Whole-lung lavage for severe pulmonary alveolar proteinosis assisted by veno-venous extracorporeal membrane oxygenation: a case report

Abstract

Pulmonary alveolar proteinosis (PAP) is a rare pathology characterized by accumulation of phospholipoproteinaceous material within the alveoli. The evolution of PAP is variable and treatment modalities are limited. Pharmacological therapeutic targets are being actively developed, but whole-lung lavage (WLL), first described in the 1960s, remains the cornerstone of therapy. The preferential treatment for PAP in our center is sequential WLL, where each lung is separately and sequentially perfused with warmed saline. However, some patients do not tolerate single lung ventilation (SLV), as there is a greater risk of severe hypoxemia with this method. Extracorporeal membrane oxygenation (ECMO), referring to an extracorporeal circuit that directly oxygenates and removes carbon dioxide from the blood, may be considered in highly selected patients with severe respiratory failure who otherwise would not be able to undergo WLL. In this context, veno-venous ECMO is most often utilized. We describe a case of a 44-year-old male diagnosed with silicosis five years earlier who presented with severe hypoxemic respiratory failure not amenable to WLL under general anesthesia with SLV, which was successfully managed with ECMO-assisted WLL.

Whole lung lavage and GM-CSF use for pulmonary alveolar proteinosis in an infant with lysinuric protein intolerance: a case report

“…Veno-venous ECMO modality was chosen as her cardiac function was normal and thus only pulmonary bypass was needed. Also, VV ECMO has been associated with lower rate of complications compared to venoarterial ECMO (12). Finally, even though WLL is classically performed through gravity with the patient being positioned in the reverse Trendelenburg and Trendelenburg positions, we were unable to drain the injected lavage uid from the lungs by positioning alone.…”

Whole lung lavage and GM-CSF use for pulmonary alveolar proteinosis in an infant with lysinuric protein intolerance: a case report

“…Veno-venous ECMO modality was chosen as her cardiac function was normal and thus only pulmonary bypass was needed. Also, VV ECMO has been associated with lower rate of complications compared to venoarterial ECMO [ 20 ]. Finally, even though WLL is classically performed through gravity with the patient being positioned in the reverse Trendelenburg and Trendelenburg positions, we were unable to drain the injected lavage fluid from the lungs by positioning alone.…”

Total alveolar lavage with oxygen fine bubble dispersion directly improves lipopolysaccharide-induced acute respiratory distress syndrome of rats

“…Furthermore, although our group is also hoping to improve the blood supply during the TAL treatment via material improvement, focusing on only the TAL treatment, we can apply TAL treatment in combination with extracorporeal membrane oxygenation (ECMO). In fact, WLL with ECMO was shown to be beneficial in that it can be performed more safely to ameliorate the respiratory failure and its causes of disease 36 . Thus, we can proceed optimistically to future prospective studies if long-term TAL treatment in rats proves successful.…”