Intra‐operative protective mechanical ventilation in lung transplantation: a randomised, controlled trial

Abstract

Primary graft dysfunction occurs in up to 25% of patients after lung transplantation. Contributing factors include ventilator-induced lung injury, cardiopulmonary bypass, ischaemia-reperfusion injury and excessive fluid administration. We evaluated the feasibility, safety and efficacy of an open-lung protective ventilation strategy aimed at reducing ventilator-induced lung injury. We enrolled adult patients scheduled to undergo bilateral sequential lung transplantation, and randomly assigned them to either a control group (volume-controlled ventilation with 5 cmH O, positive end-expiratory pressure, low tidal volumes (two-lung ventilation 6 ml.kg , one-lung ventilation 4 ml.kg )) or an alveolar recruitment group (regular step-wise positive end-expiratory pressure-based alveolar recruitment manoeuvres, pressure-controlled ventilation set at 16 cmH O with 10 cmH O positive end-expiratory pressure). Ventilation strategies were commenced from reperfusion of the first lung allograft and continued for the duration of surgery. Regular PaO /F O ratios were calculated and venous blood samples collected for inflammatory marker evaluation during the procedure and for the first 24 h of intensive care stay. The primary end-point was the PaO /F O ratio at 24 h after first lung reperfusion. Thirty adult patients were studied. The primary outcome was not different between groups (mean (SD) PaO /F O ratio control group 340 (111) vs. alveolar recruitment group 404 (153); adjusted p = 0.26). Patients in the control group had poorer mean (SD) PaO /F O ratios at the end of the surgical procedure and a longer median (IQR [range]) time to tracheal extubation compared with the alveolar recruitment group (308 (144) vs. 402 (154) (p = 0.03) and 18 (10-27 [5-468]) h vs. 15 (11-36 [5-115]) h (p = 0.01), respectively). An open-lung protective ventilation strategy during surgery for lung transplantation is feasible, safe and achieves favourable ventilation parameters.

Perioperative lung protective ventilation

“…For example, studies in multiple settings have been unable to show that temporary gains in either lung mechanics or oxygenation extend to the postoperative environment, even when the recruitment maneuver is performed shortly before extubation 7079808182. However, the benefits of recruitment maneuvers may be enhanced or prolonged by the performance of repeated maneuvers 83.…”

Anesthetic Management of Lung Transplantation: Center Specific Practices and Geographical and Centers Size Differences

“…Verbeek et al randomly assigned patients undergoing double lung transplantation to a control group that received volume-controlled ventilation with 5 cmH 2 O of PEEP and low tidal volumes (6 mL/kg for two lung ventilation and 4 mL/kg for one lung ventilation) or an alveolar recruitment group who were ventilated using pressure controlled ventilation at 16 cmH 2 O with 10 cmH 2 O of PEEP and a stepwise PEEP-based alveolar recruitment algorithm, with the final outcome being the arterial oxygen/inspired oxygen ratio 24 hours after the first lung was reperfused. 18 Although the primary outcome was the same in both groups, the patients who underwent the alveolar recruitment algorithm demonstrated an increased arterial oxygen/inspired oxygen ratio at the end of the surgery and a shorter time to tracheal extubation. 18 The purpose of the survey was to discover the international anesthetic lung transplantation practices to determine the similarities and differences in order to consider the development of guidelines in the management of these patients.…”

“…18 Although the primary outcome was the same in both groups, the patients who underwent the alveolar recruitment algorithm demonstrated an increased arterial oxygen/inspired oxygen ratio at the end of the surgery and a shorter time to tracheal extubation. 18 The purpose of the survey was to discover the international anesthetic lung transplantation practices to determine the similarities and differences in order to consider the development of guidelines in the management of these patients. It is difficult to standardize the anesthetic management because of the heterogeneity of the disease processes that predispose patients to require lung transplantation; the heterogeneity of the surgical techniques, including triggers for the use of mechanical assist devices; and the heterogeneity of the medical management, including postoperative ventilation.…”

Positive End-Expiratory Pressure (PEEP), Tidal Volume, or Alveolar Recruitment: Which One Does Matter in One-Lung Ventilation?

“…In a recent descriptive, multicenter study in which 690 patients were enrolled, iPROVE network investigators have demonstrated that open lung approach with individualized PEEP can result in less PPCs when compared with available findings [56••]. Verbeek et al conducted a RCT trial using the open lung approach (stepwise recruitment, 10 cm H2O PEEP and 4-5 ml/kg TV during OLV) in 748 patients undergoing lung transplantation surgery [57]. They compared this approach with a conventional lung-protective strategy (5 cm H 2 O PEEP, 4 ml/kg TV without ARM) and found OLA to be related with reduced duration of mechanical ventilation.…”