The patient was a 31-year-old male, smoker of 30 cigarettes a day with no other history of interest, who was admitted to the Emergency Department reporting weight loss (approximately 10 kg), asthenia and dry cough for the last 6 months. Ten days prior to admission, he had a fever of up to 39ºC, generalised myalgia and dyspnoea on moderate exertion.
The admission blood test showed a baseline arterial oxygen pressure (PaO2) of 63 mmHg; erythrocyte sedimentation rate: 92 mm/h; white blood cell count of 9300 l/mm3 (73% neutrophils); lactic dehydrogenase (LDH): 957 mg/dl, and fibrinogen: 954 mg/dl. Chest X-ray showed bilateral diffuse interstitial-alveolar infiltrate over the lung parenchyma. Chest CT showed extensive involvement of the lung parenchyma with areas of alveolar involvement, symmetrical and bilateral areas of ground-glass opacity and adenopathies in the pulmonary hilum, paratracheal and below the carina. The patient underwent a transbronchial biopsy, which was non-specific. A lung biopsy was performed in the operating theatre and the histological study showed alveolar proteinosis. The microbiological study of the biopsy isolated Nocardia sp. Fifteen days after admission, the patient presented clinical worsening with a large increase in dyspnoea, hypoxia and worsening of the alveolar-arterial gradient. Given the clinical situation, it was decided to perform bilateral bronchoalveolar lavage.
Prior to orotracheal intubation, the patient was sedated with propofol, analgesiated with fentanyl and relaxed with succinylcholine. Intubation was performed with a left Mallinckrodt 39F double-lumen tube. We checked the location of the tube by means of a paediatric fibrobronchoscope. The patient was then kept sedated and relaxed with continuous perfusion of propofol and cisatracurium.
We initially ventilated the patient for 30 minutes in pressure control, with inspired oxygen fraction (FiO2) of 100%, positive end-expiratory pressure (PEEP) of 6 cm H2O, peak pressure of 30 cm H2O and respiratory rate of 12. The patient had tidal volumes of 800 ml (volume/minute of 10 lpm) and his oxygenation was 96%.
We then measured the static compliance of each lung (25 ml/cm H2O in the right lung and 15 ml/cm H2O in the left lung), so we decided to start lavage in the left lung (the one with the worst static compliance) with the patient in the supine position.
The lavage was performed with isotonic saline solution heated to 37ºC. We infused one litre from a height of 30-40 cm above the patient and drained the patient by gravity. The same operation was carried out until the lavage fluid had cleared. Thirteen litres were necessary in this first phase. To achieve a better result and drainage, thoracic percussion was performed on the lavaged lung.
At the end of the lavage in the supine position, we observed an improvement in the static compliance of the left lung of up to 53 ml/cm H2O and an improvement in saturation of up to 98%.
The patient was then placed in prone position. We performed the same procedure as in the supine position, in this case 15 litres of saline solution at 37°C were necessary to obtain a clear drainage. The total time taken to lavage the left lung was 2 hours and 45 minutes.
After completion of the left lung lavage, we ventilated both lungs in pressure control mode with FiO2 100%, PEEP 10 cm H2O and peak pressure of 35 cm H2O for 45 minutes. The measured static compliance was 39 ml/cm H2O and oxygen saturation was 96%. We decided to ventilate the left lung alone, to check that he could tolerate right lung lavage. The patient was well tolerated with an oxygen saturation of 96%. We decided to start the lavage of the right lung starting in prone position.
In this position the drain started to clear with 20 litres of saline in one hour and 35 minutes. We changed to the supine position, and in this position only 4 litres were needed in 14 minutes to obtain a clear drainage. After 30 minutes of mechanical ventilation the static compliance of both lungs was 64 ml/cm H2O and the oxygen saturation was 98%.
Finally we changed the double lumen tube to a standard number 8 tube and started disconnecting the patient. The patient was extubated two hours after completion of the lavage.
The control chest X-ray showed a bilateral fine interstitial pattern. When the patient was discharged from the intensive care unit he had a PaO2/FiO2 ratio of 453.8 (193.8 on admission).
Sequential lavage had to be repeated twice during the following year due to worsening of his disease with good tolerance.