Definition & Overview

Total lung lavage (TLL) is the first line of treatment for pulmonary alveolar proteinosis (PAP). PAP is a rare condition marked by severe breathing difficulty or breathlessness due to the accumulation of amorphous lipoproteinaceous materials in the lung’s alveoli. These kinds of proteins are surfactant, which means that they have low surface tension making them hard to release from the lungs through natural expulsion such as coughing.

The alveoli are small sacs within the lungs where oxygen and carbon dioxide move between the lungs and the bloodstream. For some reasons, these sacs sometimes get filled with amorphous lipoproteinaceous materials making it difficult for the patient to breathe normally. The condition can be caused by an autoimmune disorder, lung infection, cancers of the blood system, or exposure to high levels of certain substances, such as aluminum dust or silica.

Total lung lavage is performed to wash out all the materials that clog the alveoli to provide symptoms relief and restore normal breathing in patients.

TLL requires general anaesthesia. Each lung is isolated using a double-lumen endotracheal tube and treated one at a time. This means that while one lung is artificially ventilated, the other lung receives large-volume lavages or washing. This technique ensures that the patient receives adequate oxygen in the body while the procedure is being performed.

Who Should Undergo and Expected Results?

Total lung lavage has a limited scope of use and is usually restricted to treating pulmonary alveolar proteinosis. Patients with this condition experience breathing difficulties because their alveoli are plugged. This means that the transfer of oxygen from the lungs to the blood is severely impaired. Other symptoms of the condition include low-grade fever, weight loss, and fatigue.

PAP is diagnosed through a chest x-ray and pulmonary function tests, which allow doctors to measure the volume of air that the patient’s lungs can hold while doing certain exercises and while resting. To make a definitive diagnosis, bronchoscopy can also be performed. This allows doctors to obtain samples of fluid from the alveoli and perform a biopsy.

The procedure has been found to be safe and extremely effective. The majority of patients around the globe reported almost 100% improvement in their overall lung health following the procedure. However, although the procedure is effective, it does not guarantee against recurrences.

How is the Procedure Performed?

Total lung lavage is not automatically recommended for people suffering from PAP. Those with few or no symptoms typically do not require treatment. However, those with disabling symptoms are advised to consult their doctor and undergo diagnostic procedures to determine the extent of the condition and the appropriate treatment plan.

It is important to note that only certain dedicated hospitals with trained medical practitioners in total lung lavage are able to conduct such a medical procedure. Because of this, many patients had to travel long distance in order to find medical practitioners who are skilled and trained to conduct TLL.

For the procedure, the patient is first administered with general anaesthesia. TLL is first carried out in the left lung while the right lung is ventilated using a double lumen endotracheal tube.

Careful cardiopulmonary monitoring is done to make sure that the patient is ventilated well while the procedure is ongoing. This is very important because the failure of the right lung to supply the body with enough oxygen while the procedure is ongoing would slow down the entire process.

The treated lung is first filled with 400ml of saline solution. A second set of 500ml-600ml warmed solution will then fill the lungs and ultimately drained. During this process, the same amount of water volume should be drained to ensure that the lungs are totally free from any foreign substances and to ensure the success of the entire process.

The initial quality of the liquid in the first drain would be unclear or milky in colour. The process is repeated until the liquid waste is clear. It usually takes 12 to 13 litres of saline water to achieve such. The procedure is then repeated on the left lung.

Possible Risks and Complications

Various case reports show that total lung lavage is extremely efficient. Most patients who underwent the procedure exhibited excellent health during a 7-year follow-up period.

However, despite its success, there are few risk and complications associated with the procedure. These include the following:

  • Intraoperative refractoriness, or the insensitivity of lung tissues during the procedure
  • Hypoxemia, or abnormally low concentration of oxygen in the blood
  • Pneumothorax, a situation where the lung would totally collapse
  • Hydropneumothorax, or the presence of air and liquid in the pleural cavity. This can be avoided if practitioners are able to successfully drain the same amount of saline solution injected into the lungs.
  • Higher arterial oxygen tension and hypotension, which are associated with high blood pressure and low blood pressure, respectively

    References:

  • US National Library of Medicine National Institutes of Health; “Whole-lung lavage for pulmonary alveolar proteinosis”; http://www.ncbi.nlm.nih.gov/pubmed/19995769

  • Departments of Pulmonary Medicine and Anesthesia, Amrita Institute of Medical Sciences, Kochi; “Whole Lung Lavage: The Salvage Therapy for Pulmonary Alveolar Proteinosis”; http://medind.nic.in/iae/t07/i1/iaet07i1p41.pdf

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