Discussion Top

PAP is a rare idiopathic autoimmune disease of lungs. Patient presents with persistent dry cough and progressive dyspnoea with intermittent low grade fever. The standard treatment of PAP is the WLL.[3] but others therapeutic approaches like subcutaneous[4] or inhaled[5] GM-CSF therapy and intravenous rituximab[6] are promosing alternative to WLL for symptomatic patients with PAP.

The right lung is relatively larger than left so if both lungs are equally involved, the left lung lavage is to be done first to support gas exchange during one lung ventilation.[7]

In the present case, the right lung was affected more than left lung. So we lavaged the right lung in first sitting to allow the better lung to provide gas exchange. During WLL, lateral decubitus keeping the lavaged lung dependent can also be done to prevent spillage of lavage fluid. Beccaria et al.[8] reported that by ventilating the dependent lung and by lavage of the nondependent lung, blood flow to the lavage lung is reduced, thus giving better ventilation perfusion ratio. Perez and Rogers[9] tried lavage in prone position with chest percussion and found that there was a statisticaly significant improvement in the clearance of material (P = 0.012).

Lavage of the lung, which is more affected, is performed in the first sitting to allow the better lung to provide gas exchange.[10] During the procedure the loss of lung isolation was detected by using continuous monitoring of:[7],[10]

  1. The appearance of bubbles in the lavage fluid draining from lavaged side
  2. Increased resistance to ventilation and appearance of rales and rhonchi on the ventilated side
  3. Imbalance between administered lavage volume and drained lavage volume.

The common complications of such procedure are hypoxia, spillage of lavage fluid, hemodynamic instability, pneumothorax[11] and hypothermia. The risk of hypoxia is more common during drainage of lavage fluid because of shunting of blood through nonventilated lung. In our case we used Positive end expiratory pressure (PEEP) in ventilating lung and confirmed the lung isolation during the procedure to prevent hypoxia. Sometimes the use of extracorporeal membrane oxygenation can be considered as a supporting modality to correct oxygen saturation in such critically ill patient.[12]

During left lung lavage we used left side DLT to prevent accidental occlusion of upper lobe of right lung with right DLT. Campos et al.[13] also noted that left sided DLT can be used for left sided thoracic surgery without any problems.

Maintaining normothermia is one of the prime importance of the procedure.[14] We used warming blanket with warm normal saline during procedure of left lung lavage for maintaining temperature of the patient.

  Conclusion Top

A team work of anesthesiologist, pulmonologist and chest physiotherapist plays an important role in the procedure of WLL and challenging situations. Strict vigilance and maintaining the vital parameters within normal limits is the key factor to uneventful outcome of PAP patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rosen SH, Castleman B, Liebow AA. Pulmonary alveolar proteinosis. N Engl J Med 1958;258:1123-42.  Back to cited text no. 1
Trapnell BC, Carey BC, Uchida K, Suzuki T. Pulmonary alveolar proteinosis, a primary immunodeficiency of impaired GM-CSF stimulation of macrophages. Curr Opin Immunol 2009;21:514-21.  Back to cited text no. 2
Ioachimescu OC, Kavuru MS. Pulmonary alveolar proteinosis. Chron Respir Dis 2006;3:149-59.  Back to cited text no. 3
Venkateshiah SB, Yan TD, Bonfield TL, Thomassen MJ, Meziane M, Czich C, et al. An open-label trial of granulocyte macrophage colony stimulating factor therapy for moderate symptomatic pulmonary alveolar proteinosis. Chest 2006;130:227-37.  Back to cited text no. 4
Tazawa R, Trapnell BC, Inoue Y, Arai T, Takada T, Nasuhara Y, et al. Inhaled granulocyte/macrophage-colony stimulating factor as therapy for pulmonary alveolar proteinosis. Am J Respir Crit Care Med 2010;181:1345-54.  Back to cited text no. 5
Borie R, Debray MP, Laine C, Aubier M, Crestani B. Rituximab therapy in autoimmune pulmonary alveolar proteinosis. Eur Respir J 2009;33:1503-6.  Back to cited text no. 6
Benumof JL. Unilateal bronchopulmonary lavage. Anaesthesia for thoracic surgery, 2nd Ed, Philadelphia, WB Saunders, 1987 p. 358-63.  Back to cited text no. 7
Beccaria M, Luisetti M, Rodi G, Corsico A, Zoia MC, Colato S, et al. Long-term durable benefit after whole lung lavage in pulmonary alveolar proteinosis. Eur Respir J 2004;23:526-31.  Back to cited text no. 8
Perez A 4th, Rogers RM. Enhanced alveolar clearance with chest percussion therapy and positional changes during whole-lung lavage for alveolar proteinosis. Chest 2004;125:2351-6.  Back to cited text no. 9
Alfery DD, Benumof JL, Spragg RG. Anaesthesia for bronchopulmonary lavage in thoracic anaesthesia. Edited by Joel A Kaplan. Churchill Livingston 1983. p. 403-17.  Back to cited text no. 10
Prakash UB, Barham SS, Carpenter HA, Dines DE, Marsh HM. Pulmonary alveolar phospholipoproteinosis: Experience with 34 cases and a review. Mayo Clin Proc 1987;62:499-518.  Back to cited text no. 11
Chauhan S, Sharma KP, Bisoi AK, Pangeni R, Madan K, Chauhan YS. Management of pulmonary alveolar proteinosis with whole lung lavage using extracorporeal membrane oxygenation support in a postrenal transplant patient with graft failure. Ann Card Anaesth 2016;19:379-82.  Back to cited text no. 12
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Campos JH, Massa FC, Kernstine KH. The incidence of right upper-lobe collapse when comparing a right-sided double-lumen tube versus a modified left double-lumen tube for left-sided thoracic surgery. Anesth Analg 2000;90:535-40.  Back to cited text no. 13
Nandkumar S, Desai M, Butani M, Udwadia Z. Pulmonary alveolar proteinosis with respiratory failure-anaesthetic management of whole lung lavage. Indian J Anaesth 2009;53:362-6.  Back to cited text no. 14
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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