A case of pulmonary alveolar proteinosis treated with whole lung lavage.

Pulmonary alveolar proteinosis is rarely seen and, thus, many critical care nurses may not be familiar with the disease. This article provides information about the epidemiology, pathophysiology, and a case study of a patient with this disease.     

Whole lung lavage in the treatment of pulmonary alveolar proteinosis.

Although a rare condition, pulmonary alveolar proteinosis (PAP) can be a very devastating diagnosis with life-altering consequences. This case study follows the path of a young woman who is currently undergoing whole lung lavage as treatment for pulmonary alveolar proteinosis. The entire concept of flooding a lung with large quantities of saline as a treatment for lung disease is contrary to normal respiratory care. Caring for the patient with PAP provides many challenges for the perianesthesia nurse. Management of the postanesthesia airway, oxygen administration and maintenance of oxygen saturation, and pain relief skills are all of high importance to the patient with PAP. These skills plus the emotional support provided by the experienced perianesthesia nurse can ensure a safe recovery from this unusual procedure.     

Extending the limits of extracorporeal membrane oxygenation: lung rest for a child with non-specific interstitial pneumonia

Objective Veno-venous extracorporeal membrane oxygenation (ECMO) is an established therapy for the treatment of respiratory failure. Traditionally ECMO has been used to support patients with an acute, reversible disease process, with a predictable outcome. We report the successful use of veno-venous ECMO for an unusual indication.Patient A 10-year old girl was admitted to intensive care with severe, hypoxic respiratory failure on the background of a 2-month history of worsening respiratory symptoms. She required high levels of conventional positive pressure ventilation, and high frequency oscillation. Lung biopsy confirmed a non-specific interstitial pneumonia, and the patient was commenced on immune suppressive therapy. Her clinical course was further complicated by pulmonary haemorrhage and severe air leak.Interventions On day 20 after admission the patient was placed on veno-venous ECMO for lung rest while awaiting a response to continued medical treatment. She required ECMO for 20 days, during which time sedation was reduced, and she was able to interact with those around her. The patients ventilatory requirements after decannulation were minimal, and she subsequently made a steady clinical recovery.Conclusions ECMO was safely and successfully used to provide a period of lung rest and time for medical therapy to take effect in a child with an unusual indication for support: a rare disease with an uncertain outcome on the background of prolonged mechanical ventilation.     

肺泡蛋白沉着症大容量全肺灌洗治疗的护理

大容量全肺灌洗是目前治疗肺泡蛋白沉着症唯一有效的方法。总结了17例肺泡蛋白沉着症患,经43侧次大容量全肺灌洗治疗的护理要点：术前做好患准备、物品准备及心理护理：术中严密观察生命体征及动脉血氧分压、经皮血氧饱和度改变,防止灌洗液溢漏入对侧肺,注意灌洗压力与引流速度,应用变换体位与胸部叩击法促进沉着蛋白随灌洗液排出;术后行呼气末正压通气并吸尽残存灌洗液,鼓励行有效咳嗽,给予吸氧,应用激素、抗生素防止肺部感染等。灌洗后17例患呼吸困难、低氧血症等情况明显改善。     

大容量全肺灌洗术治疗肺泡蛋白沉着症患者的监护

目的总结肺泡蛋白沉着症行大容量全肺灌洗术的监护措施。方法回顾性分析12例肺泡蛋白沉着症行大容量肺泡灌洗术前、术中、术后的监护措施。结果 12例大容量全肺灌洗术顺利,术后患者呼吸困难、低氧血症等情况明显改善。灌洗后患者动脉血氧分压和动脉血氧饱和度均较灌洗前高,灌洗前后比较,均P0.05,差异具有统计学意义。结论充分的术前准备;术中密切配合,严密观察病情变化;术后加强机械通气的监测和管理,预防急性肺水肿等严重并发症是全肺灌洗术成功的保证。     

双肺同期大容量灌洗治疗肺泡蛋白沉积症体会(附1例报告)

目的评价双肺同期大容量灌洗术（WLL）和纤支镜下肺叶支气管肺泡灌洗（BAL）治疗肺泡蛋白沉积症（PAP）治疗效果。方法在纤支镜下行BAL（共洗4次），每次灌入生理盐水300ml，回收液150～200ml。呈洗米水样；WLL采取全身静脉复合麻醉，双肺先右后左灌洗，灌洗总量各12000ml。回收液呈乳白色，放置后可见乳状物沉淀。术后复查胸片、肺功能和血气。结果无合并症的PAP围手术期生命指征平稳，WLL手术过程顺利。结论规范的WLL术治疗PAP较纤支镜下支镜下支气管肺泡灌洗彻底，疗效显著。     

肺泡蛋白沉着症肺泡灌洗术前后定量CT应用评价

目的 探讨定量CT在肺泡蛋白沉着症(PAP)支气管肺泡灌洗术中的应用价值.方法 定量CT通过分析PAP患者最大吸气末肺容积、肺重量、肺含气体积、平均肺密度及平均含气体积结果,对10例PAP患者共14次(两肺13次,单肺1次)肺泡灌洗术CT资料进行分析.并结合常规CT(病灶范围、密度)、肺功能(检查9次)及血气分析检查(检查14次)结果进行对比分析.结果 PAP经支气管肺泡灌洗术后,定量CT检查显示肺重量从(1594±436) g减低至(1294±374) g(P=0.000),平均肺密度从(0.5269±0.12) g/ml减低至(0.4389±0.09) g/ml(P=0.006),平均肺充气体积从(1.0989±0.5031) ml/g增加至(1.4700±0.4548) ml/g(P=0.008),肺含气体积有一定程度增加(P=0.116),肺容积在灌洗后略增加(P=0.938);肺泡灌洗前后的肺容积与肺含气体积呈显著相关(绝对系数R2=0.94,P=0.000).常规CT评价79%(11/14)CT检查结果改善.支气管肺泡灌洗术后有10次肺功能检查结果示DLCO%从45.85%±22.09%上升到54.64%±19.09%(P＝0.007)、DLCO/VA%从67.30%±22.62%上升到76.03%±18.60%(P＝0.03);FVC%、FEV1%、FEV1/FVC、PEF%也有不同程度改善,但无统计学差异(P＞0.05).14次血气分析显示从肺泡灌洗前的低氧血症[PaO2(8.07±2.1) kpa]到肺泡灌洗后的明显好转[PaO2(14.7±5.24) kpa](P=0.001).结论 定量CT可为PAP疗效评估提供客观依据,肺泡灌洗术后以定量CT结果中的肺重量、平均肺密度及平均含气肺体积改善明显.常规CT评价对PAP疗效观察具有一定价值.通过肺泡灌洗术,大部分患者病情短期内得到显著改善.     

Biochemical characterization of pulmonary washings of patients with alveolar proteinosis, interstitial pneumonitis and alveolar cell carcinoma

We have studied the biochemical compositions of fifteen pulmonary washings from seven patients with alveolar proteinosis, and two washings from two patients with interstitial pneumonitis and two from two patients with alveolar cell carcinoma. The pulmonary washing was separated into the supernatant and precipitate fractions by a brief centrifugation. Analytical results revealed that the pulmonary washings from patients with alveolar proteinosis contained much more protein and lipids as well as a higher percentage of phospholipid than did the pulmonary washings from other patients. With regards to alveolar proteinosis, the precipitate fraction, i.e., water-insoluble material, contained lipids as the major component, the majority of which was dipalmitoyl phosphatidylcholine. Protein in the sedimental material was small in amount, but was composed of proteins mainly of molecular weights of 62,000, 36,000, 28,000 and 15,000 as measured by SDS-gel electrophoresis. On the other hand, the supernatant fraction, i.e., water-soluble material, was composed predominantly of serum proteins, with the lipid content being lower than those in the precipitate fraction. These analytical findings support the idea that materials normally existing in the alveoli are excessively accumulated as alveolar-filling materials in alveolar proteinosis. It was also noted that there were marked differences in the lipid profiles between pulmonary washings from patients with alveolar proteinosis, and those from patients with other diseases, indicating that the biochemical composition of pulmonary washings tends to reflect the nature of an underlying disease. From these findings, the cause of the alveolar-filling materials found in alveolar proteinosis was discussed.     

Protective effect of extracorporeal membrane pulmonary oxygenation combined with cardiopulmonary resuscitation on post-resuscitation lung injury

BACKGROUND: Cardiac arrest (CA) is a critical condition that is a concern to healthcare workers. Comparative studies on extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) technologies have shown that ECPR is superior to CCPR. However, there is a lack of studies that compare the protective effects of these two resuscitative methods on organs. Therefore, we aim to perform experiments in swine models of ventricular fibrillation-induced CA to study whether the early application of ECPR has advantages over CCPR in the lung injury and to explore the protective mechanism of ECPR on the post-resuscitation pulmonary injury. METHODS: Sixteen male swine were randomized to CCPR (CCPR; n=8; CCPR alone) and ECPR (ECPR; n=8; extracorporeal membrane oxygenation with CCPR) groups, with the restoration of spontaneous circulation at 6 hours as an endpoint. RESULTS: For the two groups, the survival rates between the two groups were not statistically significant (P>0.05), the blood and lung biomarkers were statistically significant (P<0.05), and the extravascular lung water and pulmonary vascular permeability index were statistically significant (P<0.01). Compared with the ECPR group, electron microscopy revealed mostly vacuolated intracellular alveolar type II lamellar bodies and a fuzzy lamellar structure with widening and blurring of the blood-gas barrier in the CCPR group. CONCLUSIONS: ECPR may have pulmonary protective effects, possibly related to the regulation of alveolar surface-active proteins and mitigated oxidative stress response post-resuscitation.     

Surfactant application during extracorporeal membrane oxygenation improves lung volume and pulmonary mechanics in children with respiratory failure

Introduction  

This study was performed to determine whether surfactant application during extracorporeal membrane oxygenation (ECMO) improves lung volume, pulmonary mechanics, and chest radiographic findings in children with respiratory failure or after cardiac surgery.     

Oxygenation index in patients with meconium aspiration: conventional and extracorporeal membrane oxygenation therapy

The use of the alveolar-arterial oxygen difference P(A-a)O2 and the oxygenation index (mean airway pressure [Paw] FIO2 x 100/PaO2) have been proposed for selecting infants who will require extracorporeal membrane oxygenation (ECMO) therapy. However, the use of the oxygenation index (OI) in conjunction with Paw in an exclusive population of patients with meconium aspiration syndrome (MAS) has not been reported. Fourteen patients born in our facility and managed with conventional therapy and five infants treated with ECMO were enrolled in the study. All patients had clinical and x-ray evidence of MAS. Infants who received conventional treatment required mechanical ventilation greater than 48 h, FIO2 1.0, and were under the care and supervision of one neonatologist. Management was directed to minimize barotrauma by avoidance of routine hyperventilation, use of lower Paw, and sufficient expiratory time. One patient died before ECMO and 13 infants survived. Six survivors had an OI greater than 25 (three had an OI greater than 40), six had a Paw greater than or equal to 12 cm H2O (12 to 15 cm H2O in five infants) and six patients had a P(A-a)O2 greater than or equal to 610 torr. One surviving infant was transferred for ECMO therapy (OI 67, Paw 20 cm H2O). The five patients treated with ECMO survived (OI 48 to 92, Paw 20 to 29.5 cm H2O P(A-a)O2 627 to 650 torr). One patient in each group developed chronic lung disease with evidence of resting tachypnea. Our findings indicate that an OI greater than 40 in association with a Paw greater than or equal to 20 cm H2O may be helpful in predicting which infants with MAS need ECMO, whereas patients requiring a Paw less than or equal to 15 cm H2O can be managed with conventional therapy. An OI greater than or equal to 25 but less than 40 is not associated with high mortality in these patients. The predictive value of Paw of 16 to 20 cm H2O and the duration of an OI greater than 40 in patients with MAS need further investigation.     

Physical therapy and rehabilitation issues for patients supported with extracorporeal membrane oxygenation

Extracorporeal Membrane Oxygenation (ECMO) is widely used to support patients who have failed conventional therapies for cardio-respiratory failure. Patient immobility during management of critical illness and ECMO support can result in physical impairment that can lead to prolonged hospitalization and poor functional outcomes for ECMO survivors. Although little information regarding the role of physical therapy in improving functional outcomes for ECMO patients is available, early intervention with physical therapy may decrease duration of hospitalization and improve functional outcomes for patients supported with ECMO.     

6例特重度烧伤患者使用体外膜肺氧合联合连续性肾脏替代治疗的护理

总结体外膜肺氧合联合连续性肾脏替代治疗救治6例特重度烧伤患者的护理经验.护理要点:体外膜肺氧合联合连续性肾脏替代治疗运行中,全程化压力监测;制订个体化液体管理方案,确保容量足够;精准化抗凝管理,防止滤器凝血,同时关注创面渗血、渗液;成立感染控制专职团队,严防感染;早期保暖措施干预,防止发生低体温;在保护烧创伤皮肤的前提...     

3例心肺衰竭患者应用体外膜肺氧合技术的监护

总结了3例应用体外膜肺氧合技术救治心肺衰竭患者的监护经验.从基础生命指标监测、病人管理、并发症监护三方面对3例终末期心肺衰竭患者进行全面护理.除1例患者死于多脏器功能衰竭外,2例存活现处于康复阶段,均无严重并发症发生.完善的监护技术是提高体外膜肺氧合技术救治率不可缺少的因素.     

A sporadic COVID-19 pneumonia treated with extracorporeal membrane oxygenation in Tokyo,Japan: A case report

IntroductionAn ongoing outbreak of a novel coronavirus disease (coronavirus disease 2019, COVID-19) has become a global threat. While clinical reports from China to date demonstrate that the majority of cases remain relatively mild and recover with supportive care, it is also crucial to be well prepared for severe cases warranting intensive care. Initiating appropriate infection control measures may not always be achievable in primary care or in acute-care settings.CaseA 45-year-old man was admitted to the intensive care unit due to severe pneumonia, later confirmed as COVID-19. His initial evaluation in the resuscitation room and treatments in the intensive care unit was performed under droplet and contact precaution with additional airborne protection using the N95 respirator mask. He was successfully treated in the intensive care unit with mechanical ventilation and extracorporeal membrane oxygenation for respiratory support; and antiretroviral treatment with lopinavir/ritonavir. His total intensive care unit stay was 15 days and was discharged on hospital day 24.ConclusionsStrict infection control precautions are not always an easy task, especially under urgent care in an intensive care unit. However, severe cases of COVID-19 pneumonia, or another novel infectious disease, could present at any moment and would be a continuing challenge to pursue appropriate measures. We need to be well prepared to secure healthcare workers from exposure to infectious diseases and nosocomial spread, as well as to provide necessary intensive care.     

Survival of patients with acute pulmonary embolism treated with venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis

BackgroundTo examine whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) improves survival of patients with acute pulmonary embolism (PE).MethodsFollowing the PRISMA guidelines, a systematic search was conducted up to August 2019 of the databases: PubMed/MEDLINE, EMBASE and Cochrane. All studies reporting the survival of adult patients with acute PE treated with VA-ECMO and including four patients or more were included. Exclusion criteria were: correspondences, reviews and studies in absence of a full text, written in other languages than English or Dutch, or dating before 1980. Short-term (hospital or 30-day) survival data were pooled and presented with relative risks (RR) and 95% confidence intervals (95% CI). Also, the following pre-defined factors were evaluated for their association with survival in VA-ECMO treated patients: age > 60 years, male sex, pre-ECMO cardiac arrest, surgical embolectomy, catheter directed therapy, systemic thrombolysis, and VA-ECMO as single therapy.ResultsA total of 29 observational studies were included (N = 1947 patients: VA-ECMO N = 1138 and control N = 809). There was no difference in short-term survival between VA-ECMO treated patients and control patients (RR 0.91, 95% CI 0.71–1.16). In acute PE patients undergoing VA-ECMO, age > 60 years was associated with lower survival (RR 0.72, 95% CI 0.52–0.99), surgical embolectomy was associated with higher survival (RR 1.96, 95% CI 1.39–2.76) and pre-ECMO cardiac arrest showed a trend toward lower survival (RR 0.88, 95% CI 0.77–1.01). The other evaluated factors were not associated with a difference in survival.ConclusionsAt present, there is insufficient evidence that VA-ECMO treatment improves short-term survival of acute PE patients. Low quality evidence suggest that VA-ECMO patients aged ≤60 years or who received SE have higher survival rates. Considering the limited evidence derived from the present data, this study emphasizes the need for prospective studies.Protocol registrationPROSPERO CRD42019120370.