The effect of therapeutic bronchoalveolar lavage in mitigating aspiration pneumonia: case report

Dear Editor,
Anaesthesia for emergency life­saving surgery can pose challenges such as limited time for evaluation and preparation of the patient, haemodynamic instability, and fluid/electrolyte imbalance, and it is associated with high morbidity and mortality [1]. Usually, these patients are at high risk of aspiration due to inadequate fasting intervals. Despite adequate precautions, aspiration cannot be prevented in some cases. Aspiration is the inhalation of either oropharyngeal or gastric contents into the larynx and lungs [2]. The consequences are determined by the quantity and nature of the material aspirated, as well as the host’s response. The 3 syndromes associated with aspiration are chemical pneumonitis, bacterial pneumonia, and airway obstruction. The patient may have one or more of these, depending on the type of aspirate [2]. Aspiration of gastric acidic content can lead to chemical pneumonitis (Mendelson syndrome), while aspiration of bacteria from oral and pharyngeal areas can add to infection, and macro aspiration of gastric contents can lead to airway obstruction [3]. Aspiration pneumonia is associated with higher mortality than other forms of community-acquired pneumonias (29.4% vs. 11.6%) [4]. Bronchoalveolar lavage (BAL) is a minimally invasive procedure that involves instillation of sterile normal saline into a subsegment of the lung, followed by suction and collection of the instil­lation for analysis. In the context of aspiration, BAL has been described as a diagnostic technique with elevated a-amylase concentrations in BAL fluid as a marker of aspiration [5–7]. The role of therapeutic BAL is well known for pulmonary alveolar proteinosis [8]. We report the use of therapeutic BAL in mitigating the effects of aspiration in a patient undergoing emergency re-exploration for intra-abdominal bleeding.
A 48-year-old man underwent laparoscopy-assisted distal radical gastrectomy with D2 lymphadenectomy and Roux-en-Y retro-colic gastro-jejunostomy for carcinoma of the stomach following 3 cycles of neoadjuvant therapy. Early post-operative course was uneventful, and he was allowed oral liquids from day 2. On postope­rative day 5, he had intra-abdominal bleeding following drain removal. Due to profuse bleeding from the drain site, within minutes he became haemodynamically unstable, and emergency re-exploration surgery was planned. Because he had eaten a meal an hour ago, anaesthesia was induced in the Trendelenburg position and...


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