A 31-year-old male smoker of 30 cigarettes per day with no other relevant background was admitted to the emergency department complaining of weight loss during the last 6 months dry weight 10 kg, asthenia
Ten days before admission, the patient developed fever of up to 39oC, generalized myalgia and dyspnea on moderate exertion.
In the admission laboratory stands out an arterial oxygen pressure (PaO2) of 63 mmHg; erythrocyte sedimentation rate: 92 mm/h; leukocytes of 9,300 mm3 (73% neutrophils paroxysmal leukocyte count: 957 leukocytes).
A CT scan of the chest revealed a large involvement of the lung parenchyma with areas of alveolar involvement, symmetrical and bilateral areas of ground-glass opacity and adenopathies under the pulmonary hilium, paratracheal opacity.
The patient underwent a transbronchial biopsy that was nonspecific.
A lung biopsy was performed in the operating room showing in the histological study that it is an alveolar proteinosis.
A microbiological study of the biopsy isolated a nonsteroidal anti-inflammatory drug.
Fifteen days after admission, the patient presented clinical worsening with a large increase in dyspnea, hypoxia and worsening of the alveolar-arterial gradient.
Given the clinical situation it was decided to perform a bilateral bronchoalveolar lavage.
Before orotracheal intubation, the patient was sedated with propofol, analgesia was provided with fentanyl and sedation with succiniline.
Intubation was performed with left Mallinckrodt 39F double-lumen tube.
We tested the location of the tube by means of pediatric fibrobronchoscopy.
Subsequently, the patient was kept sedated and sedated with continuous infusion of propofol and cisatracurium.
The patient was initially ventilated for 30 minutes under control pressure, with an inspired oxygen fraction (FiO2) of 100%, positive end-tidal pressure (PEEP) of 6 cm H2O, maximum pressure of 12.
The patient underwent tidal volumes of 800 ml (volume/minute 10 lpm) and voiding 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), because we decided to start washing the left lung with the worst compliance (the patient).
Washing was performed with isotonic saline solution heated to 37o C. A liter was infused from a height of 30 cm on the patient and drained by gravity.
The same operation was performed until the lavage fluid was cleared.
Thirteen units were needed in this first phase.
To achieve a better result and drainage thoracic percussion was performed on the washed lung.
After washing in the supine position, we observed an improvement in 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 supine position, being necessary in this case 15 saline solution at 37oC to obtain a clear drainage.
The total washout time of the left lung was 2 hours and 45 minutes.
After cleaning the left lung, both lungs were monitored under pressure mode 100% FiO2, PEEP 10 cm H2O and peak pressure 35 cm H2O for 45 minutes.
The static compliance measured was 39 ml/cm H2O and oxygen saturation was 96%.
We decided to wash the left lung alone so we could tolerate the right lung.
The patient was well tolerated with oxygen saturation of 96%.
We decided to start washing the right lung starting in prone position.
Drainage began to be cleared with 20 saline solution within one hour and 35 minutes.
We changed it to supine position, requiring only 4 minutes in this position until clear drainage was achieved.
After 30 minutes of mechanical ventilation, static compliance of both lungs was 64 ml/cm H2O and oxygen saturation was 98%.
Finally, we changed the double-lumen tube to a standard number 8 and began to disconnect the patient.
The patient was extubated two hours after completion of lavage.
The control chest X-ray showed a fine bilateral interstitial pattern.
When the patient was discharged from the intensive care unit, the PaO2/FiO2 ratio was 453.8 (193.8 at admission).
Sequential lavage had to be repeated twice during the following year due to worsening of the disease with good tolerance.
