An Uncommon Procedure for a Rare Ailment: Massive Bronchoalveolar Lavage in a Patient with Pulmonary Alveolar Proteinosis

Year 2012, , 334 - 338, 01.03.2012

Hilal Günal Sazak Şaziye Şahin Polat Pehlivanoğlu Özlem Çakır Mehtap Tunç Fatma Ulus Behiye Akkalyoncu Belgin Samurkaşoğlu

https://doi.org/10.5152/balkanmedj.2012.046

Abstract

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. Turkish Başlık: Nadir Görülen Bir Hastalık İçin Nadir Bir Girişim: Bir Pulmoner Alveolar Proteinosis Hastasında Masif Bronkoalveolar Lavaj Anahtar Kelimeler: Bronkoalveolar lavaj, pulmoner alveoler proteinoz, genel anestezi Nadir bir işlem olan masif bronkoalveolar lavaj (MBAL) genel anestezi ve tek akciğer ventilasyonu (TAV) gerektiren geniş hacimli lavajdır. MBAL sırasında, bir akciğere, çift lümenli tüpün bir lümeni aracılığıyla, izotonik salin infüze edilip drene edilir. MBAL, semptomatik pulmoner alveolar proteinosis (PAP) için en etkin tedavi yöntemidir. PAP tanısı olan 27 yaşında erkek hastaya terapötik MBAL planlandı. Standart preoksijenasyon, monitörizasyon ve anestezi indüksiyonunu takiben çift lümenli tüp yerleştirildi. Tüp pozisyonu fiberoptik bronkoskopla doğrulandı. İnternal juguler ven, radiyal ve pulmoner arter kateterizasyonu uygulandı. Özafageal ısı probu ve foley sonda yerleştirildi. Her seansta ventile olmayan akciğer 1000 ml serum fizyolojik ile doldurulup, serbest direnajla boşaltıldı. Sol ve sağ akciğer 2 hafta arayla yıkandı. Sıvı retansiyonu olmayan her bir MBAL sırasında toplam 20 L serum fizyolojik kullanıldı. Yıkama sıvısı berrak geldiğinde işlem sonlandırıldı. Sol ve sağ MBAL süreleri sırasıyla 325 ve 275 dk idi. TAV sırasında arteriyel oksijenasyon, artmış şanta rağmen, kabul edilebilir sınırlarda idi. Her bir işlem sonunda, hasta ameliyathanede ekstübe edilerek, sorunsuz olarak yoğun bakım ünitesine transfer edildi. Hastanın kliniği ve laboratuvar bulgularında belirgin düzelme gözlendi. Sonuç olarak, MBAL uzun süresine ve risklerine rağmen, uygun koşullar sağlandığında güvenli ve yararlıdır.

Keywords

Bronchoalveolar lavage, pulmonary alveolar proteinosis, general anesthesia

An Uncommon Procedure for a Rare Ailment: Massive Bronchoalveolar Lavage in a Patient with Pulmonary Alveolar Proteinosis

Abstract

References

• Erol A, Reisli R, Reisli İ, Otelcioğlu Ş. The effects of sevoflurane, des- flurane and propofol on the percentages and activation molecules of the lymphocytes: A flow cytometry analysis of bronchoalveolar lavage fluid. Turkiye Klinikleri J Med Sci 2011;31:443-9. [CrossRef]
• Claypool WD, Rogers RM, Matuschak GM. Update on the clinical diagnosis, management, and pathogenesis of pulmonary alveolar proteinosis (phospholipidosis). Chest 1984;85:550-8. [CrossRef]
• Ben-Dov I, Kishinevski Y, Roznman J, Soliman A, Bishara H, Zel- ligson E, et al. Pulmonary alveolar proteinosis in Israel: ethnic clustering. Isr Med Assoc J 1999;1:75-8.
• Danel C, Israël-Biet D, Costabel U, Klech H. Therapeutic applica- tions of bronchoalveolar lavage. Eur Respir J 1992;5:1173-5.
• Benumof JL, Alfery DD. Anesthesia for thoracic surgery. In: Miller RD (ed). Anesthesia. 5th ed. Philadelphia: Churchill Livingstone, 2000;1665-752.
• Mazzone P, Thomassen MJ, Kavuru M. Our new understanding of pulmonary alveolar proteinosis: what an internist needs to know. Cleve Clin J Med 2001;68:977-93. [CrossRef]
• Dixit R, Chaudhari LS, Mahashur AA. Anaesthetic management of bilateral alveolar proteinosis for bronchopulmonary lavage. J Postgrad Med 1998;44:21-3.
• Moutafis M, Dalibon N, Colchen A, Fischler M. Improving oxygen- ation during bronchopulmonary lavage using nitric oxide inhalation and almitrine infusion. Anesth Analg 1999;89:302-4. [CrossRef]
• Webb ST, Evans AJ, Varley AJ, Klein AA. Anaesthesia for serial whole-lung lavage in a patient with severe pulmonary alveolar pro- teinosis: a case report. J Med Case Rep 2008;2:360. [CrossRef]
• Benumof JL. Anesthesia for special elective therapeutic proce- dures. In: Benumof JL, ed. Anesthesia for Thoracic Surgery. 2nd ed. Philadelphia: W.B. Saunders Company, 1995; p. 548-55.
• Swenson JD, Astle KL, Bailey PL. Reduction in left ventricular filling during bronchopulmonary lavage demonstrated by transesopha- geal echocardiography. Anesth Analg 1995;81:634-7. [CrossRef]
• Lohser J. Evidence-based management of one-lung ventilation. Anesthesiol Clin 2008;26:241-72. [CrossRef]
• Grichnik KP, Clark JA. Pathophysiology and management of one- lung ventilation. Thorac Surg Clin 2005;15:85-103. [CrossRef]
• Michaud G, Reddy C, Ernst A. Whole-lung lavage for pulmonary alveolar proteinosis. Chest 2009;136:1678-81. [CrossRef]
• 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. [CrossRef]
• Sazak HG, Göktaş U, Alagöz A, Gülhan M, Şahan L, Şavkılıoğlu E, et al. Anesthesic management of whole lung lavage in pulmonary alveolar proteinosis (Case Report). Journal of Cardio-Vascular- Thoracic Anaesthesia and Intensive Care Society 2003;9:77-81.