Corrected: Anesthetic Challenges During Whole Lung Lavage: A Case Report

Pulmonary alveolar proteinosis is an uncommon lung disease characterized by the accumulation of surfactant in the lungs. Treatment is done by whole lung lavage. One-lung ventilation in diseased lungs is a challenge to anesthesiologists due to the rapid desaturation and hemodynamic fluctuations encountered during the procedure. A 24-year-old female, a known patient of pulmonary alveolar proteinosis, who had undergone previous lung lavage presented with a dry cough and shortness of breath. Our management of the case included complete lung isolation with a double-lumen tube (DLT), one-lung ventilation, and an appropriate hemodynamic management strategy during the procedure


Introduction
Pulmonary alveolar proteinosis is a rare lung disease characterized by the accumulation of a lipoproteinaceous surfactant [1]. Most commonly, it may be autoimmune in origin or may result from mutation of surfactant genes, toxic inhalation, and hematological disorders. Whole lung lavage (WLL) is the mainstay of treatment in them [1]. Whole lung lavage is challenging to both the anesthesiologist and pulmonologist due to procedural complications like hemodynamic and oxygenation fluctuations. Here, we describe the safe anesthetic management of a young female with pulmonary alveolar proteinosis posted for whole lung lavage.

Case Presentation
A 24-year-old female presented to pulmonology OPD with increasing shortness of breath and dry cough for the past month, which was associated with bilateral diffuse chest pain. She was a known patient of pulmonary alveolar proteinosis for the last four years and had undergone whole lung lavage four times previously. High-resolution computerized tomography (HRCT) showed ground glass opacities bilaterally with a crazy paving appearance ( Figure 1).

FIGURE 1: HRCT thorax
HRCT: high-resolution computerized tomography Her previous lavage of the left lung was incomplete due to desaturation and hemodynamic changes. She was scheduled for whole lung lavage. On the day prior to surgery, informed and written consent was taken explaining the procedural complications, and she was advised alprazolam 0.25 mg at night and pantoprazole 40 mg on the morning of surgery.
On arrival at the operating room, ECG, pulse oximeter, and non-invasive blood pressure (NIBP) were attached, and her saturation was 92% on room air. 18G intravenous cannulation (left upper limb) was done and 20g radial artery cannulation was performed for continuous arterial pressure monitoring and serial arterial blood gas analysis. Anesthesia induction was done with 100 mcg of fentanyl and 70 mg of propofol, and muscle relaxation was facilitated with rocuronium 50 mg. After two minutes of ventilation, a 37Fr leftsided double-lumen endobronchial tube (DLT) was inserted and its position was confirmed by fiberoptic bronchoscope. Maintenance of anesthesia was done with 100% oxygenation and sevoflurane with volumecontrolled ventilation. A 7Fr triple lumen central venous catheterization was done on the right internal jugular vein (IJV) under ultrasound guidance. As the previous lavage was unsuccessful on the left side, it was decided to first lavage the left lung followed by the right.
For lavage on the left side, the bronchial lumen was clamped and 100% oxygen was administered with low tidal volume and high respiratory rate. Lavage was started by the pulmonology team. Before lavage was started, a bubble test was done to rule out any leaks. Each cycle was done by instilling 500 ml aliquots of warm normal saline followed by drainage under gravity. In order to achieve maximal filling and drainage of all lung segments, manual chest vibration and percussion were done by the pulmonologist. Various positional maneuvers were also done to facilitate the run-in and run-out of fluid. There were episodes of desaturation (lowest saturation 80%) during drainage, which lasted for one minute, and improvement in saturation while instilling. Due to hemodynamic instability during the procedure, the patient was started on noradrenaline 0.05 mcg/kg/min to maintain blood pressure and dobutamine 3 mcg/kg/min to alleviate right heart failure. There was an increase in airway pressure and a decrease in tidal volume delivered associated with decreasing saturation level during lavage, which prompted us to check for fluid leakage. Fiberoptic bronchoscopic inspection and suction of the ventilated lung were done, which improved the tidal volume during subsequent cycles. After six cycles of lavage, there was clear fluid effluent.
For lavage of the right lung, the bronchial lumen was unclamped and the tracheal lumen was clamped to initiate right lung lavage (Figure 2).

FIGURE 2: Lung isolation for right lung lavage
Seventeen cycles of lavage (Figure 3), each with 500 ml aliquots of warm normal saline, were done on the right lung, after which clear effluent was noted. This was better tolerated with well-maintained airway pressures and less desaturation (lowest saturation 88%), which lasted for less than 30 seconds probably due to improvement in the left lung.