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Abstract. pulmonary alveolar proteinosis (pap) is a rare disease characterized by the accumulation of lipoproteinaceous material within alveolar spaces. Whole-lung lavage (Wll) has been the most common therapeutic intervention for this disorder. however, patients presenting with pap are usually hypoxemic or in poor clinical condition, and Wll may be impossible to perform. in such cases, multiple segmental lavage (MSL) may be advocated as a first-choice therapy prior to Wll. herein, we present two cases with idiopathic pap treated successfully with both lavage techniques consecutively. after the mSl procedure, Wll was performed, and both patients showed a marked clinical and physiologic improvement. therefore, for patients who are not good candidates for general anesthesia, we recommend mSl (or 'prewash') before Wll to produce an increase in the blood oxygen level for long-duration general anesthesia. in the surgical room, close monitoring and repositioning of the patient as well as maintenance and inspection of the correct tube position, and manual chest wall percussion are extremely important for the safety and success of the procedure. IntroductionPulmonary alveolar proteinosis (PAP) is a rare disorder first described in 1958 by rosen et al (1). alveolar spaces are progressively filled with a phospholipoproteinaceous material presumably caused by malfunction of the balance between surfactant production by type ii pneumocytes and surfactant removal. the latter is affected primarily by alveolar macrophages. A diagnosis of PAP can be confirmed by typical histopathological findings of lung biopsy specimens or the appearance of bronchoalveolar lavage. Whole-lung lavage (Wll) introduced by ramirez in the late 1960s, is still the gold standard therapy (2). therapy with granulocyte macrophage colony-stimulating factor (Gm-cSF) is another option, but its long-term safety has not yet been confirmed (3). The severity and natural history of alveolar proteinosis is variable, and severe hypoxemia may occur during the course of the disease. in patients with poor clinical condition and hypoxemia, Wll is difficult to perform due to possible complications involving general anesthesia. Wll often requires more than 4 hours per lung to perform (4). For surgery, the time is longer, and complication rates can be high. in these patients, multiple segmental lavage (MSL) with flexible bronchoscopy (FB) can be initially carried out to prepare the patient for the long-lasting general anesthesia required for Wll. Materials and methodsMultiple segmental lavage. In our technique, FB is wedged as accurately as possible in all of the segments without error during the procedure. Before and during MSL, 2% xylocaine and low-dose parenteral sedation with midazolam and phentanyl are administered. in general, the lavage is preferably carried out on the lung part or lobe noted to have the most extensive accumulation as determined by radiology. While the patient breaths oxygen through a nasal cannula, a FB is passed through the mouth and placed in ea...

BackgroundEven in oligometastatic stage 4 disease, survival rates are higher when curative approaches focus on both the primary tumour and metastasis. So, we aim to analyse our results of oligometastatic disease retrospectively.MethodsIn total, data on 52 non‐small‐cell lung cancer (NSCLC) patients with limited metastasis (one to three synchronous/metachronous) were retrospectively analysed. All treatment modalities associated with various treatment modalities [surgery, chemoradiotherapy (CRT), supportive care and palliative chemotherapy] were compared in terms of survival. Curative treatment consisted of surgery or CRT (concurrent or sequential).ResultsThe median overall survival (OS) time was 35.2 ± 4.1 months. Surgery was superior to CRT in terms of OS (36.7 months vs 27.4 months, P > 0.05). Progression‐free survival was 29.4 ± 3.9 months, and survival after first progression (SAFP) was 15.6 ± 2.8 months. Patients in whom a metastasectomy was performed had significantly higher rate of SAFP as compared with those who did not have a metastasectomy (20.07 ± 3.8 months vs 7.9 ± 1.7 months P = 0.046). According to pathological type, an adenocarcinoma was associated with better SAFP than a non‐adenocarcinoma (23 ± 4.1 vs 6.4 ± 1.5, P = 0.002). The 1‐ and 2‐years OS rates were 67% and 50.4%, respectively. Among the curative treatment group, the OS of patients younger than 65 years (n = 25) was 31 months, whereas that of patients older than 65 years (n = 13) was 22 months (P = 0.88).ConclusionIn well‐selected NSCLC patients with limited metastasis, survival rates can reach up to 3 years, even in a geriatric population. Clinical N staging and co‐morbidity are important prognostic factors.

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Optimal management of respiratory diseases like asthma and chronic obstructive pulmonary disease, in patients of all ages, requires sufficient drug delivery to the airways by inhaler devices 1 ; a proper inhaling technique is also essential. Inhaler therapy is the most effective approach to treat respiratory disease patients; however, the reported proportion of patients using incorrect inhalation techniques varies widely, between 27% and 89%. 2,3 Patients should learn to use inhaler devices effectively to ensure sufficient delivery of the drug to the airways; one of the major weaknesses of aerosol therapy is the need for a specific inhalation technique for proper use of each of the different types of inhaler devices. 4 The different kinds of inhalers available have their own specific features. 5 Patient characteristics associated with a