Australian Clinical Guidelines for Radiological Emergencies - September 2012

Appendix C: Pulmonary lavage procedure

Page last updated: 07 December 2012

  • Stabilise current injuries and illnesses prior to undertaking pulmonary lavage.
  • Unless there are contraindications to doing so, the right lung should be preferentially lavaged first.
  • The procedure is performed with the patient in the lateral decubitus position.
    • Whilst it is usually the dependent lung that is lavaged, one author describes lavage of the non-dependent lung, allowing easy access to that lung for chest wall percussion during drainage of the lavage fluid. Additionally, blood flow to the (lavaged) non-dependent lung is reduced resulting in less hypoxaemia due to cardiac shunt.
  • A double lumen endotracheal tube is placed under general anaesthesia with muscle paralysis. Bronchoscopic confirmation of placement is recommended.
  • Monitor pulse oximetry, end-tidal capnography, ECG, oesophageal stethoscope, invasive blood pressure, central venous pressure, core temperature, peak and plateau respiratory pressures and continuous spirometry.
  • Absolute functional lung separation needs to be ascertained.
    • For the water bubble technique, the tracheal port of the double lumen endotracheal tube is placed under water whilst transiently maintaining a plateau pressure of 40cm through the bronchial port. The appearance of bubbles around the tracheal port signifies a leak around the bronchial cuff.
    • The balloon inflation technique substitutes a balloon for the underwater seal at the tracheal port. Any inflation of the balloon during positive pressure inflation through the bronchial cuff indicates a leak around the bronchial cuff.
  • Clamp and degass the lung to be lavaged.
  • Prior to commencement of the lavage, confirm that ventilation of the isolated lung will maintain adequate ventilation of the patient. Ventilate the isolated lung with a high inspiratory oxygen fraction, up to 1.0.
  • Carefully monitor the volumes of lavage fluid instilled and drained.
  • After pre-oxygenation, 500 to 1000 mL of warmed (37C) isotonic saline is instilled at a time and allowed to efflux immediately. Gravity is used to instill and drain the lavage fluid via large bore tubing.
    • Descriptions of the volume of lavage fluids vary. Suggested aliquots equate with the total tidal volume (7 mL/kg) delivered to the lavaged lung, or as much as an amount equivalent to the vital capacity of the individual lung. (The total vital capacity is 65-75 mL/kg lean body mass, corrected for the volume of the respective lung, i.e. 0.45 left lung, 0.55 right lung).
    • Up to 40 to 50 L are lavaged over three hours for lavage of one lung.
  • After lavage, carefully drain and suction the lung via fibreoptic bronchoscopy.
  • Retain the effluent lavage fluid for radiological analysis.
  • At the end of the procedure, positive end-expiratory pressure ventilation is performed.
  • Leakage of fluid into the ventilated lung is of greatest concern. This is recognised by falling oxygen saturation, fluid in the lumen of the ventilated lung and air bubbles in the lavage fluid. The procedure must be stopped immediately, placing the patient in the lateral decubitus position with the lavaged side down, suctioning out both lungs and rechecking the position of the double lumen tube.
  • Electrolytic disturbance may be seen due to the dialysis effects of the lavage fluid, mainly hypocalcaemia and metabolic acidosis. Periodic laboratory analysis of plasma biochemistry is recommended during extended procedures.
  • Some fluid shift may occur due to absorption of the lavage fluid from the alveoli. Changes in central venous pressure should be noted.
  • The process is repeated for the other lung after 2 to 3 days.
    • Some authors describe sequential pulmonary lavage of both lungs during the same procedure. The decision to undertake sequential pulmonary lavage is dependent on how the patient tolerates the procedure, and on resource demands (access to operating theatre and personnel, and competing patient priorities).
  • At least 10 separate occasions of pulmonary lavage are recommended.
  • The intervals between occasions of pulmonary lavage should be as brief as possible to facilitate the earliest possible lowering of the initial lung burden of the radionuclide and, therefore, the cumulative dose.