Total Lung Lavage using THRIVE for Pre-oxygenation and Oxygen Insufflation During Intubation: Our Initial Experience of Two Cases

Introduction: Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by deposition of lipoproteinaceous material in the alveoli secondary to abnormal processing of surfactant by macrophages. Total-lung lavage (TLL); a gold standard management for this disease entails washing out the proteinaceous material from the alveoli and re-establish effective oxygenation and ventilation. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), utilizes apnoeic oxygenation to extend the apnoeic window and delay rapid de-saturation common in these cases; thus allowing for safer intubation. We would like to share our experience of two cases of TLL for PAP in which we used THRIVE for pre-oxygenation and apnoeic oxygenation during intubation. To our knowledge this is the first case report demonstrating the use of THRIVE in a case of TLL in literature. Case presentation: We had two patients posted for TLL who were suffering from PAP; both had presented with breathlessness of increasing severity over the last few months. Both patients were young (35 & 40 yrs old) and had no other co-morbidities. Their baseline oxygen saturations (SpO2) and partial pressure of oxygen in blood (pO2) on air were on the lower side. Hence the decision was taken to pre-oxygenate them using THRIVE and to also use THRIVE during intubation to improve their tolerance to apnoea during intubation. Conclusion: When used for pre-oxygenation and oxygen insufflation during intubation THRIVE prolongs the tolerable apnoea time and delays de-saturation during intubation. Keywords: Pulmonary alveolar proteinosis (PAP), Total Lung Lavage (TLL), Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE).