How to minimise ventilator-induced lung injury in transplanted lungs: The role of protective ventilation and other strategies (original) (raw)
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Mechanical ventilatory support in potential lung donor patients
Chest, 2014
Lung transplantation reduces mortality in patients with end-stage lung disease; however, only approximately 21% of lungs from potential donor patients undergo transplantation. A large number of donor lungs become categorized as unsuitable for lung transplantation as a result of lung injury around the time of brain death. Limiting this injury is key to increasing the number of successful lung procurements and subsequent transplants. This narrative review by a working group of pulmonologists, respiratory therapists, and lung transplant specialists elucidates principles of mechanical ventilatory support that can be used to limit lung injury in potential lung donor patients and examines the implementation of protocolized strategies in enhancing the procurement of donor lungs for transplantation.
Lung Transplantation for Ventilator-Dependent Respiratory Failure
The Journal of Heart and Lung Transplantation, 2009
Lung transplantation of patients on mechanical ventilation is controversial, but successful transplantation of these patients has been reported. This report describes our institutional experience with lung transplantation of mechanically ventilated patients since 2003. A retrospective cohort study was performed of all adult patients who underwent transplantation between October 2003 and October 2007. The patients on mechanical ventilation before transplantation were compared with patients without mechanical ventilation before transplantation. Survival, intensive care unit and hospital length of stay, post-transplant mechanical ventilation days, and primary graft function were analyzed. Before transplantation, 15 patients received mechanical ventilation for a median of 20 days (range, 5-90 days); of these, 13 underwent transplantation, and 2 died waiting for transplantation. The control group comprised 70 patients. Time on the transplantation waiting list was significantly shorter for the study group vs the control group. The 2 groups did not differ in survival, post-transplantation hospital time, and primary graft dysfunction scores at 0, 24, 48 and 72 hours after transplantation. Median time of mechanical ventilation after transplantation and median length of stay in the intensive care unit stay were longer in the study group. The survival rate and post-operative clinical course of patients undergoing transplantation while receiving mechanical ventilation for respiratory failure suggest that these patients can be considered for lung transplantation. Despite a longer time on post-operative mechanical ventilation and length of ICU stay, outcome is similar to that of other lung transplant candidates.
The Journal of Thoracic and Cardiovascular Surgery, 2010
The study objectives were to (1) compare survival after lung transplantation in patients requiring pretransplant mechanical ventilation or extracorporeal membrane oxygenation with that of patients not requiring mechanical support and (2) identify risk factors for mortality. Data were obtained from the United Network for Organ Sharing for lung transplantation from October 1987 to January 2008. A total of 15,934 primary transplants were performed: 586 in patients on mechanical ventilation and 51 in patients on extracorporeal membrane oxygenation. Differences between nonsupport patients and those on mechanical ventilation or extracorporeal membrane oxygenation support were expressed as 2 propensity scores for use in comparing risk-adjusted survival. Unadjusted survival at 1, 6, 12, and 24 months was 83%, 67%, 62%, and 57% for mechanical ventilation, respectively; 72%, 53%, 50%, and 45% for extracorporeal membrane oxygenation, respectively; and 93%, 85%, 79%, and 70% for unsupported patients, respectively (P < .0001). Recipients on mechanical ventilation were younger, had lower forced vital capacity, and had diagnoses other than emphysema. Recipients on extracorporeal membrane oxygenation were also younger, had higher body mass index, and had diagnoses other than cystic fibrosis/bronchiectasis. Once these variables, transplant year, and propensity for mechanical support were accounted for, survival remained worse after lung transplantation for patients on mechanical ventilation and extracorporeal membrane oxygenation. Although survival after lung transplantation is markedly worse when preoperative mechanical support is necessary, it is not dismal. Thus, additional risk factors for mortality should be considered when selecting patients for lung transplantation to maximize survival. Reduced survival for this high-risk population raises the important issue of balancing maximal individual patient survival against benefit to the maximum number of patients.
Jornal brasileiro de pneumologia : publicaça̋o oficial da Sociedade Brasileira de Pneumologia e Tisilogia
To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or g...
2009
One of the most difficult organs to procure for donation is the lung. A detailed understanding of the physiology of mechanical ventilation and its effect on donor lungs is needed to impact on the outcome of lung transplantation. An organized protocol for mechanical ventilation management of the organ donor using the Open Lung Model may positively affect the number of organs that can be procured, and the function of these organs post transplant. Based on physiologic principles, the use of new modes of ventilation may affect the modulation of cytokines, decrease the transmigration of organisms into the donor lung, and preserve surfactant function in that lung. Therefore, we have developed a protocol guided by physiologic-based parameters and airway pressure release ventilation (APRV), with ongoing feedback from an advanced respiratory care team to manage donor patients closely.
Lung transplantation is warranted for stable, ventilator-dependent recipients
The Annals of Thoracic Surgery, 2000
Background. Lung transplantation for patients on ventilators is a controversial use of scarce donor lungs. We have performed 500 lung transplants in 12 years and 21 of these have been in ventilator-dependent patients. Methods. A retrospective review of patient records and computerized database was performed. Living patients were contacted to confirm their health and functional status. Results. Patients included 13 men and 8 women with a mean age of 43 years. Sixteen patients were considered stable awaiting lung transplant, whereas 5 patients were unstable with acute graft failure after prior lung transplantation. Stable patients had been ventilated for a mean of 57 ؎ 46 days whereas unstable patients had been supported for 10 ؎ 9 days. Half of the patients required cardiopulmonary bypass support during the transplant, and there was no statistical difference in the frequency of CPB in stable and unstable patients (p ؍ 0.61). Three hospital deaths included 0 of 16 of the stable patients and 3 of 5 of the unstable patients (p ؍ 0.01). Long-term actuarial survival was significantly better in stable versus unstable patients (p ؍ 0.02), with 5-year survival 40% for stable patients and 0% for unstable patients. Conclusions. Lung transplantation can be successfully conducted in stable patients who have become ventilator dependent after listing for transplantation. Acute retransplantation for early lung dysfunction is high risk and has produced poor long-term results.