The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts

SEQUENTIAL BILATERAL LUNG LAVAGE IN A CHILD WITH PULMONARY ALVEOLAR PROTEINOSUS (PAP)

D. N. Crotwell 1, R. Gibson2, R. M. DiBlasi1, J. W. Salyer1, J. M. Geiduscheck3


Introduction: PAP is a rare (0.37/100,000) disease in which lipoproteinaceous material accumulates in the alveoli, causing progressive SOB & deterioration in PFT's. We present an unusual Tx of this disease in a ped pt. Case: A 13 yo male with a Dx of PAP; Hx of gradually increasing WOB, poor nutrition, persistent productive cough, and complaints of chest congestion. CXR revealed bilateral alveolar interstitial densities and air bronchograms. CT scan showed patchy alveolar opacities and interlobular thickening of the septal walls. A lavage procedure took place sequentially over 3 days. Day 1 the pt was taken to the OR and following anesthesia, intubated with a 35 french dual-lumen ETT, which allowed independant lung ventilation. The pt was then placed on the Avea ventilator for pulmonary mechanics measurements. Settings: Mode=A/C, f=20/min, Peak Flow 30L/m, VT320 mL, PEEP 5cmH2O & FIO2 1.0. Cstat of the whole respiratory system (CRS) was determined via inspiratory hold. Data were acquired from the Avea via interface with a laptop. VT was reduced by 50% and the CRS was obtained for each lung independently. The pt was returned to the anesthesia ventilator. Procedure sequence:

(1) pt placed in Trendelenberg Decubitus position, ventilated lung down,

(2) instillation of 400mL of warmed 0.9% NaCl into the L lung via gravity, with solution bag 30cmH2O above the thorax,

(3) L lumen of the ETT clamped,

(4) PD&P of L lung performed for 5 minutes,

(5)L lumen of the ETT unclamped allowing drainage of the lavage fluid via gravity. The drainage was examined for sedimentation.

The procedure sequence was repeated 9x until the fluid was clear. After the 9th lavage, the pt was returned to the Avea. Alveolar recruitment maneuvers were done and compliance measurements were repeated. Anesthesia was discontinued and the pt was extubated to 2L/m NC and transferred to the medical floor. The pt stated, “I can already breathe easier.” After a day of rest the procedures was repeated for the R lung. The pt was discharged without incident. Discussion: There was a 31% increase in CRS of both lungs by the end of the second procedure. CRS improvement was not seen immediately after the 1st procedure, but by the time of the 2nd procedure, there was significant improvement in the treated lung. Thus the total improvement in CRS was probably greater but not revealed by measurements taken at the end of the 2nd procedure.

Compliance Measurements
 CRS Both LungsCRS Left LungCRS Right Lung
Before 1st Procedure 15 6 10
After 1st Procedure 16 8 8
Before 2nd Procedure 17 10 8
After 2nd Procedure 21 1110
    

Data are in mL/cmH2O


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