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Anesth Analg 2004;99:676-679 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000133243.59867.A1
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Abstract |
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We present a case in which the use of inhaled nitric oxide associated with temporary partial unilateral pulmonary artery occlusion further improved oxygenation during whole-lung lavage. This is the first case in the literature describing the simultaneous use of these two modalities.
IMPLICATIONS: We present a case in which the use of inhaled nitric oxide associated with temporary partial unilateral pulmonary artery occlusion further improved oxygenation during whole-lung lavage. This is the first case in the literature describing the simultaneous use of these two modalities.
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Introduction |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Pulmonary alveolar proteinosis (PAP) is a disorder characterized by alveolar accumulation of lipoprotein material causing dyspnea and hypoxemia. Whole-lung lavage (WLL) is the most effective treatment for PAP (1).
WLL involves multiple instillations of normal saline through a double-lumen tube in one whole lung. During the filling phase, the hydrostatic pressure of the fluid compresses the vasculature in the lavaged nonventilated lung and causes diversion of blood flow to the nonlavaged ventilated lung. During the drainage of the fluid, blood flow increases in the nonventilated lung because its vasculature is no longer compressed (2). With the preexisting lung disease, this may cause a severe decrease in arterial oxygenation.
Many techniques have been used to solve these oxygenation problems (1). Temporary partial pulmonary artery (PA) occlusion with a PA catheter balloon partially inflated (PACi) has been described (3). The use of inhaled nitric oxide (iNO), with or without almitrine (not available in North America) infusion, has also been reported (4).
We present a case in which the use of iNO was associated with PACi for management of hypoxemia during WLL. This is the first case in the literature describing the simultaneous use of these two modalities.
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Case Report |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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A 30-yr-old man (97 kg and 178 cm) with confirmed PAP had had three previous left WLLs. Rightside WLL could never be accomplished because PAP was more severe in the left lung (Fig. 1, A and B) and did not permit left one-lung ventilation (OLV) or right WLL. On admission, his pH was 7.41, PaCO2 was 39 mm Hg, and PaO2 was 74 mm Hg while breathing room air. His computed tomography scan showed bilateral diffuse interstitial infiltrates (Fig. 1C).
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Before proceeding with WLL, we routinely perform a bilateral trial of OLV to verify the capability of each lung to assume OLV. During the three previous WLLs, rightsided WLL had been judged not feasible because of the development of severe hypoxemia (PaO2 48–67 mm Hg and SaO2 <85%) during leftsided OLV. At the beginning of the third WLL, we tried to add iNO into the left lung ventilation but were not successful. To allow right WLL, we planned to try the combination of two known techniques (PACi and iNO) for a left-sided OLV trial.
Anesthesia was induced and maintained with propofol, sufentanil, and pancuronium as required. A 39-mm left-sided double-lumen tube was inserted, and fiberoptic bronchoscopy verified adequate positioning. Complete lung separation and seal was confirmed by a normal pressure-volume loop on the Side Stream Spirometer (5). An abnormal loop is characterized by a gap between the end and starting points, indicating that the exhaled volume is significantly less than the inhaled volume. Ventilator settings were fraction of inspired oxygen, 1.0; tidal volume, 7.5 mL/kg; and respiratory rate, 12 breaths/min. Arterial blood gas (ABG) measurements were obtained before the procedure, while the patient spontaneously breathed room air, before the anesthesia induction. Other measurements were obtained after anesthesia induction and institution of two-lung ventilation. These results are reported in Table 1. The tip of a PA catheter was positioned in the right PA under fluoroscopy. Left OLV was instituted as the right lung was deflated.
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Before initiating the WLL, we desired to verify whether the use of iNO and PACi improved oxygenation. The following sequence was therefore applied: 1) left OLV alone, 2) left OLV with the PAC balloon partially inflated in the right PA with enough air (no more than 1.5 mL) to obtain a damping of PA pressure, 3) left OLV with iNO 40 ppm, and 4) left OLV with PACi plus iNO 40 ppm. Five minutes of equilibration was allowed at each step before ABG measurements were obtained (steps 1–4 in Table 1). Five minutes of washout was allowed between each modality. During the first sequence of WLL, we measured ABG with the lavaged lung filled with fluid (step 5 in Table 1) and after its emptying (step 6 in Table 1). All these ABG measurements were performed during the same left OLV episode and within 60 min.
After the OLV trial period, WLL was performed as previously described (1). The iNO was needed continuously during the procedure to keep SaO2 >90%. PACi was used during more than 50% of the 10 sequences of drainage, prompted in response to severe desaturation (SaO2 <90%). During these episodes of drainage, severe desaturation occurred but was rapidly reversed by PACi. We easily maintained SpO2 >90% with these maneuvers, and the duration of each episode of balloon inflation was 5 to 10 min. The patient remained supine throughout the procedure.
Because of clinical and radiological deterioration (Fig. 1D), a right WLL was repeated 2 yr later. The anesthesia technique and the response to the trial period of left OLV were similar. Inhaled NO was used, but PACi was unnecessary during this WLL. The results of these interventions are reported in Table 1.
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Discussion |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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Since 1990, we have performed 42 WLLs for 16 patients, and in our experience, severe hypoxemia rarely occurs. When it does, however, few therapeutic interventions are available.
Our case showed that iNO and PACi can have an additive effect to increase PaO2. Inhaled NO has been studied extensively for OLV. Most studies have concluded that iNO alone has little or no effect on oxygenation (4,6–8). Most of these studies involved normoxic patients and/or the lateral decubitus position. The hypothesis explaining the inefficacy of iNO in normoxic patients is that iNO could not vasodilate nonconstricted pulmonary vessels (7). Similarly, iNO is less effective in the lateral position because pulmonary vessels in the dependent lung are already dilated to accommodate the increase in blood flow (8). Our patient remained supine and was clearly hypoxemic (PaO2, 54 mm Hg) before the institution of iNO. This may explain the improvement of oxygenation obtained with iNO alone.
Moutafis et al. (4,6) obtained positive results with the concomitant use of iNO and almitrine during thoracoscopic procedures and during WLL. Almitrine decreases perfusion of hypoxic lung areas by enhancing hypoxic pulmonary vasoconstriction (HPV) but is not available in our country. The technique of PACi was first described in humans by Spragg et al. (3). By locating the tip of the PAC in the artery of the hypoxic lavaged lung, blood flow is diverted from the lavaged lung (nonventilated) to the nonlavaged lung (ventilated), thereby improving oxygenation. It can sometimes be difficult to guide the PAC in the left PA, even with the use of fluoroscopy.
The risks and benefits of PAC inflation in a lavaged or atelectatic lung must be considered. First, the risks of arrhythmias and infection would be similar to the other uses of PAC. Second, the possibility of pulmonary infarction is probably less than those associated with PA occlusion pressure measurements. To warrant it, we always retain a slight phasic character on the PAP trace by keeping the balloon only partially inflated to obtain a phasic, but diminished in amplitude, PA pressure trace (9,10). Finally, the balloon is left inflated only for short periods of time.
Pulmonary vascular rupture is also a possibility because of the repetitive inflation and deflation of the balloon. Keeping the balloon deflated during the instillation phase of the lavage fluid, and inflated only during the final part of the drainage phase of the lavage fluid if hypoxemia occurs, may help to diminish the duration of partial inflation of the PAC and, consequently, the risk of PA rupture. The incidence of PA rupture in this context is not known, but it is surely much less than the incidence of hypoxemia during the drainage phase, which happens at each drainage phase in that selected population. It is logical to accept a theoretical infrequent risk of major complication (pulmonary rupture) when confronted with the presence of a potentially serious complication (desaturation). After our experience, we concluded that the PACi technique should be reserved only for the selected cases in which hypoxemia (SpO2 <90%) occurs during OLV trials even with the use of iNO. When such desaturation is present during the trial period of OLV before WLL, it is frequently the precursor of much more desaturation (as low as 80%) during the episodes of filling and drainage.
PACi and iNO act on pulmonary circulation by two different mechanisms for optimizing ventilation-perfusion matching. In our case, they had an additive effect on PaO2. The PaO2 we obtained with the use of PACi and iNO was similar to that measured with the lavaged lung full. It is probably the best ventilation-perfusion match we could obtain in these conditions.
Alternatives to the use of iNO and iPAC are the application of positive end-expiratory pressure (PEEP) in the ventilated lung or positional change. These were not tried because of their potential nonefficacy or nonapplicability during WLL. PEEP applied on the ventilated lung on the decubitus dorsal position will likely augment the shunt through the empty lavaged lung. During WLL, because of the risk for lung spillage from the lavaged lung to the inferior ventilating lung, it is very hazardous to position the patient in the decubitus lateral position with the ventilating lung in the dependent position.
It is possible that the trend toward improved PaO2 values during the trial period of OLV was related to improvement of HPV either over time or with repeated exposures. The description of this response in humans has been reported (11). It was demonstrated that HPV in humans developed progressively over two hours or longer rather than being complete after a few minutes. After the return to normoxia, reexposure to hypoxia resulted in a larger increase in HPV at one hour. Because our ABG measurements had been obtained during a single episode of left OLV and within a 60-minute period, it is improbable that our results were dependent on this HPV mechanism.
In summary, the combination of iNO with PACi can be a useful technique for WLL when significant oxygenation problems occur. Our results also add some knowledge to the pathophysiology of OLV and WLL and to the mechanism of action of iNO and PACi. Further research is needed to verify the safety and the usefulness of these maneuvers for WLL and for other indications of OLV.
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Acknowledgments |
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Supported by the Fond de Recherche d’Anesthésiologie de l’Hôpital Laval.
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References |
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TopAbstractIntroductionCase ReportDiscussionReferences |
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- Bussieres JS. Whole lung lavage. In: Kaplan JL, Slinger PD, eds. Thoracic anesthesia. 3rd ed. Philadelphia: Churchill Livingstone, 2003: 248–53.
- Cohen E, Eisenkraft JB. Bronchopulmonary lavage: effects of oxygenation and hemodynamics. J Cardiothorac Anesth 1990; 4: 609–15.[Medline]
- Spragg RG, Benumof JL, Alfery DD. New method for the performance of unilateral lung lavage. Anesthesiology 1982; 57: 535–8.[Medline]
- Moutafis M, Dalibon N, Colchen A, Fischler M. Improving oxygenation during bronchopulmonary lavage using nitric oxide inhalation and almitrine infusion. Anesth Analg 1999; 89: 302–4.
[Free Full Text] - Dorsch JA, Dorsch SE. Airway pressures, volumes, and flows. In: Dorsch JA, Dorsch SE, eds. Understanding anesthesia equipment. Philadelphia: Williams & Wilkins, 1999: 787–8.
- Moutafis M, Liu N, Dalibon N, et al. The effects of inhaled nitric oxide and its combination with intravenous almitrine on PaO2 during one-lung ventilation in patients undergoing thoracoscopic procedures. Anesth Analg 1997; 85: 1130–5.[Abstract]
- Fradj K, Samain E, Delefosse D, et al. Placebo-controlled study of inhaled nitric oxide to treat hypoxaemia during one-lung ventilation. Br J Anaesth 1999; 82: 208–12.
[Abstract/Free Full Text] - Schwarzkopf K, Klein U, Schreiber T, et al. Oxygenation during one-lung ventilation: the effects of inhaled nitric oxide and increasing levels of inspired fraction of oxygen. Anesth Analg 2001; 92: 842–7.
[Abstract/Free Full Text] - Alfery DD, Zamost BG, Benumof JL. Unilateral lung lavage: blood flow manipulation by ipsilateral pulmonary artery balloon inflation in dogs. Anesthesiology 1981; 55: 376–80.[Medline]
- Cruz K, Franklin C. The pulmonary artery catheter: uses and controversies. Crit Care Clin 2001; 17: 271–91.[Web of Science][Medline]
- Dorrington KL, Clar C, Young JD, et al. Time course of the human pulmonary vascular response to 8 hours of isocapnic hypoxia. Am J Physiol 1997; 273: H1126–34.
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