Whole-lung lavage in a toddler. Technical challenges and solutions

Introduction: Pulmonary alveolar proteinosis is a rare respiratory disease whose main treatment is the whole-lung lavage. This could be a challenging procedure in small children. Objective: The aim of this report is to show our experience coping with a 21-month-old girl with pulmonary alveolar proteinosis, who needed a whole-lung lavage due to persistent hypoxemia. Case report: Our patient was a healthy girl until she was 7 months, when she was diagnosed with myeloblastic leukemia. At the age of 13 months, a hematopoietic stem cell transplant was undergone after no response to chemotherapy. After a sepsis when she was 20 months, she had respiratory distress and hypoxemia that persisted for more than 2 weeks, so a chest CT was ordered; it showed bilateral ground-glass opacities. A bronchoalveolar lavage plus a pulmonary biopsy were undergone, confirming the diagnosis of pulmonary alveolar proteinosis. A whole-lung lavage was done, using simultaneously 2 endotracheal cuffed tubes: one (3.5 mm diameter) placed in the trachea to ventilate one lung and another of 3 mm (modified to make it longer) to instill heated saline into the bronchus to perform the lavage. This procedure was done in 2 different days: firstly on the right lung and secondly on the left one, with a total of 2.5 L saline in every lung. The procedure was well tolerated with a good clinical response, and the girl was discharged 2 weeks later. Conclusions: We found a solution to a challenging situation which is to perform a whole-lung lavage in a toddler by placing concurrently 2 tubes into the airway. We believe it is possible to perform a whole-lung lavage in small children despite not having specific double-lumen tubes for children aged below 8 years.