Eur J Cardiothorac Surg 2004;26:1050-1051
© 2004 Elsevier Science NL
Use of extracorporeal membrane oxygenation (ECMO) during whole lung lavage in pulmonary alveolar proteinosis associated with lung cancer
Kyung-Hwan Kim*,
Jin Hyun Kim,
Young Whan Kim
Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, South Korea
Received 10 May 2004;
received in revised form 19 July 2004;
accepted 10 August 2004.
* Corresponding author. Tel.: +82 2 760 3971; fax: +82 2 764 3664. (E-mail: kkh726{at}snu.ac.kr).
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Abstract
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We describe a case of pulmonary alveolar proteinosis in a male adult with lung cancer. To achieve the successful operation of lung cancer, we used percutaneous veno-venous extracorporeal membrane oxygenation (ECMO) during whole lung lavage (WLL) of the contralateral lung. We performed successful WLL under ECMO support.
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1. Introduction
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Pulmonary alveolar proteinosis (PAP) is a rare disease, and involves the deposition of insoluble proteinaceous material in the alveoli of the lungs [1]. Usually, patients present mild dyspnea and hypoxia. Derangement of the surfactant mechanism is a possible cause. We experienced a patient with PAP and lung cancer. To achieve the successful operation of one lung, we used percutaneous veno-venous extracorporeal membrane oxygenation (ECMO) during whole lung lavage (WLL) of the contralateral lung [2,3].
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2. Patient, diagnosis and treatment
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A 59-year-old man visited a hospital 1 month ago for intermittent cough, febrile sense and dyspnea. Chest radiography and computed tomography revealed hazy infiltration (crazy-paving appearance) in both lung parenchymae (Fig. 1), and left lower lobar mass. Bronchoalveolar lavage (BAL) was done and a periodic acid-Schiff (PAS)-positive lipid and proteinrich granular material were detected. Squamous cell carcinoma in left lower lobe was diagnosed by bronchoscopic biopsy and preoperative stage was T2NoMo. He was transferred to our hospital for further evaluation and work up. For the successful resection of lung cancer, BAL was necessary to treat PAP.
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Fig. 1. Preoperative chest computed tomography shows pulmonary alveolar proteinosis in whole lung field.
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PaO2 in room air was 52.5mmHg. Initially, BAL was performed on the left lung without any reduction in arterial oxygen saturation. For the second BAL of right lung, we anticipated hypoxia because his left lower lobar bronchus was totally obstructed. Five days after the initial BAL, we performed the second and as we anticipated, he could not tolerate right lung collapse during double lumen endotracheal anesthesia. Oxygenation was poor (PaO2 of 50mmHg), and we prepared a venovenous ECMO circuit, and a pulmonologist started right WLL with isotonic saline solution. Arterial oxygen saturation decreased by around 85%, and we started ECMO support. Venovenous cannulation was performed using the right and left femoral veins. A 21 Fr percutaneous venous cannula (Medtronic® Inc., Minneapolis, MN, USA) was inserted into the right femoral vein for outflow, and a 17 Fr percutaneous venous cannula (Medtronic® Inc., Minneapolis, MN, USA) was inserted into the left femoral vein. The inflow cannula was positioned more adjacent to the right atrium than the outflow cannula for satisfactory mixing of the oxygenated blood. 5000IU heparin was used prior to cannulation and ACT was maintained at around 250s. We used a centrifugal pump with an oxygenator and reservoir. Flow rate was maintained between 0.8 and 3.5l/min. We achieved an arterial oxygen saturation of 95–100% under 0.7–1.0 of FiO2. WLL was performed smoothly using 20l of isotonic saline. During lavage, vigorous chest percussion was done. The total pump time was 105min. The patient recovered without problems. Chest radiography (Fig. 2) showed a normal finding in both lung parenchyme except for the known lung cancer. Left lower lobectomy was done and final stage was T2N1Mo.
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3. Discussion
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In this report, we described a PAP patient with lung cancer. Generally, patients have mild hypoxia and rarely, they present with a severe respiratory difficulty. Our patient had a tolerable general condition. If he did not have lung cancer with total bronchial obstruction, BAL could be performed without the aid of ECMO. In patients with PAP and unilateral or bilateral obstructive lung lesion, we recommend ECMO preparation for hypoxia during the procedure.
In the adult population, we found only six reported cases of ECMO in PAP [2–7]. In five out of these reports [2–6], only one lung was lavaged using the BAL procedure. Four cases [2–4,7] used venovenous cannulation and two cases [5,6] used venoarterial cannulation. We used venovenous ECMO and both femoral veins were used for percutaneous cannulation. The inflow cannula was positioned adjacent to the right atrium so that oxygenated blood could reach the right atrium more easily. If the two cannulae were placed at the same level, they could compete and jeopardize satifactory oxygenation.
ECMO support allowed us to perform BAL without refractory hypoxia. We were able to maintain arterial oxygenation to more than 95%. Patient underwent left lower lobectomy without life threatening hypoxia. Lung cancer resection was done successfully after the successful BAL with ECMO support. We recommend that even if a patient has mild hypoxia, ECMO support should be borne in mind.
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4. Conclusion
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We performed successful WLL in a case of PAP associated with lung cancer under ECMO support.
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References
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- Rosen SH, Castleman B, Liebow AA. Pulmonary alveolar proteinosis. N Engl J Med 1958;258:1123-1142.
- Cooper JD, Duffin J, Glynn MF, Nelems JM, Teasdale S, Scott AA, Martin B. Combination of membrane oxygenator support and pulmonary lavage for acute respiratory failure. J Thorac Cardiovasc Surg 1976;71(2):304-308.[Abstract]
- Sivitanidis E, Tosson R, Wiebalck A, Laczkovics A. Combination of extracorporeal membrane oxygenation (ECMO) and pulmonary lavage in a patient with pulmonary alveoloar proteinosis. Eur J Cardiothorac Surg 1999;15:370-372.[Abstract/Free Full Text]
- Zapol WM, Wilson R, Hales C, Fish D, Castorena G, Hilgenberg A, Quinn D, Kradin R. Venovenous bypass with a membrane lung to support bilateral lung lavage for acute respiratory failure. J Thorac Cardiovasc Surg 1976;71:304-308.
- Altose MD, Hicks RE, Edwards Jr MW. Extracorporeal membrane oxygenation during bronchopulmonary lavage. Arch Surg 1976;111:1148-1153.[Abstract/Free Full Text]
- Freedman AP, Pelias A, Johnston RF, Goel IP, Hakki HI, Oslick T, Shinnick JP. Alveolar proteinosis lung lavage using partial cardiopulmonary bypass. Thorax 1981;36:543-545.[Abstract/Free Full Text]
- Cohen ES, Elpern E, Silver MR. Pulmonary alveolar proteinosis causing severe hypoxemic respiratory failure treated with sequential whole-lung lavage utilizing venovenous extracorporeal membrane oxygenation. Chest 2001;120:1024-1026.[Abstract/Free Full Text]
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Abstract
1. Introduction
