Risk Factors for Postoperative Sore Throat in Patients with a Double-lumen Endotracheal Tube / 中山大学学报(医学科学版)

ObjectiveTo investigate risk factors for postoperative sore throat in patients with double-lumen endotracheal intubation. MethodsThe data used in this post-hoc analysis were prospectively collected from a randomized， controlled trial. Age from 18 to 65 years old， ASAI-Ⅲ patients undergoing general anesthesia with a double-lumen endotracheal tube were enrolled. The perioperative data collected retrospectively were as follows： gender， age， smoking history， endotracheal tube diameter， duration of endotracheal tube， dose of Sufentanil， use of Flurbiprofen Axetil， cough after extubation， etc..Dynamometer was applied to assess extubation force. According to occurrence of postoperative sore throat， patients were divided into two groups： those who experienced sore throats and those who did not. Comparative analysis and multivariate logistic regression analysis were performed to screen the risk factors. ROC curve was used for predicting the predictive value of risk factors. ResultsAmong the 163 patients ， 74 （45.4%） had postoperative sore throat vs 89 （54.6%） not had. Multivariate logistic regression showed female ［OR95%CI=3.83（1.73， 8.50）， P=0.000 1］ and extubation force ［OR95%CI=1.78（1.45， 2.17）， P＜0.001］ were independent risk factors for postoperative sore throat. AUC value showed the extubation force was 0.773［95%CI（0.701， 0.846）， P＜0.001］. Youden index was 0.447， and the cut-off valve of extubation force was 13N. ConclusionFemale and extubation force were risk factors for sore throat in patients with double lumen endotracheal intubation.

Right visual double lumen endotracheal tube versus common right double lumen endotracheal tube lung isolation technique: A randomized controlled study / 中国胸心血管外科临床杂志

@#Objective    To compare the clinical efficacy between right visual double lumen tube (VDLT) intubation and right common double lumen tube (DLT) intubation in lung isolation technique. Methods    A total of 57 patients undergoing thoracoscopic surgery with right DLT lung isolation technique in the First People's Hospital of Chenzhou City and West China Hospital from June 2020 to June 2021 were randomly divided into two groups: a DLT group (n=29, 16 males and 13 females, with a mean age of 54.3±13.2 years) and a VDLT group (n=28, 18 males and 10 females, with a mean age of 55.1±13.7 years) at 1 : 1 with random number table generated by the computer. The clinical data of the two groups were compared. Results    Compared with the DLT group, the catheter positioning time in the VDLT group was statistically shorter (74.9±47.5 s vs. 151.6±88.9 s, P<0.001), the right upper lung occlusion rate (21.4% vs. 51.7%) and the intraoperative re-adjustment catheterization rate (14.3% vs. 48.3%) were lower (P<0.05). The quality of lung collapses immediately after thoracotomy (67.9% vs. 24.1%) and 20 minutes after thoracotomy (100.0% vs. 75.9%) were improved (P<0.05). There was no significant difference in the rate of fiberoptic bronchoscope assistance for positioning, or the incidence of pharynx pain and hoarseness between the two groups (P>0.05). Conclusion    Compared  with common DLT, VDLT is more efficient, accurate and intuitive in the location of right bronchial intubation.

Bronchial Blocker and Double?Lumen Endotracheal Tube Combination to Facilitate Lung Isolation during Esophagectomy

Lung isolation is an essential anesthetic technique utilized in thoracic surgeries. We present a patient undergoing esophagectomy that developed an iatrogenic injury to the left mainstem bronchus that damaged the bronchial cuff of a left?sided double?lumen endotracheal tube (DLETT). A bronchial blocker (BB) was placed in the tracheal lumen of the DLETT as a rescue method to facilitate continued lung isolation. This unusual combination of a DLETT and a BB proved useful once the bronchial cuff was compromised and may serve as a viable solution to maintain lung isolation in similar circumstances

Efficacy of early cold budesonide atomization inhalation on postoperative sore throat following double-lu-men endotracheal intubation / 实用医学杂志

Objective To evaluate the efficacy of early controlled cold atomization inhalation of budesonide in the treatment of post-operative sore throat (POST) after double-lumen endotracheal intubation. Methods A total of 105 ASAⅠ~Ⅲpatients having POST after thoracic surgery with double-lumen endotracheal intubation were randomly divided into three groups(n = 35 each). The patients in the control group were treated with atomization inhalation of 12 mL 20℃saline(Group C)and those in the observation groups were treated with 10 mL 20℃saline plus 2 mL(1 mg)budesonide(Group R)or 10 mL 0℃saline plus 2 mL(1 mg)budesonide (Group L)for 15 minutes immediately after extubation. The 4-score scale was used to evaluate sore throat,dry throat,hoarseness and swallowing difficulty 1,2,6 and 24 h after the extubation and QoR-40 scale to assess post-operative recovery at 24 h. Results The scores of sore throat and dry throat were significant lower in group L than those in group C(P < 0.05)at 1,2 and 24 h and the score of swallowing difficulty(dysphagia)was also signifi-cant relieved at 1,6 and 24 h after the extubation in group L. Furthermore,the score of sore throat was significant lower in group L than that in group R(P<0.05)at 1 h. There were no significant differences of hoarseness in three groups(P > 0.05). The total score of QoR-40 scale was the significantly highest in group L than that in group C and group R(P<0.05)24 h postoperatively. Conclusion Cold atomization inhalation of budesonide immediately after the extubation of double-lumen endotracheal can alleviate POST and bring more benefits to patients which help to enhance the recovery after throracic surgery.

Management of right main bronchial rupture with a double lumen endotracheal tube in a patient with blunt chest trauma

Tracheobronchial disruption is one of the most severe injuries caused by blunt chest trauma. It may cause airway obstruction and resulting life-threatening respiratory deficiency. However, the clinical presentations are variable and frequently difficult to diagnose. We report a case of a previously healthy 16-year-old man with complete right main bronchial transection sustained after a vehicular accident, who had progressive dyspnea, subcutaneous emphysema in the neck and anterior chest wall, and bilateral tension pneumothorax. Prompt chest tube drainage for suspected bilateral tension pneumothorax and a tracheal intubation were performed. Shortly after the positive pressure ventilation, severe subcutaneous emphysema developed and he was at risk for developing shock. Additional chest tubes were inserted. An emergency bronchoscopy showed rupture of the right main bronchus. After changing to a double lumen endotracheal tube, the patient’s condition improved. A surgical closure was performed and postoperative bronchoscopy showed good repair. The patient was discharged without complications.

Double-lumen endobronchial intubation-related anatomical factors of respiratory tract in adult pa-tients: measurement of glottis and left main bronchus using computed tomography / 中华麻醉学杂志

Objective To investigate the double-lumen endobronchial intubation-related anatomical factors of respiratory tract in adult patients through measurement of the parameters of glottis and left main bronchus using computed tomography(CT). Methods A total of 206 patients of both sexes, aged 20-80 yr, of American Society of Anesthesiologists physical status Ⅰ-Ⅲ, scheduled for elective surgery, were enrolled in this study.The cervical and thoracic CT images were evaluated.The anteroposterior glottic diame-ter(AP-GD), anteroposterior tracheal diameter(AP-TD), transverse tracheal diameter(Tr-TD), left and right main bronchus diameters(LBD and RBD)and length between glottis and carina(G-TL)were measured.Multiple linear regression analyses were performed to detect the correlations between obtained pa-rameters and between obtained parameters and height. Results AP-GD was(19±3)mm, AP-TD(20± 4)mm, Tr-TD(16.6±2.4)mm, LBD(12.3±2.0)mm, RBD(13.7±2.0)mm and G-TL(126± 11)mm.AP-GD, height, AP-TD and Tr-TD were moderately correlated with LBD(r was 0.522, 0.584, 0.648 and 0.606, respectively, P<0.05).AP-TD +Tr-TD+AP-GD+height served as the inde-pendent variable, the fitting curve was confirmed, and the results showed that AP-TD, Tr-TD and height were the affecting factors for LBD, and the degree of correlation with LBD was as follows from high to low:Tr-TD(b′=0.334), AP-TD(b′=0.323), height(b′=0.243). When AP-GD served as the independ-ent variable and curve fitting was performed, there was no significant difference(P>0.05). Conclusion Tr-TD and AP-GD should be considered besides double-lumen endobronchial intubation-related anatomical factors such as LBD and height in adult patients.

Effects of superior laryngeal nerve block combined with intratracheal surface anesthesia on stress response in elderly hypertensive patients undergoing double-lumen tracheal intubation / 临床麻醉学杂志

Objective To observe the effects of ultrasound-guided laryngeal nerve block combined with intratracheal surface anesthesia on the intubation reaction of double-lumen endotracheal tube in elderly hypertensive patients.Methods Sixty elderly hypertensive patients,including 37 males and 23 females, with ASA physical statusⅡor Ⅲ,aged 65-85 years,scheduled for thoracic surgery under general anesthesia requiring one-lung ventilation,were equally and randomly divided into either laryngeal nerve block combined with intratracheal surface anesthesia group (group S)or general anesthesia group (group C).Internal jugular vein blood samples were taken to measure the plasma concentrations of epinephrine (E)and norepinephrine (NE) when patients entering the operating room (T0 ),before intubation (T1 ),immediately after intubation (T2 ),at 1 min (T3 ),3 min (T4 ),5 min (T5 )and 10 min (T6 )after intubation.Adverse e-vents,such us hypertension and tachycardia,were recorded during induction and intubation.Results Com-pared with T0 ,the plasma concentrations of E and NE were significantly increased at T2-T5 in group C (P<0.05 or P <0.01),while there were no such significant changes in group S.The plasma concentration of E and NE at T2-T5 in group S were significantly lower than that in group C (P <0.05 or P <0.01).The incidence of hypertension in group S was significantly lower than that in group C during induction of intuba-tion (0% vs 37%,P <0.01).There were no hypotension,tachycardia and bradycardia during induction and intubation in both groups.Conclusion Ultrasound-guided laryngeal nerve block combined with intratra-cheal surface anesthesia can effectively inhibit the intubation reaction of double-lumen endotracheal tube in elderly hypertensive patients,which is helpful for maintaining the hemodynamic stability during anesthesia induction.

Study on airway management of patients with double-lumen tracheal intubation during anesthesia recovery period / 中国生化药物杂志

Objective To explore the airway management strategy of patients with double-lumen tracheal intubation during anesthesia recovery period.MethodsA retrospective analysis of clinical data of 60 patients who underwent double-lumen tracheal intubation were enrolled from december 2014 to december 2016 in oue hospital was conducted.The mean arterial pressure (MAP), blood oxygen saturation (SpO2), heart rate (HR) and respiration (R) of all patients were measured at different time points,before and after operation, before and after extubation.ResultsThere was no significant difference in MAP and SpO2 between before and after operation,the levels of MAP and SpO2 before extubation and in extubation were significantly higher than those before operation (P<0.05), and five to ten minutes after extubation returned to the preoperative level.There was no significant difference in HR and R indexes between before and after operation, and the HR and R indexes in extubation and before extubation were significantly higher than those before operation, the difference was statistically significant(P<0.05), which was returned to preoperative level ten minutes after extubation.ConclusionIn the patients with double-lumen tracheal intubation, the observation and scientific care of the airway in the recovery period of anesthesia can not only ensure the stability of the vital signs, but also improve the safety of the patients.It is worthy of clinical application.

Clinical differences between artificial pneumothorax and double lumen intubation in thoracoscopic esophagectomy / 局解手术学杂志

Objective To explore the advantages and disadvantages of the double lumen endotracheal intubation and single -lumen endo-tracheal intubation and continuous carbon dioxide insufflation in thoracoscopic esophagectomy .Methods The clinical data of 90 patients in our department of thoracic surgery after thoracoscopic esophagectomy from January 2014 to April 2015 were analyzed .All patients were divid-ed into single-lumen endotracheal intubation (group A)and double lumen endotracheal intubation group (group B).The endotracheal intuba-tion time,operation time,incidence of pulmonary infection,intraoperative and postoperative PaO2,PaCO2,incidence of anastomotic fistula, hospitalization expenses ,length of hospital stay and the incidence of postoperative chylothorax between two groups were compared .Results The difference in intraoperative PaO2,PaCO2,incidence of pulmonary infection,endotracheal intubation time,operation time,hospitalization days and the hospitalization cost between two groups were statistical significance .The difference of the rest index between two groups were no statistical significance.Conclusion Group A has certain advantages in perioperative management ,hospitalization cost and so on,but has disadvantages in perioperative hypoxemia and carbon dioxide retention and acid -base balance disorders .

Small incision thymectomy under single lumen endotracheal intubation of thoracoscope / 中国内镜杂志

Objective To investigate the difference between single lumen endotracheal intubation of thoracoscope and traditional double lumen endotracheal intubation of thoracoscope in process of thymectomy. Methods From January 2010 to June 2014, clinical data of 30 cases with thymectomy under single lumen endotracheal intubation of thoracoscope (group A) and 30 cases with thymectomy under traditional double lumen endotracheal intubation thora-coscope (group B) were analyzed. Results There were no death patients in both groups. Group A:endotracheal intu-bation time (2.67 ± 0.72) min, surgery time (48.37 ± 4.64) min, the bleeding (26.17 ± 9.62) ml; Group B:endotracheal intubation time (5.55 ± 0.71) min, surgery time (52.10 ± 5.68) min, the bleeding (33.00 ± 7.94) ml. Conclusion Compared with traditional double lumen endotracheal intubation under thoracoscope, the single lumen endotracheal intubation of thoracoscope showed that intubation time was significantly shorter, and reduced the oc-currence of postoperative complications, the operative field was exposed more completely, reduced operation time and blood loss.

Comparison of Shikani optical stylet and Macintosh laryngoscope for double-lumen endotracheal tube intubation / 北京大学学报(医学版)

Objective:To compare the efficacy and safety of Shikani ( S) optical stylet and Macintosh (M) laryngoscope for double-lumen endotracheal tube intubation .Methods:In the study, 60 patients undergoing elective thoracic surgery were randomly allocated to group S ( n=30 ) and group M ( n=30 ) . After general anesthesia induction , the patients in group S and group M were intubated double-lumen en-dotracheal tube ( DLT) by Shikani optical stylet ( SOS) and macintosh laryngoscope respectively .Intuba-tion time, intubation attempts , cuff broken and oral mucosal or dental injury were recorded;Blood pres-sure and heart rate at baseline ( T0 ) , at the time of intubaiton onset ( T1 ) , 1 minute after intubaiton (T2), 3 minutes after intubation (T3) and 5 minutes after intubation (T3) were also recorded;Hoarse-ness and throat sore of the patients 24 hours after surgery were evaluated .Results:The intubaiton time with the SOS was faster than with the Macintosh [(37.4 ±9.7) s vs.(43.9 ±13.7) s, P=0.039] and the first attempt success rate (87%vs.80%, P=0.488) did not differ between the groups; No tube cuff broke in both the groups;Group S had fewer patients who suffered oral mucosal or dental injury than group M (8 vs.2, P=0.038);The blood pressure and heart rate at T0,T1,T2,T3 and T4 did not differ between the groups;Throat sore(7 vs.10, P=0.390) and hoarseness (5 vs.7, P=0.519) incidence did not differ between the groups .Conclusion:By comparison of the Macintosh laryngoscope , the SOS provides faster DLT intubation and causes less oral Mucosal or dental injury .

The effect on the strees response of laryngeal mask airway as a transition method after double endotrache-al anesthesia / 临床麻醉学杂志

Objective This study was to investigate the effect of using laryngeal mask airway (LMA)as a transition method after double lumen endotracheal anesthesia on the stress response dur-ing the extubation period.Methods Ninety patient underwent general anesthesia with double lumen endotracheal intubation were randomly divided into 3 groups:group A,B and C (n=30).Patients in group A were extubated directly after surgery.The double lumen endotracheal tube were changed to single lumen endotracheal tube under deep anesthesia in group B patients,while the double lumen en-dotracheal tube were changed to LMA in group C.MAP,HR and rate pressure product (RPP)at the end of surgery (T0 ),1 minute before extubating the endotracheal tube (laryngeal mask)(T1 ),1 mi-nutes (T2 ),5 minutes after extubating (T3 )were recorded.The reaction of extubation,such as buc-king or restlessness,was also observed.Results Compared with T0 ,the MAP,HR,and RPP were significantly increased in groups A and B at T1-T3 (P <0.05 ).Compared with group A,the MAP, HR,RPP were significantly decreased in groups B and C at T1-T3 (P <0.05 ).The number of buc-king and restlessness in group C were lower than that in group A and group B (P < 0.05 ). Conclusion The use of laryngeal mask during the transition period in double lumen endotracheal anes-thesia to can reduce hemodynamic fluctuations and stress reaction during the extubation.

Clincal effect and anatomy of single lung ventilation by double-lumen endotracheal intubation / 局解手术学杂志

Objective To investigate the effects of two different methods of double-lumen endotracheal intubation in minimally invasive thoracoscopic surgery. Methods Based on different methods of endotracheal intubation,120 patients with bullae and spontaneous pneumo-thorax were randomly divided into the single left intubation group (60 cases) and the left and right intubation group (60 cases). The opera-tion time,blood loss,chest drainage volume,the time of pulmonary air leaks,white blood cell count and other indexes of the two groups were evaluated. Results The proportion of patients whose atelectasis degree was over 50% in the left and right intubation group occupied 48%, and it occupied 32% in patients whose atelectasis degree was over 70%. While the corresponding data in the single left intubation group were 5. 00% and 93% respectively. The differences were statistically significant (P<0. 01). The operative time and postoperative indicators of the single left intubation group were more significantly lower than those in the left and right intubation group. Conclusion The left double-lu-men endotracheal intubation has obvious advantages in maintenance and control of lung expansion and pulmonary ventilation during surgery, and it should be used in video assisted thoracoscopy surgery.

Endobronchial hemorrhage after intubation with double-lumen endotracheal tube in a patient with idiopathic thrombocytopenic purpura for minimally invasive cardiac surgery: a case report / 대한마취과학회지

Minimally invasive cardiac surgery (MICS) requires lung isolation. Lung isolation is usually achieved with double-lumen endotracheal tube (DLT). Patients with idiopathic thrombocytopenic purpura (ITP) have an increased risk of bleeding events. We suspected endobronchial hemorrhage after exchange of DLT during induction of anesthesia for replacement of mitral valve in a 62-year-old man with a known ITP. The MICS was stopped and bronchial artery embolization was performed in the angiographic room. In the present case, in order to reduce the risk of bronchial arterial injury in ITP patient we intubated with single lumen endotracheal tube. Lung isolation led to achievement of intermittent total lung deflation. Based on the results, we recommend a high-dose intravenous immunoglobulin therapy and platelet transfusion prior to cardiac surgery in patients with ITP to increase platelet count. Moreover, it is proposed that in order to clear the vision during the operation, ventilation can be held or made intermittent both prior to cardiopulmonary bypass or at its conclusion to permit exposure.

Transient bilateral vocal cord paralysis after endotracheal intubation with double-lumen tube: A case report / 대한마취과학회지

Vocal cord paralysis is one of the most serious anesthetic complications related to endotracheal intubation. The practitioner should take extreme care, as bilateral vocal cord paralysis can obstruct the airway and lead to disastrous respiratory problems. There have been many papers on bilateral vocal cord paralysis after neck surgery, but reports on such a condition after lung surgery are very rare. We report a case of bilateral vocal cord paralysis detected after removal of a double-lumen endotracheal tube in a 67-year-old patient who underwent wedge resection by video-assisted thoracoscopic surgery. We also note that he recovered spontaneously without complications within a day.

Total Atelectasis after Intubation of a Double Lumen Tube: A case report / 대한마취과학회지

The intubation of a double lumen endotracheal tube (DLT) has become the technique of choice for most procedures requiring one lung ventilation (OLV). The potential complications of the use of DLT are airway ruptures and malpositions of the DLT which can induce an increase of airway pressure, hypercapnia, severe hypoxemia, and other effects during the induction of general anesthesia. The intractable hypoxia due to total lung atelectasis is one of the very rare complications during and after intubation of the DLT. We experienced a 16 year-old male patient with severe hypoxia scheduled for thoracoscopy after a position change from supine to lateral decubitus. The hypoxia was unable to be easily corrected by endobronchial suction, rechecking of DLT position with fiberoptic bronchoscope, and manual positive ventilation, even after a position change to supine. An emergent chest X-ray revealed total atelectasis of the right lung that was relieved gradually by general supportive care at the intensive care unit.

Reexpansion Pulmonary Edema Occurred after Evacuating the Hepatic Hydrothorax in a Liver Transplant Patient: A case report / 대한마취과학회지

A hepatic hydrothorax is a pleural effusion that develops in patients with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. It is a complication of end-stage liver disease, and a liver transplant is the treatment of choice. In our case, a reexpansion pulmonary edema occurred after evacuating 4,250 ml of ascites and aspirating 3,600 ml of the pleural effusion within 15 minutes aimed at visually improving the surgical field in a 46-year-old male patient receiving a liver transplant. 1 hour 30 minutes after aspirating the pleural effusion, the level of oxygen saturation decreased from 100% to 95%, and serosanguinous fluid spilled over from the endotracheal tube. We inserted a double lumen endotracheal tube to both separate and protect the unaffected left lung, and applied CPAP 10 cmH2O at the affected right lung. The reexpansion pulmonary edema was successfully treated using this supportive management.

Successful Intubation of a Double-Lumen Endobronchial Tube Using the Modified Seldinger Technique Following Intubation of a Single-Lumen Endotracheal Tube in a Case of Difficult DLT Intubation -A case report- / 대한마취과학회지

Intubation of an double-lumen endotracheal tube (DLT) in either a normal or a difficult airway may be more difficult than the intubation of a single-lumen endotracheal tube (ETT). A 72-year-old man undergoing right upper lobectomy could not be intubated with either a 37 Fr or a 35 Fr DLT after induction of anesthesia due to an inability to visualize the glottis. Difficult intubation had not been foreseen, but inspection through the laryngoscope revealed a Cormack grade III condition. Following two attempts to place the DLT, fibroptic bronchoscopy also proved unsuccessful. We intubated a 8.0 mm ETT with OELM (optimal external laryngeal manipulation) and followed this by inserting an infusion set catheter into the ETT as a guiding stylet. The ETT was then withdrawn with the catheter in situ in the trachea, and a 35 Fr DLT successfully introduced. After removing the catheter, the position of the DLT was corrected by fibroptic bronchoscopy. No further complication occurred and surgery was finished satisfactory. We achieved successful DLT intubation using the modified Seldinger technique with an infusion set catheter through an intubated ETT in a patient with an unanticipated difficult airway.

Incidence of Malposition and it's Affecting Factors of Left-Sided Double-Lumen Endotracheal Tube / 대한마취과학회지

Backgroud: In one-lung ventilation using the left-sided double-lumen tube (LDLT), it is important to place the LDLT in correct position to maintain adequate ventilation. We investigated the frequency of and the factors affecting the LDLT malposition in endotracheal intubation. Methods: Ninety one (55 male and 36 female) patients were observed. After endotracheal intubation, using 35 and 37 Fr. sized Robertshaw type LDLT, auscultation and fiberoptic bronchoscope were performed to make sure the correct position of LDLT. The heights, weights, age, and sex were noted. The lengths and diameters of trachea, and the angles and diameters of both bronchi on chest x-ray were measured for comparison. Results: Normal in auscultation and gross malposition were 87.9% and 12.1%. Among those normal in auscultation, normal in bronchoscope, advancing and removing fine malposition were 66.2%, 18.8% and 15.0%, respectively. The angle of left bronchus is 37.71+/-4.60degrees in normal in ausculation and 37.71+/-4.60degrees in gross malposition. The length of trachea is 13.41+/-0.90 cm in normal in bronchoscope, 14.49+/-0.78 cm in advancing fine malposition and 11.86+/-0.35 cm in removing fine malposition. The patient's height is 167.27+/-7.12 cm in normal in brochoscope, 172.45+/-6.67 cm in advancing fine malposition and 163.12+/-6.54 cm in removing fine malposition. Conclusions: The angle of left bronchus is a factor affecting gross malposition. And the length of trachea and the patient's height are factors affecting fine malposition. Thus it is necessary to obtain in advance information on patient's height, length of trachea and angle of left bronchus on chest x-ray, to reduce the occurrence of the LDLT malposition.

Bilateral Sequential Bronchopulmonary Lavage in One Stage for Recurred Pulmonary Alveolar Proteinosis: A case report / 대한마취과학회지

Pulmonary alveolar proteinosis is a rare disease of unknown etiology characterized by the accumulation of phospholipids and proteinaceous material in the alveolar spaces. Sequential bronchopulmonary lavage with 2-4 days interval has been the most acceptable method of treatment. Prognosis after bronchopulmonary lavage is very variable. We have experienced recurred case of pulmonary alveolar proteinosis. In this case we have performed sequential lavage in one stage safely. Complete removal of lavage fluid, facilitation of oxygenation by ventilation of lavaged lung with positive end expiratory pressure, and adequate evaluation of oxygenation enabled sequential lavage in one stage. We report a case of sequential bronchopulmonary lavage in one stage in a patient with a recurred pulmonary alveolar proteinosis.