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Peri-Procedural and Anesthetic Management of Bilateral Therapeutic Whole Lung Lavage for Pulmonary Alveolar Proteinosis
Amir Khazaieli, M.D., Ali Jahan, M.D., Vivek Sabharwal, M.D., Mani Kavuru, M.D., Marc J. Popovich, M.D.
Surgical ICU/General Anesthesiology and Pulmonary Departments, The Cleveland Clinic, Cleveland, Ohio.
INTRODUCTION: Pulmonary alveolar proteinosis (PAP) is a rare disease that afflicts sufferers with disabling symptoms of hypoxemia. Therapeutic whole lung lavage (WLL) is a treatment that frequently offers symptomatic relief.1 Patients must undergo general anesthesia, one-lung ventilation, and as much as 20 L saline instilled in 0.5 to 1 L aliquots into the treated lung.2 Conventional management includes unilateral WLL over consecutive days; lateral decubitus or prone positioning, and chest physiotherapy (CPT) by a respiratory therapist (RRT) during the procedure; and extended postoperative ventilation.2 Such management typically results in at least 2 days of hospitalization. For the past 5 years we have employed the following peri-procedure management protocol: propofol total intravenous anesthesia; bilateral sequential WLL during the same anesthetic, with 12-18 L lavage fluid per lavaged lung; supine positioning; furosemide diuresis between each WLL; and a 2-hour postprocedure strategy including pressure-controlled ventilation with PEEP 10-15 cm H2O. In addition, since March 2001 we have supplanted the need for the RRT by administering CPT with a pneumatic oscillation vest clearance system during and after the procedure.3 The purpose of this study was to determine the effect of our treatment protocol on post-procedure oxygenation and length of stay.

METHODS: We reviewed the records of all patients diagnosed with PAP who received WLL according to our protocol. We collected patient demographics and pre-procedure oxygen use. Procedural data collected included total anesthesia time and one-lung ventilation times. Post-procedure we recorded PEEP requirements and total PACU time. We also noted oxygen requirements at discharge. Results are presented as median; [interquartile range (IQR)].

RESULTS: There were 7 patients (5 male, 2 female; age 40; [38, 44]) and 9 WLL episodes (2 patients underwent 2 separate procedures with the protocol). The findings are demonstrated in Table 1.All patients tolerated the perioperative management protocol. Of the 9 episodes, 8 patients were discharged on post-procedure day 1, and one on day 2.

CONCLUSIONS: Conventional WLL strategies for PAP, including one lung lavage per anesthetic, voluminous lavage fluid, positioning changes during the procedure, and the need for an RRT to perform CPT, may be unnecessary. Using our peri-procedure management protocol, which includes bilateral WLL, lavage fluid < 18 L per lung, no positioning changes, a pneumatic chest oscillation vest clearance system, and a standardized post procedure ventilation strategy, patients were usually able to be discharged from the hospital by the next day and required less oxygen than before the procedure. Thus, patients with PAP can receive symptom-improving WLL with reduced use of anesthesia and hospital resources.


1 Kavuru MS, Popovich MJ. Chest 2002; 122:1123-4

2 Walsh FW, Rumbak MJ. J Crit Illness 1996; 11:191-7

3 Davis J, Popovich MJ. Respir Care 2001; 46:1098 [abstract]

Anesthesiology 2003; 99: A429
Table 1. Bilateral WLL Peri-procedure Variables
Total anesthesia timemin195180, 205
One lung ventilation, Rmin6045, 70
One lung ventilation, Lmin4540, 60
PACU PEEPcm H2O1210, 15
Total PACU timehr4.57, 13
Pre-procedure O2L/min42.5, 4
Discharge O2L/min22, 3