2001 OPEN FORUM Abstracts
BRONCHOSCOPIC SURFACTANTLAVAGE IN SEVERE ARDS: CASE REPORT
David Willms MD, ArtCastro RRT. Sharp Memorial Hospital, San Diego, California
Introduction: Replacementof diminished surfactant activity in the lungs has been proposed to be of benefitin ARDS. We present a case in which bronchoscopic surfactant lung lavage causeddramatic temporal improvements in gas exchange.
Case Summary: A 40 yr oldwoman had group A streptococcal pneumonia, bacteremia, and profound septic shock.She was intubated and within hours had diffuse bilateral infiltrates, reducedcompliance, and hypoxemia consistent with ARDS. CVVHD was begun for anuric renalfailure. High dose vasopressors, paralysis, FiO2 1.0, and PC-IRV were required.Despite this, the patient remained severely hypoxemic with O2 saturations inthe 70s. Inhaled NO was begun with some improvement in oxygenation. Prone positioninginitially caused marginal improvement in PaO2 but soon became ineffective. Byday 4, the patient was on FiO2 varying from .80 to 1.0, remained hemodynamicallyunstable, and had distal extremity gangrene. Bronchoscopic lavage with commerciallyavailable surfactant was considered as a possible salvage. After consent wasobtained, a quantity of beractant (Survanta®), a bovine surfactant, was acquiredand divided into 15 syringes, each containing 16 ml of surfactant 25 mg/ml (totaldose 125 mg/kg). Bedside bronchoscopy was then performed. The scope was wedgedinto a segment (in some cases 2 segments per syringe) and surfactant instilled.After 10-20 sec the area was suctioned; each segment was treated similarly.The procedure took 30 min. No oxygen desaturation occurred. Immediate improvementin oxygenation was seen (Table), and by 12 hours later the FiO2 could be loweredto .50. Rapid hemodynamic and gas exchange improvement followed over 48 h. Thepatient eventually required extremity amputations, but otherwise fully recoveredand was extubated 18 days following surfactant.
Discussion: Large-scale studiesof aerosol and bolus delivery of surfactant have thus far failed to show convincingbenefit in ARDS. Two small series of bronchoscopic lavage with surfactant diddemonstrate physiologic improvements. The present case adds to this literatureand suggests that at least some ARDS patients may benefit from bronchoscopicinstillation of effective formulations of surfactant. Controlled clinical trialsof this method are urgently needed.