Therapeutic limited bronchoalveolar lavage with fiberoptic bronchoscopy as a bridging procedure prior to total lung lavage in a patient with pulmonary alveolar proteinosis: a case report

Damith Rodrigo, Amila Rathnapala, Wijitha Senaratne

Therapeutic total lung lavage under general anesthesia is the current mainstay of treatment for pulmonary alveolar proteinosis, which is a rare lung disease characterized by alveolar accumulation of surfactant. Therapeutic limited bronchoalveolar lavage is considered an alternative treatment to conventional total lung lavage. A 61-year-old, previously healthy, Sri Lankan Moor woman presented to our facility with progressively worsening difficulty in breathing and persistent dry cough for one year. Her respiratory examination revealed bibasal fine end-inspiratory crepitations. A chest radiograph showed bilateral mid and lower zone alveolar interstitial shadows and a high-resolution computed tomography scan of her chest revealed septal thickening with ground-glass shadows more on mid and lower zones bilaterally. A diagnostic bronchoalveolar lavage fluid analysis revealed diastase-resistant protein clumps in periodic acid Schiff stain. The diagnosis was made as pulmonary alveolar proteinosis. An arterial blood gas analysis performed prior to intervention revealed a significant hypoxia (partial pressure of oxygen - 64mmHg) with alveolar-arterial gradient was 35.4mmHg. Therapeutic limited bronchoalveolar lavage was arranged and her right and her left lung were lavaged separately in two sessions done two weeks apart under local anesthesia. Our patient had significant clinical improvement and resolution of the bilateral septal thickening with minimal resolution of the ground-glass opacities in a repeat high-resolution computed tomography scan done two weeks later. Subsequently, a total lung lavage under general anesthesia was also done, which improved her dyspnea and arterial hypoxemia. Therapeutic limited bronchoalveolar lavage can be successfully performed as an interval bridging procedure, as a 'prewash', prior to conventional total lung lavage for pulmonary alveolar proteinosis.