Chest
Volume 122, Issue 4, October 2002, Pages 1480-1485
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Selected Reports
Pulmonary Alveolar Proteinosis: Treatment by Bronchofiberscopic Lobar Lavage

https://doi.org/10.1378/chest.122.4.1480Get rights and content

The current mainstay of treatment for pulmonary alveolar proteinosis (PAP) is whole-lung lavage. Therapy with granulocyte-macrophage colony- stimulating factor is a possibility, although its long-term safety has not been determined. An alternative procedure is selected lobar lavage by fiberoptic bronchoscopy (FOB). We report here our experiences with lobar lavage by FOB in treating three patients with PAP. PAP was diagnosed in three patients (two men, one woman) who had dyspnea and hypoxemia after undergoing open-lung biopsy. The patients underwent lobar lavage by FOB under local anesthesia. The bronchoscope was wedged into a lobar bronchus. Approximately 2,000 mL warm normal saline solution was instilled via syringe in 50-mL aliquots through a fiberoptic bronchoscope. After undergoing multiple lobar lavages, two patients showed clinical, physiologic, and radiologic improvement. The third patient, who had more advanced disease, showed improvement only in oxygenation. The major complications were severe cough and hypoxemia during lavage. Our experience suggests that bronchoscopic lobar lavage is simple and safe, and may find application in patients in whom a whole-lung lavage with generalized anesthesia may be hazardous, and in patients with less advanced disease whose proteinaceous substances can be removed with a small volume of lavage fluid.

Section snippets

Materials and Methods

Three patients in whom PAP had been diagnosed by open-lung biopsy were enrolled in the study. Blood gases and pulmonary function were measured at the time of hospital admission (Table 1). Bronchoscopic lavage was performed under local anesthesia, with 2% xylocaine given to the patient before and when needed during the FOB. No parenteral sedation or analgesia was used. While the patient breathed oxygen through a nasal cannula, a bronchoscope was passed through the nose and was placed in a

Case 1

A 36-year-old man, a cigarette smoker of 20 pack-years, was brought to our emergency department due to progressive shortness of breath for 6 months and intermittent fever for 5 days. He had been a cement worker for 10 years. He was tachypneic and cyanotic. There were coarse rales over bilateral lower lung fields. A chest radiograph (Fig 1) disclosed diffuse alveolar infiltrates predominantly in the lower lobes. Arterial blood gas analysis on the patient's arrival in the emergency department

Discussion

Whole-lung lavage is now considered to be the most effective treatment for PAP. The major adverse effect of whole-lung lavage is hypoxemia, especially during the emptying phase, which decreases airway pressure and increases the perfusion of the lavaged lung.1112 Hemodynamic instability may develop during a whole-lung lavage,1113 which may necessitate invasive BP monitoring and may further complicate the course of treatment. Noninvasive hemodynamic monitoring by bioimpedance has been found to be

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