Bronchoalveolar lavage improved ventilation/perfusion matching in pediatric severe mycoplasma pneumoniae pneumonia with lung consolidation.

A 15-year-old girl was admitted to our Pediatric Intensive Care Unit (PICU) due to respiratory failure and septic shock. She was intubated and mechanically ventilated and received vasoactive drugs therapy. Chest CT scan showed opacities in both lungs with marked consolidation in the right (figure 1A). Saline contrast-enhanced electrical impedance tomography (EIT) was conducted with 10 ml 5% NaCl bolus injection through the central venous catheter.1 Significant reductions in ventilation and perfusion were observed in the right dorsal regions (figure 2A). Shunt percentage was much higher in the dorsal regions. The patient received bedside bronchoalveolar lavage with fiberoptic bronchoscope therapy in PICU. The airway mucosa was congested, edematous and diffusely hemorrhagic. White mucus plugs were observed in the right airway, especially in the basal segment of the right lower lobe. The terminal bronchioles (generations 5-7) were completely blocked (figure 3A-B). A total of 100 ml sterilized isotonic saline was instilled in five aliquots and the lavage fluid and sputum were sucked out subsequently with 100 mmHg negative pressure after each insufflation (figure 3C-D). The bronchoalveolar lavage fluid next-generation sequencing test suggested that the pathogen was mycoplasma pneumoniae and the patient was treated with levofloxacin. After receiving bronchoscopy and bronchoalveolar lavage for three consecutive days, bedside EIT measurement suggested improvements of ventilation and perfusion in the right dorsal regions (figure 2B). Shunt percentage was significantly reduced. The findings were coincided with subsequent CT scans (figure 1B). The patient was successfully weaned from ventilator 1 day after last bronchoalveolar lavage. To our knowledge, this is the first clinical report to evaluate the efficacy of bronchoalveolar lavage on regional ventilation and perfusion at the bedside in severe mycoplasma pneumoniae pneumonia with lung consolidation. In severe mycoplasma pneumoniae pneumonia, about 24.9% patients were accompanied with lung consolidation. Fiberoptic bronchoscopy and bronchoalveolar lavage therapy can help detecting mycoplasma pneumoniae pneumonia pathogen in time, with detecting infection, locating sputum plug and inflammatory polyps, and improving consolidation. 22 However, a real-time bedside tool for evaluating the effectiveness of bronchoalveolar lavage in PICU was still missing. Saline-bolus based EIT evaluating the ventilation-perfusion matching has been implemented in adult lung diseases. 1,31,3 This case shows that EIT has the potential to identify regional ventilation and perfusion defects in the lesion areas, as well as to evaluate the corresponding improvement after bronchoalveolar lavage. No side effects were observed after the 10 ml 5% NaCl bolus injection. Further studies are warranted to confirm the clinical use of EIT in bronchoalveolar lavage in various pediatric age group and lung diseases This article is protected by copyright. All rights reserved.