36: Saving the Airless Lung: VV-ECMO – Assisted Whole Lung Lavage in Pulmonary Alveolar Proteinosis - A Case Report

Background: Pulmonary alveolar proteinosis (PAP) is a rare interstitial lung disease characterized by intra-alveolar accumulation of surfactant-derived lipoproteinaceous material, resulting in impaired gas exchange and progressive hypoxemic respiratory failure. Whole lung lavage (WLL) remains the standard therapeutic intervention; however, performing WLL in patients with severe refractory hypoxemia poses significant procedural risk. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) may provide temporary cardiopulmonary support, facilitating safe completion of lavage. Case Description: A 62-year-old male presented with progressive dyspnea and hypoxemia requiring intensive care unit admission. High-resolution computed tomography demonstrated diffuse ground-glass opacities with a “crazy paving” pattern. Transbronchial cryo lung biopsy confirmed pulmonary alveolar proteinosis. Despite noninvasive ventilation and corticosteroid therapy, the patient remained severely hypoxemic. Given the high risk of desaturation during planned whole lung lavage, endotracheal intubation and VV-ECMO were initiated as a bridge to definitive therapy. Intervention and Outcome: VV-ECMO was established via femoral–jugular cannulation, providing stable oxygenation and carbon dioxide clearance. Sequential bilateral whole lung lavage was performed under general anesthesia with ECMO support. The right lung underwent nine lavage cycles with a total volume of 8.05 liters, and the left lung underwent seventeen cycles totaling 16.35 liters. ECMO support ensured hemodynamic stability and adequate gas exchange throughout the procedure. Significant clearance of proteinaceous material was achieved, with subsequent improvement in lung compliance and oxygenation. The patient was successfully weaned from mechanical ventilation on day 4 and decannulated from VV-ECMO on day 5. Conclusion: This case highlights the role of VV-ECMO as an effective bridge to whole lung lavage in patients with pulmonary alveolar proteinosis complicated by severe hypoxemia. ECMO support enhances procedural safety and enables successful lavage when conventional ventilatory strategies are insufficient.Fig 1: HRCT Thorax: Crazy paving pattern