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Baumgärtel M, Würflein D, Neff U, Böhm J, Ficker JH, Swol J. Bridging Whole-Lung Lavage with Venovenous Extracorporeal Life Support for Pulmonary Alveolar Proteinosis. J Cardiothorac Vasc Anesth 2020; 34:1115-1117. [DOI: 10.1053/j.jvca.2019.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022]
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Boyce DSK, Lee JW, Shah P, Freeman JH, Aboudara MC, Hostler DC. Combined-modality therapy for pulmonary alveolar proteinosis in a remote setting: a case report. BMC Pulm Med 2019; 19:61. [PMID: 30866900 PMCID: PMC6417025 DOI: 10.1186/s12890-019-0822-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 02/25/2019] [Indexed: 01/15/2023] Open
Abstract
Background Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterized by accumulation of phospholipoproteinaceous material in the alveoli. The presentation is nonspecific but typically includes dyspnea; the spectrum of disease includes rapidly progressive hypoxic respiratory failure. Whole lung lavage (WLL) is the treatment of choice in symptomatic PAP, but transient worsening of oxygenation sometimes requires salvage modalities of support such as extracorporeal membrane oxygenation (ECMO). Granulocyte macrophage colony-stimulating factor (GM-CSF) plays a role in the pathophysiology of PAP. We highlight a case of severe PAP treated with exogenous GM-CSF and sequential lobar lavage due to the unavailability of salvage methods of oxygenation. Case presentation A 36 year old female was admitted with fevers, chills, and progressive dyspnea. On presentation she was tachypneic, tachycardic, and hypoxemic; labs revealed leukocytosis and lactic acidosis. Chest CT identified diffuse ground glass opacities in a ‘crazy-paving’ pattern. Following intubation due to impending respiratory failure, bronchoscopy with bronchoalveolar lavage was performed. The lavage return stained positive with Periodic Acid Schiff, confirming the diagnosis of PAP. Continued deterioration necessitated treatment; however, at this geographically remote center without ECMO services WLL was judged to carry significant risk. Nebulized GM-CSF was administered without significant improvement. Subcutaneous GM-CSF was administered and isolated subsegmental lavages of the bilateral upper lobes were performed, with rapid improvement in oxygenation. Additional sequential lobar lavage and continued GM-CSF therapy as an outpatient resulted in complete resolution of oxygen requirement and return to normal pulmonary physiology. Conclusions The autoimmune form of PAP is the most common, indicating that therapy with GM-CSF may play an important role for many patients. Treatment with WLL may be impractical in some clinical settings due to the expertise and salvage modalities required. Sequential lobar lavage requires less specialized expertise and may incur less risk of refractory hypoxemia. We posit that this combined-modality therapy is ideally suited to geographically-remote centers such as our own.
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Affiliation(s)
- Dacia S K Boyce
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Rd, Tripler AMC, Hawaii, 96859, USA.
| | - John W Lee
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Phalgoon Shah
- Division of Pulmonary, Critical Care & Sleep Medicine, Case Western Reserve MetroHealth Medical Center, Cleveland, USA
| | - Judy H Freeman
- Department of Pathology & Laboratory Services, Tripler Army Medical Center, Tripler AMC, USA
| | - Matthew C Aboudara
- Division of Allergy, Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David C Hostler
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Rd, Tripler AMC, Hawaii, 96859, USA
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Jouneau S, Kerjouan M, Briens E, Lenormand JP, Meunier C, Letheulle J, Chiforeanu D, Lainé-Caroff C, Desrues B, Delaval P. La protéinose alvéolaire pulmonaire. Rev Mal Respir 2014; 31:975-91. [DOI: 10.1016/j.rmr.2014.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 08/20/2014] [Indexed: 01/30/2023]
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Abstract
The present article is the second in a series on rare lung diseases. It focuses on pulmonary alveolar proteinosis (PAP), a disorder in which lipoproteinaceous material accumulates in the alveolar space. PAP was first described in 1958, and for many years the nature of the material accumulating in the lungs was unknown. Major insights into PAP have been made in the past decade, and these have led to the notion that PAP is an autoimmume disorder in which autoantibodies interfere with signalling through the granulocyte-macrophage colony-stimulating factor receptor, leading to macrophage and neutrophil dysfunction. This has spurred new therapeutic approaches to this disorder. The discussion of PAP will begin with a case report, then will highlight the classification of PAP and review recent insights into the pathogenesis of PAP. The approach to therapy and the prognosis of PAP will also be discussed.
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Sihoe ADL, Ng VMW, Liu RWT, Cheng LC. Pulmonary Alveolar Proteinosis in Extremis: The Case for Aggressive Whole Lung Lavage with Extracorporeal Membrane Oxygenation Support. Heart Lung Circ 2008; 17:69-72. [PMID: 17337244 DOI: 10.1016/j.hlc.2006.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 11/15/2006] [Accepted: 11/16/2006] [Indexed: 10/23/2022]
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare disorder in which lipoproteinaceous material is deposited in the alveoli, compromising gaseous exchange. We report the case of a 29-year-old female patient presenting with the most extreme case of PAP yet reported. She successfully managed by aggressive bilateral whole lung lavage (WLL) in a single sitting using extracorporeal membrane oxygenation (ECMO) support. Despite critical hypercarbia and ventilator-dependence for 12 days before lavage, the patient experienced rapid recovery of pulmonary function after WLL and ECMO could be discontinued on-table. Aggressive WLL with ECMO support can be safe and effective even in the most severe cases of PAP.
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Affiliation(s)
- Alan D L Sihoe
- Division of Cardiothoracic Surgery, The University of Hong Kong, Grantham Hospital, Hong Kong SAR, China
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Cohen ES, Elpern E, Silver MR. Pulmonary alveolar proteinosis causing severe hypoxemic respiratory failure treated with sequential whole-lung lavage utilizing venovenous extracorporeal membrane oxygenation: a case report and review. Chest 2001; 120:1024-6. [PMID: 11555544 DOI: 10.1378/chest.120.3.1024] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Pulmonary alveolar proteinosis is characterized by the accumulation of proteinaceous material in the alveoli leading to varying degrees of impairment in gas exchange. Generally, the degree of hypoxemia is mild, and it is rare to have respiratory failure requiring mechanical ventilation. We present a 53-year-old woman with the most severe degree of hypoxemia associated with alveolar proteinosis reported in the English-language adult literature. Her therapy of sequential whole-lung lavage performed while receiving venovenous extracorporeal membrane oxygenation in one operative session is the first reported successful use of this approach.
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Affiliation(s)
- E S Cohen
- Section of Pulmonary and Critical Care Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA
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Moutafis M, Dalibon N, Colchen A, Fischler M. Improving oxygenation during bronchopulmonary lavage using nitric oxide inhalation and almitrine infusion. Anesth Analg 1999; 89:302-4. [PMID: 10439735 DOI: 10.1097/00000539-199908000-00008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- M Moutafis
- Department of Anesthesiology, Hôpital Foch, Suresnes, France
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Moutafis M, Dalibon N, Colchen A, Fischler M. Improving Oxygenation During Bronchopulmonary Lavage Using Nitric Oxide Inhalation and Almitrine Infusion. Anesth Analg 1999. [DOI: 10.1213/00000539-199908000-00008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sivitanidis E, Tosson R, Wiebalck A, Laczkovics A. Combination of extracorporeal membrane oxygenation (ECMO) and pulmonary lavage in a patient with pulmonary alveolar proteinosis. Eur J Cardiothorac Surg 1999; 15:370-2. [PMID: 10333038 DOI: 10.1016/s1010-7940(99)00013-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We describe a rare case of pulmonary alveolar proteinosis in a young woman with dyspnea and progressive hypoxaemia due to the alveolar deposition of insoluble, surfactant-like material. Routine treatment includes whole-lung-lavage (WLL) using double-lumen-tubes for selective lavaging of each lung. We performed three whole-lung-lavages and used veno-venous extracorporeal membrane oxygenation (v-vECMO) to support oxygenation during these procedures.
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Affiliation(s)
- E Sivitanidis
- Department of Cardiac and Thoracic Surgery, Ruhr-University-Hospital Bergmannsheil, Bochum, Germany
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Nagasaka Y, Takahashi M, Ueshima H, Tohda Y, Nakajima S. Bronchoalveolar lavage with trypsin in pulmonary alveolar proteinosis. Thorax 1996; 51:769-70. [PMID: 8882090 PMCID: PMC472506 DOI: 10.1136/thx.51.7.769] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Two cases of pulmonary alveolar proteinosis were treated with bronchoalveolar lavage (BAL) via a fibreoptic bronchoscope. Additional clinical improvement was seen when trypsin was added to the lavage fluid. Analysis of effluents in the BAL fluid showed marked reduction of protein constituents with clinical improvement after treatment with trypsin in the lavage. BAL with trypsin was well tolerated.
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Affiliation(s)
- Y Nagasaka
- Fourth Department of Medicine, Kinki University School of Medicine, Osaka, Japan
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Hurrion EM, Pearson GA, Firmin RK. Childhood pulmonary alveolar proteinosis. Extracorporeal membrane oxygenation with total cardiopulmonary support during bronchopulmonary lavage. Chest 1994; 106:638-40. [PMID: 7774361 DOI: 10.1378/chest.106.2.638] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Partial cardiopulmonary bypass with extracorporeal membrane oxygenation to allow bilateral bronchopulmonary lavage in pulmonary alveolar proteinosis has been described. However, this technique is complicated by a very low arterial PO2 and cardiovascular embarrassment. Total cardiopulmonary support avoids these problems and was successfully used in a 2 1/2-year-old girl.
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Affiliation(s)
- E M Hurrion
- Department of Pediatric Cardiothoracic Surgery, Groby Road Hospital, Leicester, United Kingdom
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Dahmash NS, Al-Majed S, Sassi M. Fulminant respiratory failure secondary to alveolar proteinosis. Ann Saudi Med 1993; 13:375-7. [PMID: 17590705 DOI: 10.5144/0256-4947.1993.375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- N S Dahmash
- Departments of Pulmonary Critical Care Medicine and Pathology, King Khalid University Hospital, Riyadh, Saudi Arabia
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Moulton SL, Krous HF, Merritt TA, Odell RM, Gangitano E, Cornish JD. Congenital pulmonary alveolar proteinosis: failure of treatment with extracorporeal life support. J Pediatr 1992; 120:297-302. [PMID: 1341413 DOI: 10.1016/s0022-3476(05)80448-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pulmonary alveolar proteinosis, a rare disease in neonates, is characterized by the accumulation of insoluble amorphous material within the alveoli. We describe two pairs of siblings with pulmonary alveolar proteinosis in two otherwise unaffected families. All four patients were term neonates in whom severe pulmonary failure developed within hours after birth; three had mature lung profiles. Radiographic lung markings were characterized by an early granular pattern followed by lung opacification. All patients were treated with extracorporeal life support for periods of 212 to 381 hours, but none survived. Life spans ranged from 16 to 190 days. We speculate that pulmonary alveolar proteinosis in neonates results from a genetic defect in surfactant processing that may not be amenable to conventional or unconventional therapies, including extracorporeal life support.
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Affiliation(s)
- S L Moulton
- Department of Surgery, University of California San Diego
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Affiliation(s)
- R H Bartlett
- University of Michigan Medical Center, Ann Arbor
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Jansen HM, Zuurmond WW, Roos CM, Schreuder JJ, Bakker DJ. Whole-lung lavage under hyperbaric oxygen conditions for alveolar proteinosis with respiratory failure. Chest 1987; 91:829-32. [PMID: 3581931 DOI: 10.1378/chest.91.6.829] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Whole-lung lavage under hyperbaric oxygen conditions was performed in two patients suffering from severe respiratory insufficiency in pulmonary alveolar proteinosis. Under these conditions, gas exchange was maintained and the mixed venous partial pressure of oxygen and oxygen saturation showed increases to acceptable levels. This enabled us to limit the FIO2 in order to extend the oxygen tolerance and to perform lavage procedures more effectively. Both patients showed a very significant improvement of their clinical course, and we conclude that elective use of hyperbaric oxygen in unilateral lung lavages should be considered in these severe cases.
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Prakash UB, Barham SS, Carpenter HA, Dines DE, Marsh HM. Pulmonary alveolar phospholipoproteinosis: experience with 34 cases and a review. Mayo Clin Proc 1987; 62:499-518. [PMID: 3553760 DOI: 10.1016/s0025-6196(12)65477-9] [Citation(s) in RCA: 168] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A retrospective review of Mayo Clinic records through 1983 revealed 84 patients (24 male and 10 female; mean age, 41 years) with the diagnosis of pulmonary alveolar phospholipoproteinosis. The major clinical features were dyspnea, cough, fever, and chest pain. Chest roentgenograms usually showed bilateral symmetric alveolar infiltrates, but asymmetric, unilateral, and chronic patchy patterns were also noted. Diagnosis was established by thoracotomy-lung biopsy in 26 patients. Histologic analysis revealed uniform filling of the alveoli by periodic acid-Schiff-positive material and maintenance of normal alveolar architecture. Electron microscopy showed enlarged alveolar macrophages with lamellar osmiophilic inclusions, dense granules, and myeloid bodies. Of the 21 patients who underwent therapeutic bronchoalveolar lavage, 13 had no recurrence of the disease during a mean follow-up of 8.8 years. In patients who underwent pulmonary function testing both before and after lavage, significant restrictive dysfunctions present before the procedure were alleviated afterward. Three deaths occurred among the 34 patients. Pulmonary alveolar phospholipoproteinosis may result from defective clearance of phospholipids by the alveolar macrophages, excessive production of phospholipids by type II pneumocytes, or both. It is likely a nonspecific response to a variety of injuries to the alveolar macrophage or type II pneumocyte or both, including exposure to certain dusts and chemicals and occurrence of hematologic diseases or infections. The uncommon occurrence of this disorder suggests individual susceptibility.
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Fernandez-Bujarrabal Villoslada J, Garcia De Cabo A, Hermida Gutierrez J, Nevado Caballero A, Sanchez Agudo L, Guerra Sanz F. Proteinosis alveolar: a proposito de tres observaciones. Arch Bronconeumol 1985. [DOI: 10.1016/s0300-2896(15)32192-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Claypool WD, Rogers RM, Matuschak GM. Update on the clinical diagnosis, management, and pathogenesis of pulmonary alveolar proteinosis (phospholipidosis). Chest 1984; 85:550-8. [PMID: 6368143 DOI: 10.1378/chest.85.4.550] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Hiratzka LF, Swan DM, Rose EF, Ahrens RC. Bilateral simultaneous lung lavage utilizing membrane oxygenator for pulmonary alveolar proteinosis in an 8-month-old infant. Ann Thorac Surg 1983; 35:313-7. [PMID: 6830367 DOI: 10.1016/s0003-4975(10)61565-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Pulmonary alveolar proteinosis can result in severe hypoxemia. Treatment of symptomatic patients using unilateral or lobar staged lung lavage often results in improved oxygenation and functional capacity. Lung lavage is technically difficult in infants and small children because of inability to ventilate part of the lung safely and adequately during lavage of other areas. We used extracorporeal membrane oxygenation to facilitate adequate gas exchange during lung lavage for severe respiratory failure in a 3.7 kg, 8-month-old child with pulmonary alveolar proteinosis. Oxygenation was markedly improved immediately following the procedure. Extracorporeal membrane oxygenation permits satisfactory respiratory support in the setting of severe respiratory failure and should be considered an adjunct for treatment of pulmonary alveolar proteinosis when lung lavage cannot be otherwise safely accomplished.
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Heymach GJ, Shaw RC, McDonald JA, Vest JV. Fiberoptic bronchopulmonary lavage for alveolar proteinosis in a patient with only one lung. Chest 1982; 81:508-10. [PMID: 7067517 DOI: 10.1378/chest.81.4.508] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Bronchopulmonary lavage with a fiberoptic bronchoscope was performed on a patient with alveolar proteinosis and only one lung. Lavage was performed under general anesthesia with continuous monitoring of oxygen saturation. Sequential washing of subsegments of his right upper and middle lobes did not compromise gas exchange to the remaining lower lobe. The patient tolerated the procedure without difficulty and had rapid improvement in pulmonary function and exercise capability, persisting during two months of follow-up. The necessity for cardiopulmonary bypass to provide oxygenation was anticipated and new equipment was designed should it have been required.
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Freedman AP, Pelias A, Johnston RF, Goel IP, Hakki HI, Oslick T, Shinnick JP. Alveolar proteinosis lung lavage using partial cardiopulmonary bypass. Thorax 1981; 36:543-5. [PMID: 7314027 PMCID: PMC1020439 DOI: 10.1136/thx.36.7.543] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
An adult case of pulmonary alveolar proteinosis presented with an arterial oxygen tension of 27 mmHg (3.6 kPa) while breathing air. Dangerous hypoxaemia during lung lavage was avoided by using partial cardiopulmonary bypass.
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