Anaesthesia for serial whole-lung lavage in a patient with severe pulmonary alveolar proteinosis: a case report

A 34-year-old Caucasian man was diagnosed with severe pulmonary alveolar proteinosis. He developed severe respiratory failure and subsequently underwent serial whole-lung lavage. Our anaesthetic technique included the use of pre-oxygenation, complete lung separation with a left-sided double-lumen endotracheal tube, one-lung ventilation with positive end-expiratory pressure, appropriate ventilatory monitoring, cautious use of positional manoeuvres and single-lumen endotracheal tube exchange for short-term postoperative ventilation.Patients with pulmonary alveolar proteinosis may present with severe respiratory failure and require urgent whole-lung lavage. We have described a safe and effective strategy for anaesthesia for whole-lung lavage. We recommend our anaesthetic technique for patients undergoing this complex and uncommon procedure.Pulmonary alveolar proteinosis (PAP) is a rare disorder characterised by the intra-alveolar accumulation of lipoproteinaceous material that is now thought to be surfactant [1]. The mainstay of treatment is whole-lung lavage (WLL), and we would like to present a case of this disease to illustrate a safe anaesthetic technique to facilitate this procedure.A 34-year-old Caucasian man presented to a hospital in the UK with a 1-month history of progressive exertional dyspnoea and non-productive cough. He was a current cigarette smoker but had no other medical problems. He was found to be severely hypoxaemic while breathing room air at rest (arterial haemoglobin oxygen saturation, SaO2 87%; arterial partial pressure of oxygen, PaO2 5.4 kPa) and chest X-ray showed bilateral patchy air-space infiltration. Pulmonary function testing demonstrated a restrictive ventilatory defect (forced expiratory volume in 1 s, FEV1 2.4 L; forced vital capacity, FVC 2.5 L; FEV1/FVC 43%) and impaired diffusion capacity (carbon monoxide diffusion capacity 45% of predicted value). Thoracic computed tomography indicated that the right lung was more severely diseas