Mechanical Ventilation After Lung Transplantation

Abstract

IntroductionTo explore the hypothesis that early ventilation strategies influence clinical outcomes in lung transplantation, we have examined our routine ventilation practices in terms of tidal volumes (Vt) and inflation pressures.Methods 124 bilateral lung transplants between 2010 and 2013 were retrospectively assigned to low (<6ml/kg), medium (6-8ml/kg) and high (>8ml/kg) Vt groups based on ventilation characteristics during the first 6 hours after surgery. Those same 124 patients were also stratified to low-pressure (<25cm H2O) and high-pressure (≥25cm H2O) groups. ResultsEighty per cent of patients were ventilated using pressure control mode. Low, medium and high tidal volumes were applied to 10%, 43%, and 47% of patients respectively. After correcting for patients requiring extracorporeal support, there was no difference in short to mid-term outcomes among the different Vt groups. Low inflation pressures were applied to 61% of patients, who had a shorter length of ICU stay (5 vs. 12 days; p=0.012), higher FEV1 at 3 months (77.8% vs. 60.3%; p<0.001), and increased 6-month survival rate (95% vs. 77%; p=0.008). ConclusionLow Vt ventilation has not been fully adopted in our practice. Ventilation with higher inflation pressures, but not tidal volumes, were significantly associated with poorer outcomes after lung transplantation.Response to Reviewers: Dear Prof. Lumb, Article ID: JCRC-D-15-00340 -Mechanical ventilation following lung transplantationWe are most grateful to the reviewers for taking the time and care to appraise this manuscript, and for your constructive critique. We have addressed all of the points that were raised and have amended the manuscript accordingly. We feel that your suggestions has significantly improved the original manuscript.Responses to Reviewer #1 Reviewer #1: "The manuscript does not add anything new to the literature. It has been known for a very long time that excessive tidal volume and/or inflation pressures adversely affect patient outcome."Author response: We are grateful that you have taken the time to review our manuscript, although we are disappointed by your conclusions. We have made detailed arguments in both the introduction and discussion that highlight the need for this work within lung transplantation, combined with our unique approach to this clinical problem. Your statement is in direct opposition with the views of the other reviewers, who have helpfully pointed out the potential importance of our study within this field. Your critique also fails to acknowledge the major ongoing debate regarding the special importance of driving pressures, and the relative roles of tidal volumes and pressures in acute lung injury. As a rebuttal, we would respectfully suggest that our manuscript does add to the existing body of knowledge on this topic. As stated in the manuscript, we believe that our manuscript fills an important gap within the literature on VALI by providing new observations on lung ventilation practices in lung transplant recipients, a population that was...

Analysis of different levels of positive end-expiratory pressure during lung retrieval for transplantation: an experimental study

“…In the present study, the animals remained hemodynamically stable, regardless of the PEEP administered, with all groups showing similar heart rate, perfusion, and lactate levels, data similar to those of the literature (4,7,13).…”

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

“…The patients ventilated using volume-control were divided into low tidal volumes o 6 mL/kg, medium tidal volumes between 6 to 8 mL/kg, and high tidal volumes 4 8 mL/kg, and the authors found that in both the volume-and pressure-control patients, the only factor that predicted pulmonary complications after transplantation was high inflation pressures, defined as a PIP Z 25 mmH 2 O in patients receiving pressure-control ventilation and a plateau pressure Z 25 mmH 2 O in patients receiving volume-control ventilation. 17 As long as the plateau pressure remained o25 mmH 2 O, the incidence of pulmonary complications did not increase with increasing tidal volumes. 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.…”

“…One strategy is the use of volume-controlled ventilation with tidal volumes set at 6 mL/kg of the donor weight, with 5 to 10 cmH 2 O of PEEP, and a goal of keeping the peak airway pressures o30 mmHg; however, the use of pressure-control ventilation is becoming more prevalent. Thakuria et al 17 compared the records of patients who had undergone double lung transplantation, the strategies used to ventilate them, and the patient outcomes and found that the majority of patients were ventilated using a pressure-control mode. The patients ventilated using volume-control were divided into low tidal volumes o 6 mL/kg, medium tidal volumes between 6 to 8 mL/kg, and high tidal volumes 4 8 mL/kg, and the authors found that in both the volume-and pressure-control patients, the only factor that predicted pulmonary complications after transplantation was high inflation pressures, defined as a PIP Z 25 mmH 2 O in patients receiving pressure-control ventilation and a plateau pressure Z 25 mmH 2 O in patients receiving volume-control ventilation.…”

International consensus recommendations for anesthetic and intensive care management of lung transplantation. An EACTAIC, SCA, ISHLT, ESOT, ESTS, and AST approved document

“…It also calls for ongoing critical appraisal of our management goals and for constant quality improvement to understand and exploit new strategies to reduce complications, to enhance patient's perioperative journey and to improve both short-and long-term survival of lung transplant recipients. [13][14][15][16][17][18] This redefined role has major implications for our specialties in pushing the boundaries of super specialization in transplant anesthesia and intensive care and also with regard to closer team working with the surgical and respiratory teams from the time of patient listing through the transplant operation and postoperative ICU stay. 19,20 Building a consensus framework These worldwide trends have been considered by the Transplant Subcommittee of the European Association of Cardiothoracic Anesthetists (EACTA), which represents a distinctive international subspecialty group of cardiothoracic anesthetists and critical care physicians delivering perioperative care for lung transplants recipients.…”