Yeungnam Univ J Med.  2021 Oct;38(4):374-380. 10.12701/yujm.2021.01284.

Anesthetic management during whole-lung lavage using lung ultrasound in a patient with pulmonary alveolar proteinosis: a case report

• Jung JW
• Lee H
• Oh J

• KMID: 2521720
• DOI: http://doi.org/10.12701/yujm.2021.01284

Abstract

Pulmonary alveolar proteinosis (PAP) is an uncommon disease characterized by progressive accumulation of lipoprotein material in the lungs due to impaired surfactant clearance. Whole-lung lavage (WLL) is the current standard treatment and consists of sequential lavage of each lung to mechanically remove the residual material from the alveoli. Although WLL is considered safe, unexpected complications can occur. Moreover, due to the rarity of the disease itself, this procedure is unknown to many physicians, and management of intraoperative complications can be challenging for anesthesiologists. Lung ultrasound (LUS) provides reliable and valuable information for detecting perioperative pulmonary complications and, in particular, quantitation of lung water content. There have been reports on monitoring the different stages of controlled deaeration of the non-ventilated lung during WLL using LUS. However, it has been limited to non-ventilated lungs. Therefore, we report the use of LUS in WLL to proactively detect pulmonary edema in the ventilated lung and implement a safe and effective anesthesia strategy. Given the limited diagnostic tools available to anesthesiologists in the operating room, LUS is a reliable, fast, and noninvasive method for identifying perioperative pulmonary complications in patients with PAP undergoing WLL.

Keyword

Anesthesia; Extravascular lung water; One-lung ventilation; Pulmonary alveolar proteinosis; Ultrasonography

Figure

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  Fig. 1. (A) Chest radiograph shows ill-defined increased opacities in both lower lung zones. (B) High-resolution computed tomography scan shows ill-defined ground-glass opacities and consolidations with crazy-paving appearance in both lungs.

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  Fig. 2. Picture of patient’s position during whole-lung lavage. (A) During inflow of lavage fluid, the patient was positioned in the reverse Trendelenburg to facilitate the instillation. (B) While draining the lavage fluid, the patient was placed in the Trendelenburg position.

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  Fig. 3. To ensure the reproducibility of ultrasound acquisition during the entire procedure, the exact point of the lung ultrasound examination was marked on the skin. Three regions (phrenic point, upper and lower BLUE points) were identified bilaterally in each hemithorax according to the bedside lung ultrasound in emergency (BLUE) protocol.

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  Fig. 4. The typical sequence of ultrasound findings of the lung. Our lavage procedure was terminated when a tissue pattern (pattern 3, II) appeared in all areas of the non-ventilated lung and/or three or more B-lines (pattern 2, II) appeared in the ventilated lung. Reventilation was associated with reduced B-lines in the ventilated lung and a reappearance of pattern 2 (alveolar-interstitial syndrome) in the lavaged lung. Prolonged ventilation with PEEP (18 hours later, ventilation with 10 cmH2O PEEP) resulted in the return of pattern 1 (normal pattern) in both lungs. PEEP, positive end-expiratory pressure.

Reference

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