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With great interest we read the article by Dirikgil et al . in which they demonstrate the potential of home-monitoring to reduce hospital admissions by safely surveying clinical symptoms and vitals [1]. They encourage to further consider strategies of home-monitoring in larger patient groups and particularly in patients with confirmed COVID-19.

Background: Autoimmune pulmonary alveolar proteinosis is an ultra-rare pulmonary disease. Whole lung lavage (WLL) is considered the gold standard therapy. We report a protocol for a new modified lavage technique (nMLT) in which controlled repetitive manual hyperinflation (MH) and intermittent chest percussion are used to enhance WLL efficacy. Methods: We included all subjects with autoimmune pulmonary alveolar proteinosis treated with nMLT between 2013 and 2018. nMLT consisted of repetitive MH with intermittent chest percussion every third wash. We reported: instilled volume, protein concentration, and optical density using spectrophotometry. Pulmonary function (FVC %predicted and DLCO %predicted) at start of nMLT was recorded. Data are displayed as mean (±SD), median [interquartile range], or number (%). Comparisons within individuals were made using Students t test. Results: We included 11 subjects (64% male) in whom a total of 67 nMLTs were performed. One nMLT consisted of 15 [12-18] washes. Protein removal was 9.80 [7.52-12.66] g per nMLT. After the first, second, and third cycle of 3 washes, 56% [49% to 61%], 81% [77% to 84%], and 91% [88% to 94%] of the final protein yield was removed, respectively. Optical density was measured 116 times and increased from 1.13 (±0.52) to 1.31 (±0.52) after MH ( P <0.001). Conclusion: Efficacy of WLL seems to be enhanced by applying MH every 3 washes. Our technique of WLL with nMLT could be used to increase the amount of protein recruited while instilling the lung with the smallest volume of fluid as possible.

Background. Autoimmune pulmonary alveolar proteinosis (aPAP) is an ultra-rare pulmonary disease. Due to heterogeneity and small patient cohorts, no standardized treatment protocol exists. Whole lung lavage (WLL) is considered the gold standard therapy and aims to remove the highest protein amount by flushing the lung with the lowest possible instilled volume. We report a new protocol for a new modified lavage technique (nMLT) in which controlled repetitive manual hyperinflation (MH) and intermittent chest percussion are used to enhance WLL efficacy. Methodology. We included all patients with aPAP treated with nMLT between 2013 and 2018. nMLT consisted of repetitive MH with intermittent chest percussion every third wash cycle. We reported: instilled and recovered volume, protein concentration, and optical density (OD) using spectrophotometry. Pulmonary function (FVC %predicted and DLCO %predicted) and serum biomarkers (LDH, CA 15 − 3, SP-D, and YKL-40) two months prior and post nMLT, and one year after nMLT treatment were evaluated. Data are displayed as mean (± SD) or median [IQR]. Comparisons were made using Student t-test and Wilcoxon test. Results. We included 11 patients (64% male) in whom a total of 65 nMLTs were performed. One nMLT consisted of 15 [12–18] wash cycles. Protein removal was 9.80 [7.52–12.66] grams per nMLT. After 3–4, 6–7, and 9-10L of instilled and recovered volume 56 [49–61] %, 81 [77–84] % and 91 [88–94] % of protein was removed respectively. OD was measured 116 times and increased from 1.13 (± 0.52) to 1.31 (± 0.52) after MH (p < 0.001). Our study also showed that pulmonary function improves after WLL with nMLT. Improvement of biomarkers was only reflected by CA 15 − 3. No adverse events related to the procedure were observed. Conclusion. Efficacy of WLL seems to be enhanced by using manual hyperinflation and applying this every third cycle. Our technique of WLL with nMLT could be used to increase the amount of protein recruited while instilling the lung with the smallest volume of fluid as possible. The duration of anesthesia and the risk of complications is thereby reduced.