Elsevier

Heart & Lung

Volume 31, Issue 1, January–February 2002, Pages 43-49
Heart & Lung

Issues in Pulmonary Nursing
Pulmonary alveolar proteinosis: Step-by-step perioperative care of whole lung lavage procedure*

https://doi.org/10.1067/mhl.2002.119831Get rights and content

Abstract

Background: Pulmonary alveolar proteinosis is a rare disease characterized by the accumulation of surfactant-like material within the alveolar spaces that causes progressive respiratory failure. Improvement can be achieved with whole lung lavage. Objective: Our objective was to conduct a study of the feasibility of treating pulmonary alveolar proteinosis in a community hospital. Methods: Five patients were treated. We assessed procedure pulmonary functions. Results: No major sequelae occurred. Each lung was lavaged with 12 to 20 L of normal saline in cycles of 970 ± 150 mL each (mean ± standard deviation), over 106 ± 49 minutes. Extubation was performed when compliance of the lavaged lung was restored. All patients showed subjective improvement. Resting and exercise oxygen saturation improved within 1 week after the lavage. A significant improvement was also noted in forced expiratory volume in 1 second, forced vital capacity, and maximal oxygen uptake, whereas total lung capacity and carbon monoxide single-breath diffusion capacity remained unchanged. Conclusion: Although retrospective and based on a small sample size, our results suggest that whole lung lavage may be performed safely even in medical centers that have limited experience, if strict adherence to a protocol is maintained. (Heart Lung® 2002;31:43-9)

Section snippets

Methods

A countrywide survey was conducted during which pulmonologists were questioned about patients with PAP. All patients included had typical clinical and chest x-ray findings and PAP confirmed histologically by a pathologist. Progressive effort intolerance or significant hypoxemia on room air while exercising (oxygen saturation, 90%) were indications to perform WLL. Prelavage assessment included medical history (with emphasis on possible exposure to dust), physical examination, and chest x-ray. In

Whole lung lavage

The WLL team included at least 1 anesthesiologist, a pulmonologist, a nurse, and a physiotherapist. WLL was performed with the patient lying in the supine position in an intensive care bed (with the ability to change patient position as required). The bed was located in the middle of the room to enable a convenient approach from all sides of the patient during the procedure. The following additional equipment was prepared and carefully checked before the procedure by the nursing team: an

Statisticsal analysis

The results were analyzed using the paired t test and are expressed as mean ± standard deviation (SD).

Patients

Five patients with PAP (3 males; mean age, 36 ± 6 years; range, 32-46 years) were included in the study. All were Jewish immigrants of North African ethnic origin. All patients were nonsmokers and 1 had a history of exposure to industrial aluminum dust. Other clinical tests that included PPD and serologic tests for immunologic disorders were negative in all patients.

Whole lung lavage

The 5 patients underwent 10 WLL procedures cumulatively. Anesthetic time lasted 240 ± 56 minutes. Induction (including intubation,

Discussion

Despite the small number of patients and lack of previous experience, therapeutic WLL using lung separation with a double-lumen tube was successfully performed. After the lavage, all patients had marked subjective improvement. Objectively, resting and exercise oxygen saturation, FEV1, and FVC consistently improved (20%-32%), but total lung capacity and the diffusion capacity showed less consistent improvement (Fig 3).

PAP may result from defective clearance of phospholipids by the alveolar

Conclusion

In contrast to other interstitial lung diseases, PAP is sometimes amenable to effective treatment. However, because of the rarity of the disease, many medical centers lack experience in this procedure. Although retrospective and based on a small sample, our results suggest that WLL may be performed safely and effectively if strict adherence to the guidelines and physiologic principles described earlier is maintained. In this regard, maximal cooperation between different team members is crucial

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