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INTRODUCTION ECMO as support during whole lung lavage (WLL) for pulmonary alveolar proteinosis is reserved for severe cases where oxygenation is inadequate to support the patient using the ventilator alone. While most publications describe a venovenous cannulation with variable results we present a successful case using venoarterial cannulation and discuss the potential benefits of this mode of ECMO support. CASE PRESENTATION We present the case of a 44 year old female with a past medical history of Behcets disease and a BMI of 37 who was diagnosed with pulmonary alveolar proteinosis (PAP) on a lung biopsy after presenting with dyspnea. As her supplemental oxygen needs escalated she was intubated and was difficult to oxygenate on a conventional ventilator. She was urgently taken to the operating room for venoarterial ECMO support and whole lung lavage. The patient was cannulated femorally using a 20 french venous catheter and an 18 french arterial catheter, with a retrograde arterial catheter to preserve distal perfusion to the right lower extremity. ECMO flow was satisfactory at 4L/min. The whole lung lavage was performed bilaterally using 12 liters of normal saline in one liter instillations with chest physiotherapy between liters. The character and color of the fluid was initially opaque and sero-sanguinous; at the conclusion of the 12 liter lavage the fluid was serous and transparent. Her oxygenation improved immediately post operatively and she was decannulated from ECMO on the fifth post-operative day without complications. DISCUSSION We propose that venoarterial ECMO is superior to venovenous ECMO during whole lung lavage because total cardiopulmonary support can be provided to the patient to maintain adequate oxygenation and hemodynamics. During whole lung lavage while the pulmonary vascular resistance increases, strain on the right ventricle increases and can be avoided with venoarterial ECMO. CONCLUSIONS Venoarterial ECMO for support during whole lung lavage for PAP may provide a superior alternative to venovenous ECMO in patients who are difficult to ventilate and/or oxygenate due to the severity of their disease. REFERENCES 1. 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 Sep;120(3):1024-6. 2. Centella T, Oliva E, Andrade IG, Epeldegui A. The use of a membrane oxygenator with extracorporeal circulation in bronchoalveolar lavage for alveolar proteinosis. Interact Cardiovasc Thorac Surg. 2005 Oct;4(5):447-9. Epub 2005 Jun 27. 3. Rogers RM, Szidon JP, Shelburne J, Neigh JL, Shuman JF, Tantum KR. Hemodynamic response of the pulmonary circulation to bronchopulmonary lavage in man. N Engl J Med. 1972 Jun 8;286(23):1230-3.

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