1. Effect of whole lung lavage on the elimination of CO2 and
dead space in patients with pulmonary alveolar proteinosis
Katayama N., Shono A., Fujihara T., Kakuta N., Saito Y.
Shimane University Faculty of Medicine, Dept of Anaesthesiology, Izumo City, Japan
Background
Results
Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by the progressive accumulation of alveolar surfactant and hypoxemia. Whole lung lavage (WLL) is considered to be a standard therapy to improve oxygenation and quality of life in patients with PAP. Although a large amount of warmed saline is used in WLL, there are no established response criteria to evaluate its therapeutic effect.
Please export the PowerPoint document as a PDF (File – Save as – PDF) and upload the PDF into the system. Please use the font in the document or a similar one and do not use a font size smaller than 16.
Goal of Study
Perioperatively investigate the improvement in efficient alveolar ventilation after WLL by measuring elimination of CO2 and dead space.
VTCO2,br at T2 and T3 increased by 3.7%
and 5.4%, respectively, compared to T1
Cases
2 patients diagnosed with PAP were scheduled for WLL.
Case 1:
62-year-old man with a symptom of dyspnea on exertion.
Hugh-Jones classification 3
Case 2:
48-year-old woman with no symptoms.
Infiltrative shadow in chest X-ray was presented 3 years ago.
Case 1
Case 2
Shunt-related dead space decreased by 20.8% at
T3 (mean ± SD: 0.32 ± 5.4) compared to T1 (mean ± SD:0.40 ± 4.5)
Chest CT in both cases showed a diffuse
crazy paving pattern in the bilateral lung.
Methods
Mean EVLWI increased from 11.2 ml/kg at T1 to 14.1 ml/kg at T3.
Measurements
Evaluation for 4 trials of WLL in 2 patients
✓CO2 elimination per breath (VTCO2, br)
　 Indirect calorimetry (the breath by breath technique)
✓ Shunt-related dead space
　 Enghoff’s modification of Bohr’s dead space formula
✓ Extravascular lung water index (EVLWI)
　 Thermodilution technique (PiCCO)
Volume of saline
Time of WLL(min)
P/F ratio T1 T2 T3
Case 1
Trial 1
6000 ml
211
418
233
307
Trial 2
10600 ml
357
398
177
290
Case 2
3460 ml
239
339
243
347
11150 ml
379
313
180
349
Time points of measurements
　T　
WLL
ICU　　　 T1
Before initiation of WLL T2
end of WLL T3
12 hours after WLL
Discussion
　Increase in VTCO2,br and decrease in shunt-related dead space after WLL indicated that WLL increased efficient ventilation area related to gas exchange by the drainage of accumulated surfactant in alveoli. However, lavage fluid might be partially absorbed into pulmonary interstitium, resulting in an increase in extravascular lung water.
　Responsiveness to WLL is normally subjectively evaluated by clarity of the effluent. However, the improvement of gas exchange can be detected by physiologically monitoring these parameters.
Schema of VTCO2,br and dead space
(according to volumetric capnography)
Enghoff’s modification of Bohr’s
dead space
VTCO2,br
Conclusions
VDEnghoff / VT =
PaCO2
PaCO2 – PĒCO2
Area under the curve
of volumetric capnogram
For the first time, we confirmed the usefulness of using these parameters for the assessment of improved gas exchange by WLL.
1) R. Borie, et al. Pulmonary alveolar proteinosis. Eur Respir Rev 2011;20:98-107
2) Suarez-Sipmann F, et al. Volumetric capnography: the time has come. Curr Opin Crit care 2014;20:
References