Preoperative Trapped Lung Is Associated With Increased Mortality After Orthotopic Liver Transplantation

Abstract

Introduction: Trapped lung, characterized by atelectatic lung unable to reexpand and fill the thoracic cavity due to a restricting fibrous visceral pleural peel, is occasionally seen in patients with end-stage liver disease complicated by hepatic hydrothorax. Limited data suggest that trapped lung prior to orthotopic liver transplantation may be associated with poor outcomes. Research Question: What is the clinical significance of trapped lung in patients receiving orthotopic liver transplantation? Design: We performed a retrospective analysis of patients who underwent liver transplantation over an 8-year period. Baseline clinical characteristics and postoperative outcomes of adult patients with trapped lung were analyzed and compared to the overall cohort of liver transplant recipients and controls matched 3:1 based on age, sex, Model for End-Stage Liver Disease (MELD) score, and presence of pleural effusion. Results: Of the 1193 patients who underwent liver transplantation, we identified 20 patients (1.68%) with trapped lung. The probability of 1 and 2-year survival were 75.0% and 57.1%, compared to 85.6% and 80.4% (p = 0.02) in all liver transplant recipients and 87.9% and 81.1% (p = 0.03) in matched controls respectively. Patients with trapped lung had a longer hospital length of stay compared to the total liver transplant population (geometric mean 54.9 ± 8.4 vs. 27.2 ± 0.7 days, p ≤ 0.001), when adjusted for age and MELD score. Discussion: Patients with trapped prior to orthotopic liver transplantation have increased probability of mortality as well as increased health care utilization. This is a small retrospective analysis, and further prospective investigation is warranted.

Implications of Pleural Fluid Composition in Persistent Pleural Effusion following Orthotopic Liver Transplant

“…Thus, LDH-rich fluid may suggest an inflammatory pleural effusion etiology driven by an active process rather than a simple third-spacing of fluid into body cavities [ 31 , 32 ]. Chronic inflammatory pleural effusions have been associated with worse outcomes in OLT patients, and can even lead to the development of trapped lung [ 33 ]. Our findings add to the current understanding of pleural effusion biomarkers and their ability to predict outcomes in OLT recipients, and are aligned with previously published data suggesting that elevated PF LDH is an indicator of active pleural inflammation while protein is a sign of abnormal pleural lymphatics and capillary permeability [ 15 , 29 ].…”

Help, My Lung is Trapped! – A Case Report

“…Trapped lung is characterized by the atelectatic lung that is unable to expand and fill the thoracic cavity, due to a restricting fibrous visceral pleural peel. To diagnose trapped lung, drainage of the pleural space must result in both radiographic findings of a resultant pneumothorax ex-vacuo and a thickened visceral pleura [6]. The resulting fluid filled chronic pleural space, and the persistence of the fluid is solely due to hydrostatic equilibrium [7].…”

Postoperative Trapped Lung After Orthotopic Liver Transplantation is a Predictor of Increased Mortality

“…Hepatic hydrothorax is typically thought of as a bland, transudative fluid, resulting from the changes in the hydrostatic and oncotic pressure gradients that occur commonly with portal hypertension and cirrhosis ( 21 – 23 ). However, trapped lung has been described as a rare complication in patients with ESLD and hepatic hydrothorax as well ( 15 – 17 ). Our data reveal that pleural effusions among the TL cohort were nearly all exudative by Light’s criteria and one quarter were due to empyema.…”

“…Exudative effusions resulting from inflammatory and infectious conditions have been identified as a risk factor for the development of fibrinous change in the visceral pleura ( 13 – 14 ). Trapped lung is less commonly associated with ESLD, although a few small studies have shown it to be a complication of hepatic hydrothorax in a small subset of patients ( 15 – 17 ). When it does occur, trapped lung and pleural disease have been shown to be indicative of poor outcomes in liver transplant recipients ( 15 , 18 ).…”

“…Trapped lung is less commonly associated with ESLD, although a few small studies have shown it to be a complication of hepatic hydrothorax in a small subset of patients ( 15 – 17 ). When it does occur, trapped lung and pleural disease have been shown to be indicative of poor outcomes in liver transplant recipients ( 15 , 18 ).…”