Anesthetic Management of Pulmonary Lavage in Adults

8/10/2019 Anesthetic Management of Pulmonary Lavage in Adults

1/8

Anesth Analg

56:

61-668,1977

661

nesthetic Management of Pulmonary Lavage in dults

MAURICE LIPPMANN, MD*

MARTIN

S.

MOK, MDt

Torrance, Cal i fo rn ia

A 6-yea r exper ience in the an es the t i c manage-

me nt of 34 successful whole- lung lavages

on

11

adul t pat ients wi th pulmonary a lveolar prote in-

osis i s descr ibed. Al l pat ients were radio-

graphically physiological ly a nd sym ptom at ical -

ly improved a f t e r th e p rocedures .

The anwthe t i c p ro toco l fo r lung l avage in -

cludes: 1) uni la tera l whole- lung lavages

2 to 4

d a y s a p a r t ; 2) general a n e s t h e s i a w i t h t h e

placement

of

a Car lens tube ;

(3)

isotonic

sa-

l ine

as

the l avage so lu t ion ; (4) mechanical

ches t pe rcussion dur ing l avage ; 5) s e r i a l a r t e -

N PULMONARY alveolar proteinosis, an

I

amorphous lipoproteinaceous material

fills the acini of the lungs, resulting in hy-

poxemia which becomes more marked with

exercise.1 This disorder was first described

by Rosen and coworkers2 in 1959, but its

etiology is still unknown.

Th e disease is usually manifested by dysp

nea, cough (with 'or without much sputum

production), weight loss, easy fatigability,

and cyanosis due to progressive hypoxia.

The diagnosis

is

established by open-lung

biopsy or autopsy. In some patients,

im-

provement

is

spontaneous, but in many,

death occurs from hypoxia or complicating

disease, especially superimposed infections.3

Ramirez and associates4 first

used

repeated

washings of segments of the lung by means

of an indwelling catheter passed into the

trachea via a subglottic approach. Subse-

quently, they lavaged one whole lung at a

time.5

r i a l b lood-gas de te rmina t ion and measuremen t

o f lung compl iance in th e in t r aope ra t ive and

immediate post lav age period.

The au thors conc lude tha t who le - lung l avage

i s

a

safe and effect ive pal l ia t ive procedure

in

pulmonary a lveolar prote inosis and

in the

t r e a t -

men t of pat ients wi th pulmonary disease such

a s cyst ic f ibrosis

or

asthm a in which f i ll ing of

the lung acini by l iquid or sol id mater ia l im-

pa i r s oxygena t ion of th e pulmonary capi l lary

blood.

The major benefit

of

lavage lies in the

niechanical removal of inspissated material

from the finer branches of the tracheobron-

chid tree. It is unlikely that there is any

basic alteration

of

the underlying disease

process. Nevertheless, when employed judi-

ciously, this technic provides relief for the

patient with severe hypoxia, especially after

conventional respiratory therapy has proved

unsuccessful.

In our institution, from March 1970 to

March 1976, 34 pulmonary lavage proce-

dures were performed on 11 adult patients,

as

described following.

METHODS AND PROCEDURES

Since patients are usually pulmonary

cripples when scheduled

to

undergo pulmo-

nary lavage, preoperative laboratory stud-

ies should include CBC, urinalysis, ECG,

blood-chemistry panel, chest x-ray, pulmo-

nary function tests, and arterial blood gases.

*Associate Professor and Chief, Division

of

Cardiovascular Anesthesia.

?Assistant Professor and

Staff

Physician.

$Department of Anesthesiology, UCLA School of Medicine, Harbor General Hospital Campus, Torrance,

California 90509.

Paper received: September 29, 1976

Accepted

for

publication: February 3,1977


2/8

662

In this group of patients, the Hct and Hb

are usually elevated due to chronic hypoxia

(HB 15 to 18 gm , Hct 45 to 55%).

Usually, electrolyte,

BUN,

and creatinine

are normal unless the patient has associated

renal disease; plasma proteins are within

normal limits; and albumin content exceeds

globulin content. The

ECG

sometimes shows

cor pulmonale changes. Chest x-ray reveals

bilateral diffuse infiltrates. Pulmonary func-

tion tests sometimes show restrictive lung

changes. More significant

is

the impaired

diffusing-capacity measurement. Arterial

blood-gas studies show moderate to severe

hypoxemia with hypocarbia.

Since most of the patients are well-moti-

vated to undertake the lavage procedure to

relieve their respiratory distress, light pre-

medication is needed. Usually a combina-

tion of

a

sedative (diazepam or

a

phenothi-

azine) and

a

small dose of belladonna alka-

loid (atropine

0.4

mg or scopolamine 0.3

mg) will suffice. The use of belladonna

drugs appears not to adversely affect the

clearing of the inspissated secretions. In

fact, the drug may help dilate the bronchial

tree.

The patient is induced with IV thiopen-

tal,

3

to

4

mg/kg, and insertion of a Carlens

tube

is

facilitated by the administration

of

siiccinylcholine 1 to 2 mg/kg) or pan-

curonium bromide (0.08 mg/kg) Before

intubation, the trachea is anesthetized with

a topical application of 4 ml of a

4

percent

lidocaine solution. This helps to decrease

the stimulation of the patients trachea

caused by the insertion of the large tube.

Anesthesia is maintained with 1 o 2 percent

halothane or enflurane and 02 o minimize

the

risk of hypoxemia, we did not use N20

in the anesthetic mixture.

An indwelling arterial catheter is inserted

for serial blood-gas determinations, which

are performed before the beginning of the

lavage procedure; a t the end of the filling

phase; the end of the drainage phase; and

before removal of the Carlens tube a t the

end of the procedure. The patient is kept

paralyzed by incremental doses of pancu-

ronium bromide (0.5 to 1mg) when needed,

so that ventilation can be controlled through-

out the procedure.

Complete separation of both lungs

can

be

ascertained by repeated auscultation during

alternate occlusion of each lung. It is also

tested by holding a filament of cotton over

the open proximal end of the channel lead-

RESERVOIR

- - 0

rn ABOVE

MID

CHEST

FIG .

Schematic showing Carlens

tube in

trachea

astride carina

of

patient.

ing to one lung while the contralateral lung

is maintained in a hyperinflated

state

with

35 to

40

cm H 2 0 pressure. Flutter of the

cotton filament signifies a leak of air from

the hyperinflated lung.

Complete isolation of the lungs from each

other is essential

so

that the lavage solution

will enter only one lung while ventilation

is maintained in the other (fig 1). After

good separation

is

assured, compliance of

each lung separately and both lungs

to-

gether

is

measured by an in-circuit Wright

respirometer and an air-pressure gauge at

the inspiratmy limb.

Using an Air Shields

Volume Respirator, we determine compli-

ance by measuring the pressure with a pre-

set volume during the course of ventilation

before and after the lavage procedure.

Ventilation

is

controlled with

99

percent

0, for 15 minutes, to ensure maximal tissue

FIG2.

Schematic showing left lung being filled

with lavage fluid.


3/8

Pulmonary Lavage . Lippmann and

Mok

663

oxygenation and washout of lung

N,.

Then

N saline solution, warmed to

37

C is at-

tached to the Carlens tube to the lung to

be lavaged (fig 2 ) . As 0, absorption takes

place, the saline flows

into

the lung. This

degassing process takes approximately 5

minutes. The patients degassed lung

is

then

filled with the saline to a height of

30

cm

above midchest level. When no more fluid

flows into the lung at 30 cm saline pressure

(usually 1200 to 1800 ml saline), the inlet

tubing

is

clamped off and the fluid-filled

lung is allowed to drain by gravity to 25

c m

below the patients midchest level, until the

amount of saline instilled is retrieved with

no more than

100

ml remaining in the lung.

The lung is again filled with a fresh solu-

tion to 30 cm pressure and similarly drained.

The lavaged lung is percussed mechanically

during the final 2/3 of filling and the initial

2/3 of lung drainage. The area of the chest

overlying the lung being percussed is pro-

tected by a layer

of

moleskin. Percussion

considerably enhances removal of the insol-

uble; material in the lung acini. The lavage

effluent is characteristically turbid, and a

progressive decrease in turbidity becomes

apparent with increasing lavages. When the

insoluble sediment in the effluent becomes

sparse, the procedure is completed.

Upon completion of the procedure, metic-

ulous endotracheal suction is taken to opti-

mally clear the tracheobronchial tree of

saline. Compliance

is

again measured, as

previously described. High-volume ventila-

tion is repeatedly given the lavaged lung,

and suctioning is repeated until compliance

of the lavaged lung a t least equals that

of

the gas exchanged lung. The patients neu-

romuscular blockade is reversed by

I V

atropine and neostigmine, as guided by a

blockade monitor. The Carlens tube

is

then

removed in the operating room when the

patient

is

generating adequate tidal and

minute ventilation volumes, as measured by

the Wright respirometer. Chest x-rays are

then taken. The patient remains supine

throughout the entire procedure.

Patient data are summarized in table

1.

CASE REPORT

In

1 9 7 5 ,

a 30-year-old man first developed

frequent afebrile cold symptoms, with

dyspnea on exertion and a cough, produc-

tive of small amounts of yellowish, thick

sputum,

which

persisted over the next sev-

eral months. His dyspnea became progres-

TABLE 1

Summary

of

Patient Data

Age: Youngest 20 years

Oldest 44 years

Average 31 years

Ma1e:female ratio:

1O:l

A n e s th e t ic a g e n t s N u m b e r o f l a v a g e s

Halothane 17

En flurane 16

Methoxyflurane 1

N u m b e r cf

Muscle

r e l a x a n t l a v a g e s R a n g e A v e r a g e

Succinylcholine 5 400-2300 mg

1100

mg

d-Tubocurarine 5 24-54 m g 36.5 mg

Gallamine

3 1 0 0 -4 5 0 mg

270mg

Pancuronium

bromide 21 7-15 mg 10.6 mg

Hematocrit: Range 36-54

Average 46.5

Surgical time:

Anesthesia time:

Range 100-235 min

Average 178 min

Range 135-325 min

Average 236 min

sively worse and he was unable to work as

a construction worker. An open-lung biopsy

in August 1 9 7 5 confirmed the diagnosis of

pulmonary alveolar proteinosis.

The patient was admitted to our hospital

on January 13 , 1976, for pulmonary lavage.

On admission, his vital signs were

BP

125/

8 0 , P

86, R 20. His height was 185 cm and

weight

80

kg, with calculated body surface

area of 2.05 m2. Chest x-ray showed bilateral

diffuse infiltrates

(fig 3). Pulmonary func-

tion tests before and after the lavage proce-

dure are shown in table

2.

On January

19 ,

the patient underwent a

left lung lavage with no complications. Post-

lavage chest x-ray is shown in figure 4

On January 23, the patient underwent a

right lung lavage, tolerating the procedure

well. Summary of the anesthetic course,

pulmonary compliance studies, and intra-

operative blood gas studies are shown in

table 3.

The patient was treated with intermittent

positive pressure breathing and pulmonary

toiletry after each lavage. Following pulrno-

nary lavage, he was markedly relieved of his


4/8

66

FIG .

Chest x-ray taken

before

lung lavage.

TABLE 2

Pulmon ary Function Change

in

Patient w ith

PAP

Before and After

Pu mona

ry

Lavage

Test

Predicted

1/15/76. /22/76? 1/26/76

~

~ ~~ ~

Mechanics

Vital capacity, ml

FEVJVC

Maximal expiratory

flow, L/min

Maximal breathing capacity, L/min

Distribution

Single breath

O2

7

minute N washout

Diffusion

C O diffusing capacity, ml/min/mm Hg

DL/VA

Blood gases (room air)

Pa , torr

Pam2, orr

Bicarbonate, mM

Alveolar-arterial

0

gradient, torr

PH

5416

72

300

187

2

2

34.5

6.37

9 5

38-42

7.38-7.42

2 4

2 0

5221

74

640

149

2.5

1.3

18.9

3.76

60

35

22.5

7.43

5336

75

698

157

2.25

0.8

25.8

5.32

5420

75

6 4 0

189

2.1

0.9

27.3

5.61

89

40

7.40

24.5

*Four

days before left lung lavage.

?Approximately

72

hours after left pulmonary lavage.

SApproximately

72

hours after right pulmonary lavage.


5/8

Pulmonary Lavage

. .

Lippmann and

Mok

665

FIG

. Chest x-ray taken

24

hours after left lung lavage (same patient as fig

3) .

symptoms of dyspnea and his exercise toler-

ance was markedly improved. Chest x-ray

taken

72

hours after both lung lavages

is

shown in figure 5.

The patient was discharged

on

the 6th

postoperative day after right lung lavage.

Follow-up on April 21, 1976, showed that

the patient was symptom free. He has re-

turned to work.

DISCUSSION

As pulmonary lavage represents a physi-

ologic trespass, or an intentional drown-

ing, particular attention must

be

paid to

potentially serious complications such as

severe hypoxemia. Reduction of complica-

tions

can

be achieved by an understanding

of the physiologic derangements involved in

this procedure.

Pulmonary lavage has been shown to

produce:

1.

An increase in intrathoracic and intra-

vascular pressure. Smiths group showed

in man that there

is a

rise

in central venous

pressure (CVP) when the lung is filled with

a large volume of liquid and a fall in CVP

when the lung was drained after each lavage

cycle. They also showed

that,

in anesthe-

tized dogs and calves undergoing pulmonary

lavage, there is a marked increase in left

ventricular end diastolic pressure (LVEDP)

pulmonary artery pressure, pulmonary cap-

illary wedge pressure, and intraesophageal

pressure following instillation

of

liquids into

one lung. When the lung was drained, these

pressures returned toward control values. It

must be noted that the increase in LVEDP

is a reflection of the transmitted pressure

and not an indication of left ventricular

failure.

2. An acute shift

of

mediastinal struc-

tures away from the liquid-filled lung. Ra-

diography of the animal chest with the lung

filled with liquid demonstrated the medi-

astinum acutely shifting away from the

liquid-filled lung and returning to the nor-

mal position once the lung was drained.

During the degassing phase, the mediasti-

num shifted toward the atelectatic side.7

3. Severe hypoxia, as manifested by clin-

ical signs as well as blood-gas studies. This

can occur due to marked intrapulmonary

shunting when the lavaged lung is drained

of the lavage solution and may necessitate

discontinuing lavage. Wasserman and co-

workers8 showed that when the lung is filled

with solution to a pressure of 25 cm of

saline, the blood is shunted away from the


6/8

TABLE

3

Patients Right Lung Lavage-1

/23/76*

Premedication:

Morphine sulfate 10 mg, diazepam 10 mg

Atropine 0.5 mg

Pancuronium bromide 15 mg

Enflurane-0%

Anesthetic: Thiopental

300 m g

Duration of anesthesia: 280 minutes

Type of

tube:

Carlens 39

Number

of

lavage: 10; total volume 22.1 L

solution N saline

lnt raop erative Compliance

Before lav age After lav age

1275

m l

Bilateral 23 cm 55 rnl/cm

H I 0

1450

ml

Bilateral 25 cm 58 ml/cm

H O

1050 ml 1125 ml

1100

ml

1200

ml

Right

30 cm 35

ml/cm H O Right 31 cm 36 ml/cm H O

Left

30 cm 37

ml/cm HIO Left 29 cm

41

ml/cm H20

lnt raop erative Blood-Gases

FIO?9%

Baseline value before lavage: Paol

320,PacoI 24, pH,, 7.50,

A B

18

End

of

filling

phase: Paoe

410,

Paco?

23.5,

pH,

7.48,

AB

17

End

of

draining phase: Paor

58,

Paco2

22.5, pH,

7.69, A B

17

End of lavage

procedure:

Pao?310, Pacol 32, pH:, 7.46,

AB

20

Same patient

as

in

table

2.

lung. Calculation of venous admixture indi-

cated tha t only to

13

percent of the car-

diac output could be perfusing the lavaged

lung

at

the time of maximal filling with

lavage fluid. However, when the alveolar

pressure of the lavaged lung was decreased

to -20

cm

of water during the emptying

phase, the venous admixture increased to

30

to 52 percent of the cardiac output.H This

often results in a marked decrease in the

Pao,, as shown in table 3 of

our

case report.

The amount of venous admixture during

the drainage phase increased as the lavage

progressed. This marked right-to-left shunt

can result in severe hypoxia, and necessi-

tated discontinuance of the lavage proce-

dure in one patient in

our

series.

Our experience emphasizes several addi-

tional points:

1. Complete separation of both lungs is

absolutely necessary. Isolation of each lung

must be watertight before starting lavage.

2. A Carlens tube works best. Satisfac-

tory separation of both lungs could not be

obtained with

a

White tube.

3.

A s

much lavage fluid as possible should

be recovered. Compliance is decreased right

after lavage. Extubation should never be

hastened, and ventilation is necessary until

compliance of both lungs is essentially equal,

with satisfactory arterial blood-gas tensions.

This takes approximately one hour from the

termination of the last lavage.

4. Although pulmonary lavage under topi-

cal anesthetic was initially reported by

Smith and by Ramirez,z we used general

anesthesia to avoid subjecting a conscious,

seriously ill patient to the stress and dis-

comfort of pulmonary lavage. Coughing,

bucking, and breath-holding can be mini-


7/8

Pulmonary Lavage Lippmann and Mok

667

FIG

. Chest x-ray taken 72 hours after both lung lavage procedures (same patient s fig 3).

mized, while more effective ventilation con-

trol is achieved with general anesthesia and

skeletal muscle paralysis.

5.

Electrolytes change, and hemodilution

occurs but is transient and not clinically

significant, since most of the lavage solution

is

retrieved,

as

reported by Wassermans and

confirmed by our serial determinations.

6.

After using the Ramirezs formula-N

saline containing 10 gm of acetylcysteine

and 7500

U

of heparin/G-for lavage, we

changed to plain

N

saline. No reduction

was detected in the effect of the lavage by

the omission of acetylcysteine and hepa-

rin.9

10

Of

the 34 lavages described, 17 were per-

formed under halothane-0, anesthesia, 16

under enflurane-O,, and only one with meth-

oxyflurane-Of,. We believe that halothane

and enflurane are equally useful in this type

of procedure, but that methoxyflurane is not

suitable because of its renal toxicity on such

prolonged exposures, the average anesthesia

time for this procedure being 236 minutes

(table 1 ) .

We used

4

different muscle relaxants in

our series of patients (table 1 ) . Pancuroni-

urn w a s

found best because of its minimal

cardiovascular effects and lack of histamine

release, thus avoiding the possibility of

bronchospasm.

CONCLUSIONS

We conclude that judicious use of lung

lavage is safe and effective for patients with

pulmonary alveolar proteinosis and those

with pulmonary disease, such as cystic

fi-

brosis or asthma, in which filling of the

lung acini by liquid or solid material im-

pairs oxygenation of the pulmonary capil-

lary blood.

A C KN OW L E D GME N T

The authors wish to thank John R.

Benfield, MD, Chief of Thoracic and Pul-

monary Surgery, for his kind assistance in

reviewing the manuscript and for his aid

during the lavage procedures.

REFERENCES

1. Rupp

GH,

Wasserman

K .

Ogawa M. et al:

Rronchopulmonary fluid in pulmonary alveolar

proteinosis. Allergy Clin Immunol

51

:227-237,

1973

2

Rosen SH, Castleman B, Liebow AA:

Pul-

monary alveolar proteinosis.

N

Engl

J

Med 258:

1123-1142, 1959

3. Bala RM, Snidal DP: Pulmonary alveolar

proteinosis: a case report and review of the litera-

ture. Dis Chest 49:643-651, 1966


8/8

4. Ramirez RJ, Nyka W, McLaughlin J: Pul-

monary alveolar proteinosis. N Engl J Med 268:

165-171, 963

5. Ramirez RJ, Kieffer RF, Ball WC: Broncho-

pulmonary lavage in man. Ann Intern Med 63:819-

828, 1965

6.

Wasserman K: Pulmonary alveolar pro-

teinosis. West J Med

1:59-60, 976

7.

Smith

J,

Millen J, Safar P, et al: Intra-

thoracic pressure, pulmonary vascular pressure,

and gas exchange during pulmonary lavage. Anes-

thesiology

33: 01-405, 970

8.

Wasserman K, Blank

N,

Fletcher G: Lung

lavage (alveolar washing) in alveolar proteinosis.

Am J Med

44:611-617, 1968

9.

Wasserman K: Solutions used for lune lavaee

in alveolar proteinosis. J Wadsworth Ge; Hoip

217-222, 1968

10.

Kao D, Wasserman

K,

Costley D, et al:

Advances

in

the treatment of pulmonary alveolar

proteinosis. Am Rev Respir Dis 111:361-363, 1975

11. Passy V Ermshar C, Brothers M: Broncho-

pulmonary lavage to remove pulmonary casts and

plugs. Arch Otolaryngol

102:193-197, 976

ELECTROENTEROGRAPH Y AF TE R CHOLECY STECTOMY. The electrical activity

of the stomach and intestine was monitored during the postoperative period in

30

patients

who underwent cholecystectomy. In all patie nts endotracheal intubation aft er thiopen tal

and succinylcholine was followed by

60

t o 65 percent NO

in

O,, pancuronium, and

mechanical ventilation. Some received high epidural analgesia (inse rted

T7-8)

during

surgery and postoperatively, and others, fentany l analgesia dur ing surg ery and nico-

morphine afterward. Electroenterography (EEnG) showed that electrical activity de-

creased following sur gery and retu rned to base line on the 3rd or 4th day after operation.

A marked increase in amplitude and frequency of EEnG oscillations was recorded in

80

percent

of

patients who received epidurals

(6

to 10 ml

0.25

percent bupivacaine).

A

decrease was almost always recorded af te r nicomorphine injections. During the post-

operative period, eating caused

a

considerable increase in t he amplitude and frequency

of the electrical activity of the stomach and intestine in patients treated by epidural

analgesia, whereas no observable change was recorded in pati ents treated by nicomorphine

injections. I t appears th at high epidural analgesia may be useful in the trea tme nt of

postoperative adynamic ileus.

G e l m a n

S,

Feigenberg 2 i n t zm an M , et al : Electro-

enterog raph y a f t er cholecyst ec tomy: T he ro le of high epidural analges ia . Arch Surg

112:580-583

977)

Documents

Anesthetic Management of Pulmonary Lavage in Adults