AIIMS Bhubaneswar doctors conduct complex Whole Lung Lavage procedure to remove unwanted protein from patient lungs

The patient was very breathless and was unable to walk around or perform her day-to-day activities, at the time of admission to AIIMS hospital. Before coming to AIIMS hospital, this patient had been diagnosed as PAP at multiple hospitals since 2018 both in and outside Odisha but had not yet been able to be treated. In PAP, the accumulated proteins need to be removed.

According to AIIMS, the treatment involves a procedure called Whole Lung Lavage (WLL). In this procedure, the one-side lung is washed with large volumes (10 to 15 litres) of warmed normal saline while the patient undergoes single lung ventilation of the other side lung. This is a tricky procedure because both the lungs are severely affected by this disease and the procedure has to be done with ventilation of one lung. The procedure lasts for around four to five hours. Hence the procedure is done in centres where experienced cardio-thoracic anaesthetists are present. After three to four weeks, WLL is performed on the opposite lung. In 50% of cases, a one-time bilateral whole lung lavage done over two sittings is sufficient. For others, repeat lavages may be necessary after a variable duration of 1-5 years. The prognosis is excellent for patients who undergo bilateral whole lung lavage.

Dr. Shakti Kumar Bal, assistant professor of pulmonary medicine, led the team doing the procedure on the patient. The first WLL (left lung) was performed on January 21, 2021 and the second WLL (right lung) on February 23, 2021. Dr. Bal told Medical Dialogues, " First the protein of the left lung was washed out while right lung was allowed to breathe on January 21. Meanwhile, a sufficient supply of oxygen in the lungs was also maintained. On February 23, the right lung was cleaned while the left one worked. Each lung cleaning took almost five hours in a process called Whole Lung Lavage (WLL). Around 15 litres of saline was used for each lung."

In normal individuals, special proteins called surfactant proteins are secreted and removed continuously in the lungs. These proteins are essential for easy expansion and oxygen exchange in the lungs. In Primary Pulmonary Alveolar Proteinosis, these surfactant proteins fail to get removed from the lungs. Eventually, large amounts of surfactant proteins accumulate in the lungs, impair oxygen transfer and cause progressive difficulty in breathing. When questioned about the difficulty of conducting the procedure, he stated, "Cleaning the first lung was more difficult since both the lungs were not functioning fully due to the accumulation of unwanted protein on both the lungs. Cleaning the second one was easier as the first one was clean and functioning better."

As per a recent pressed release by AIIMS Bhubaneswar, the anesthesia team led by Dr Prasanta Kumar Das (Assistant Professor & Cardio-Thoracic anesthetist) under the guidance of Dr Satyajeet Mishra (Additional Professor & Cardio-Thoracic anesthetist) along with the Pulmonary Medicine team led by Dr Shakti Kumar Bal (Assistant Professor) under the guidance of Dr Sourin Bhuniya (Additional Professor), Dr Manoj Panigrahi (Additional Professor) and Dr Prasanta Raghab Mohapatra (Professor) were involved in the management of this patient. She required 15 litres/minute of oxygen to saturate 90% (normal oxygen saturation is above 96% on room air. She was breathing freely on room air and was able to walk around by the time of her discharge on Feb 26, 2021. According to the sources, she will continue to be followed up at AIIMS hospital every 3 months.

Dr. Sachidananda Mohnti, MS of the Hospital told Medical Dialogues, " This was a difficult surgery which required specific expertise. We are now considered to be just next to AIIMS Delhi and this could be possible for the dedication of all the people of all categories. We are handling rare cases to provide the best services to the people of the region. A few days ago a number of difficult procedures like a complex case of total joint replacement surgery have been conducted by the experts as well. We are striving for excellence."