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Contemporary Reviews in Critical Care Medicine |

Mechanical Ventilatory Support in Potential Lung Donor PatientsMechanical Ventilatory Support in Lung DonorsMechanical Ventilatory Support in Lung Donors FREE TO VIEW

Ruchi Bansal, MD; Adebayo Esan, MD, FCCP; Dean Hess, PhD, RRT, FCCP; Luis F. Angel, MD; Stephanie M. Levine, MD, FCCP; Tony George, MD; Suhail Raoof, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Drs Bansal, Esan, George, and Raoof), New York Methodist Hospital, Brooklyn, NY; Respiratory Care Services (Dr Hess), Massachusetts General Hospital, Boston, MA; and the Division of Pulmonary and Critical Care Medicine (Drs Angel and Levine), University of Texas Health Science Center, San Antonio, TX.

CORRESPONDENCE TO: Suhail Raoof, MD, FCCP, New York Methodist Hospital, Pulmonary & Critical Care Medicine, 506 Sixth St, Brooklyn, NY 11215; e-mail: suhailraoof@gmail.com


FOR EDITORIAL COMMENT SEE PAGE 4

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(1):220-227. doi:10.1378/chest.12-2745
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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.

Figures in this Article

Lung transplantation has proven to be a lifesaving procedure and an established therapeutic option for patients with end-stage lung disease. Until recently, the demand for lung transplantation greatly exceeded the supply of donor lungs. Although the gap between donors and those waiting for transplant has narrowed, further advancements in lung donation could result in reductions in both time and mortality on the waiting list. In 2011, only about 21% of lungs from donors were transplanted.1 However, the majority of donor lungs (64.4%) were deemed incompatible because of the lung damage that generally predates but in some instances supervenes following brain death.1 This effect may be compounded by complications emanating during the treatment of potential lung donor patients, including the mechanical ventilation strategies selected. Advances in lung donor patient management may obviate these detrimental effects and thereby enhance the procurement of donor lungs for transplantation.

Prior to brain death, donor lungs may have been damaged from trauma, resuscitation maneuvers, mechanical ventilation, aspiration of blood or gastric content, or pneumonia.2,3 After brain death, lungs are at a risk for the development of lung injury resulting from the onset of neurogenic pulmonary edema (NPE).2,3 Although well recognized as a sequela to CNS injury, NPE remains poorly understood and underdiagnosed.4

The manner in which brain death leads to NPE is postulated to involve complex hemodynamic and inflammatory pathophysiologic mechanisms,4,5 triggered by a transient sympathetic storm,2,3 as well as an alteration in pulmonary capillary permeability also resulting from direct sympathetic stimulation.2,3 The overall degree of pulmonary edema that can occur has been demonstrated in animal studies, revealing that up to 72% of the circulating blood volume may be redistributed within the lungs and left side of the heart following brain death.6

A secondary cardiovascular collapse may also follow the aforementioned sympathetic storm due to a loss in sympathetic tone.7,8 Because of the preexisting NPE, hemodynamic management becomes challenging, as fluid loading to correct hypotension carries the risk of worsening oxygenation.9 Furthermore, brain death is also believed to induce various inflammatory and immunologic responses, which in turn trigger a systemic inflammatory response syndrome associated with the release of cytokines. This further stimulates neutrophilic infiltration that can incite damage to the lung parenchyma, potentially increasing the risk of the development of the ARDS and consequently primary graft dysfunction.2,3,7

By the time the lungs are ready to be harvested, potential lung donor patients may have developed pulmonary edema as a result of systemic inflammatory responses occurring in the periods before and after brain death pronouncement. This may predispose the donor lungs to ventilator-induced lung injury, which in turn may further compound the problem of hypoxemic respiratory failure. Donor gas exchange before procurement has been shown to be associated with early and long-term outcomes; furthermore, a steep increase in the relative risk of death occurred with donor Pao2/Fio2 < 350 mm Hg.10 It is unclear how low the Pao2/Fio2 can be without affecting transplant outcome, as ratios < 300 mm Hg have been reported.11,12 Nonetheless, appropriate oxygenation in potential lung donor patients is believed to be the most important indicator for the functional quality of the lung8 and is, therefore, a required criterion in most transplant programs.13-15 It is, therefore, no surprise that for many years, the majority of lungs were deemed unsuitable for transplantation, having not met the ideal criteria of oxygenation set forth by expert panel recommendations.7 These criteria include a clear chest radiograph, a Pao2 > 300 mm Hg on an Fio2 of 1.0, and a positive end-expiratory pressure (PEEP) equal to 5 cm H2O.7

Use of low tidal volume (Vt) ventilation has been shown to decrease mortality by 9% in patients with ARDS16; however, the vast majority of potential lung donor patients do not have ARDS at the time of intubation.17 Nonetheless, the use of higher Vt ventilation has been associated with an increased likelihood of developing lung injury in patients with normal lung function at the onset of mechanical ventilation18-21 and in patients with acute brain injury.22 In a meta-analysis of patients without ARDS, the use of low as opposed to high Vt ventilation was associated with a lower risk of developing ARDS, fewer pulmonary infections, less atelectasis, and reduced mortality.23 This suggests that low Vt ventilation may be protective in patients with normal lungs following intubation.24 Consequently, the use of aggressive lung-protective ventilatory management strategies may obviate or reverse conditions such as ventilator-induced lung injury, NPE, and atelectasis in potential lung donor patients.25 To achieve these goals, the principles of mechanical ventilation are proposed in Table 1.3

Table Graphic Jump Location
TABLE 1  ] Principles of Mechanical Ventilation in Potential Lung Donor Patients

IBW = ideal body weight; PEEP = positive end-expiratory pressure; Spo2 = oxygen saturation by pulse oximetry.

Studies have shown that with the implementation of a specific and aggressive lung donor patient management protocol, many of the lungs that were previously deemed unsuitable may be salvageable. A few pertinent studies depicting this are summarized.26-28

Lung-Protective Strategy in Organ Donors

A multicenter randomized controlled trial was reported in potential organ donor patients with beating hearts from September 2004 to May 2009.28 Patients were randomized into two ventilator groups, one that used a conventional approach and the other that used a lung-protective approach (Table 2).

Table Graphic Jump Location
TABLE 2  ] Randomized Comparison of Ventilatory Strategies in Potential Lung Donor Patients28

Vt = tidal volume. See Table 1 legend for expansion of other abbreviations.

A total of 118 patients were enrolled; 59 patients were randomized to the conventional ventilation group and 59 patients to the protective ventilation group. The number of patients who met lung donor eligibility criteria (Pao2/Fio2 > 300 mm Hg, Fio2 of 1.0, peak inspiratory pressure [PIP] < 30 cm H2O) after a 6-h observation period, required for the declaration of brain death, was 32 of 59 (54%) in the conventional ventilation group and 56 of 59 (95%) in the protective ventilation group. Lung donor issues occurring at the moment of harvest, after the diagnosis of brain death, or during open chest inspection, as well as lung recipient issues such as incompatibility or matching size logistical problems, limited the number of lungs harvested. Consequently, lungs were harvested in 16 of 59 patients (27%) in the conventional ventilation group vs 32 of 59 patients (54%) in the protective ventilation group. Although it is difficult to determine which of the interventions used in the lung-protective strategy group (lower Vt, higher PEEP, CPAP for apnea testing, or use of a closed circuit for airway suctioning) was the most important determinant of the positive results, the authors conclude that the use of a lung-protective strategy increased the number of eligible and harvested lungs in comparison with a conventional strategy. It may be implied that a lung-protective ventilator strategy with a Vt of 6 to 8 mL/kg ideal body weight (IBW) and PEEP of 8 to 10 cm H2O probably should be used in potential lung donor patients.

San Antonio Lung Transplant Protocol

In a study by Angel et al26 published in 2006, 330 patients were retrospectively studied for four years (1997-2001) before the implementation of the protocol. Thereafter, from 2001 to 2005, 381 potential lung donor patients were studied prospectively based on absolute and extended criteria (Table 3). These patients were then assessed and further divided into groups labeled ideal, extended, or poor donors, as depicted in Table 4.

Table Graphic Jump Location
TABLE 3  ] SALT Protocol Criteria26: Absolute and Extended Criteria

SALT = San Antonio Lung Transplant.

Table Graphic Jump Location
TABLE 4  ] SALT Protocol Criteria26: Ideal, Extended, and Poor Donor Criteria

See Table 3 legend for expansion of abbreviation.

Recruitment maneuvers were used when an initial blood gas result showed a Pao2/Fio2 ratio < 300 mm Hg or if pulmonary edema and/or atelectasis were present. For recruitment purposes, pressure-control ventilation (PCV) with a PIP of 25 cm H2O and PEEP of 15 cm H2O for 2 h was used. It is of interest to note that this is a rather gentle recruitment maneuver compared with those used for refractory hypoxemia in patients with severe ARDS.29,30 After recruitment, the patient was returned to volume-control ventilation (VCV) with Vt of 10 mL/kg IBW and PEEP of 5 cm H2O. Nonventilatory strategies were also used as part of the lung donor patient management protocol. Success was defined as an improvement in the Pao2/Fio2 to at least 300 mm Hg and an improvement noted in the chest radiograph findings. However, a final Pao2/Fio2 > 400 mm Hg was the strongest donor factor associated with the acceptance of lungs by transplant centers.

Although a retrospective comparison cohort was used, the implementation of the San Antonio Lung Transplant (SALT) protocol resulted in a greater than twofold increased procurement of lungs for transplantation without increasing hospital or ICU length of stay and without compromising the lung function or survival rates of the lung transplant recipients.26

Gift of Life Michigan

Kirschbaum and Hudson27 collected retrospective data on lung donor patients from 2003 to 2004. They then implemented their donor management protocol in 2005 and followed patients prospectively to 2008.

VCV was used with a Vt of 10 to 12 mL/kg IBW, PIP was kept at < 35 cm H2O, and Vt was reduced as necessary to achieve this goal. Respiratory rate was adjusted to maintain the Paco2 between 35 and 45 mm Hg while maintaining the pH between 7.35 and 7.45. Alternatively, when PCV was used, the PIP was kept at < 35 cm H2O, and respiratory rate was adjusted to keep pH between 7.35 and 7.45. In both modes, PEEP was set at 5 to 8 cm H2O, and Fio2 remained at 40%, or the lowest possible Fio2 was used to maintain adequate oxygenation.

Alveolar recruitment to improve oxygenation was performed using CPAP of 40 cm H2O for 30 s, repeated every 20 min for a total of three times, and once, whenever the ventilator circuit was broken. Other measures to improve oxygenation included reducing flow to 40 to 50 L/min (volume control) or increasing inspiratory time (pressure control) to increase mean airway pressure. Less commonly used methods were prone positioning and the administration of inhaled nitric oxide. Similar to the SALT protocol,26 nonventilatory measures were also used as part of the lung donor patient management. Notwithstanding the study’s limitation by being retrospective in nature, the authors concluded that use of this lung donor patient management protocol contributed to increased lung transplantation from 37 lungs transplanted in 2004 to 135 lungs transplanted in 2008.27

Ventilatory strategies using large Vts are associated with overdistention and alveolar damage16 and may worsen donor lung injury, which may already be present from a systemic inflammatory response.8 Both VCV and PCV have been used to prevent overdistention and alveolar opening/closing injury through the use of volume-limited and pressure-limited ventilation as well as appropriate levels of PEEP in patients receiving mechanical ventilation; however, no study has shown superiority of one ventilator mode over another in lung donor patients who are brain dead.

Volume-Control Ventilation

This is the most commonly used mode of ventilation in potential lung donor patients, and donor management protocols used by organ procurement organizations have traditionally recommended Vt ranges from 10 to 15 mL/kg and PEEP levels averaging around 5 cm H2O.15,26-28,31 One may argue that such large Vt ranges are necessary to combat atelectasis and contribute to tidal alveolar recruitment; however, derecruitment can occur during exhalation without appropriate PEEP levels. Furthermore, the use of these Vt ranges have been shown to increase the likelihood of lung injury in patients with relatively normal lungs.18-24 Following brain death, treatment strategies shift from cerebral protection to optimizing organs for transplantation.3,31 Consequently, both an initial target oxygenation (ie, Pao2/Fio2 > 300 mm Hg) and lung protection are essential during ventilatory support, to facilitate lung procurement. The previously described study by Mascia et al28 used a lung-protective strategy using low Vts of 6 to 8 mL/kg IBW with higher PEEP levels of 8 to 10 cm H2O in comparison with a conventional lung strategy using high Vts of 10 to 12 mL/kg IBW with lower PEEP levels of 3 to 5 cm H2O, resulting in more eligible and harvested lungs with the lung-protective strategy. One may, therefore, infer that in potential lung donor patients, the application of a higher PEEP level in conjunction with low Vts would likely limit the extent of pulmonary edema and prevent both atelectasis and alveolar opening/closing injury. In clinical practice, most of the donor lungs harvested for transplantation with a Pao2/Fio2 ratio > 300 mm Hg have oxygen saturations ranging from 92% to 95% or higher. Consequently, following an initial oxygenation with a Pao2/Fio2 ratio > 300 mm Hg, the lowest Fio2 (eg, Fio2 ≤ 0.5) that allows an oxygen saturation from 92% to 95% should be targeted to prevent absorption atelectasis that can result from reduced intra alveolar nitrogen due to high Fio2 levels.27,32

Pressure-Control Ventilation

PCV can be used per clinician preference in potential lung donor patients as an alternative to VCV, as there is no evidence of one mode being more lung protective than the other.33,34 Consequently, the goals in this mode of ventilation are similar to that of VCV (ie, ensuring adequate oxygenation and lung protection using volume and pressure limitation). Interestingly, in the study by Mascia et al,28 both the lung-protective strategy and the conventional strategy groups had similarly low peak inspiratory and plateau pressure ranges of 22 to 23 cm H2O and 16 to 18 cm H2O, respectively, during the 6-h observation period required for the declaration of brain death. Suffice it to say, pressure-control parameters should, therefore, be set to achieve similar Vts of 6 to 8 mL/kg IBW in conjunction with adequate PEEP levels of 8 to 10 cm H2O as used in the study.28

Airway Pressure Release Ventilation

Airway pressure release ventilation (APRV) is another mode of ventilation that has been used in potential lung donor patients to improve hypoxemia or to limit PIP.35,36 It applies a high airway pressure (Phigh) over a prolonged inspiratory time with brief pressure releases to a low airway pressure (Plow), causing progressive lung recruitment and enhancing oxygenation.35,37 In transitioning from more conventional ventilator modes to APRV, the initial settings in adult lung donor patients usually consist of a Phigh (lasting 4-6 s) that is equivalent to the plateau airway pressure from the prior VCV or the previous PIP on PCV and a Plow of 0 cm H2O (lasting 0.2-0.8 s).35,37 A major benefit associated with APRV is lost in potential lung donor patients. In a patient who is not brain dead, APRV allows spontaneous breathing, thereby theoretically allowing better recruitment of dorsal dependent lung regions. However, in patients who are brain dead, this theoretical benefit does not exist.37 Thus, in this setting, it functions like pressure-controlled inverse ratio ventilation. A retrospective case series compared VCV to APRV in potential lung donor patients.36 Initial settings on VCV were 10 to 12 breaths/min, Vt of 5 to 10 mL/kg, Fio2 of 0.4, and PEEP of 5 cm H2O, whereas on APRV they were 6 to 10 breaths/min, Phigh of 20 to 25 cm H2O, and Fio2 of 0.4.36 However, the Vt generated, the presence or absence of auto-PEEP, and the duration of both Phigh and Plow (ie, prolonged inspiratory time and inspiratory time for the low CPAP level) were not reported. Nonetheless, patients on APRV had a higher mean Pao2/Fio2 (498 ± 43 mm Hg vs 334 ± 104 mm Hg) following a 45-min 100% oxygen challenge, which the authors attributed to improved alveolar recruitment and resolution of pulmonary atelectasis. They further suggest that this improvement in oxygenation may have led to concurrent rise in the rate of lung donation (95% vs 18%) in organ donors meeting standard criteria, with posttransplant survivals in both ventilator groups comparing favorably with national averages.36 This study, however, is limited by its retrospective nature as well as unreported ventilator data, which may have played a role in improving oxygenation.

Figure 1 summarizes an algorithmic approach to mechanical ventilation in potential lung donor patients based primarily on the approach used in the randomized control study by Mascia et al28 and further complemented by the approaches used by Angel et al26 and Kirschbaum et al.27

Figure Jump LinkFigure 1  Algorithmic approach in lung donor candidate. IBW = ideal body weight; PC = pressure above positive end-expiratory pressure; PCV = pressure-control ventilation; PEEP = positive end-expiratory pressure; P/F = Pao2/Fio2; Pplat = plateau pressure; SpO2 = oxygen saturation by pulse oximetry; VCV = volume-control ventilation; VT = tidal volume.Grahic Jump Location

Once a potential lung donor patient is identified and brain death is confirmed, all the criteria that may exclude the patient as a donor are reviewed (Tables 3, 4). A protective lung ventilatory strategy with the patient receiving Vts of 6 to 8 mL/kg IBW, plateau pressures < 30 cm H2O, PEEP of 8 to 10 cm H2O, and an initial Fio2 of 1.0 should be commenced.28 If the Pao2/Fio2 remains > 300 mm Hg on an initial blood gas measurement, the lowest Fio2 (eg, Fio2 ≤ 0.5) that permits an oxygen saturation ≥ 92% to 95% should then be used, and further assessment of suitability for lung donation should take place. However, if the Pao2/Fio2 is < 300 mm Hg or if pulmonary edema and/or atelectasis are present, a recruitment maneuver using either VCV with Vts of 6 to 8 mL/kg IBW and PEEP of 15 cm H2O (keeping plateau pressure < 30 cm H2O) or PCV with pressure control setting of 10 to 15 cm H2O and PEEP of 15 cm H2O (keeping PIP < 30 cm H2O) on an Fio2 of 1.0 for a duration of 2 h should take place.26 Following the recruitment maneuver, the ventilator parameters are returned to prerecruitment settings (Vt of 6-8 mL/kg IBW, PEEP of 8-10 cm H2O, and Fio2 of 1.0). Recruitment is considered to be successful if the subsequent Pao2/Fio2 is ≥ 300 mm Hg and chest radiography reveals significant improvement.26

Meticulous care must be exercised to limit lung injury right from the moment of intubation. Brain death can initiate a systemic inflammatory response that can potentially result in significant damage to the lungs.2,3,22,38 Traditionally, donor management protocols implemented by organ procurement organizations have used Vts ranging from 10 to 15 mL/kg in ventilating potential lung donor patients whose lungs are usually deemed to be relatively normal. However, despite its limitations, the meta-analysis by Serpa Neto et al23 demonstrated that lower Vts (6-8 mL/kg IBW) were associated with better clinical outcomes in patients without ARDS. Furthermore, with the implementation of specific and aggressive lung donor patient management protocols, many of the lungs that are usually deemed unsuitable may be salvaged, thereby contributing to an increased procurement of lungs for transplantation (Table 5).26-28 Although further prospective studies are needed, the use of lung donor patient management protocols that include lung-protective ventilatory strategies with adequate PEEP levels28 should be used in potential lung donor patients to further enhance lung procurement.

Table Graphic Jump Location
TABLE 5  ] Ventilatory Strategies and Lung Transplant Protocols in Potential Lung Donor Patients

APRV = airway pressure release ventilation; LT = lung transplantation; NR = not reported; RCT = randomized controlled trial. See Table 3 legend for expansion of other abbreviation.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Esan participated as a consultant on a United Therapeutics Corp advisory board on the diagnosis and treatment of pulmonary arterial hypertension. Dr Hess discloses relationships with Koninklijke Philips N.V., ResMed, Breathe Technologies, Inc, PARI International, Covidien, and MAQUET Holding B.V. & Co KG. Drs Bansal, Angel, Levine, George, and Raoof have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

APRV

airway pressure release ventilation

IBW

ideal body weight

NPE

neurogenic pulmonary edema

PCV

pressure-control ventilation

PEEP

positive end expiratory pressure

Phigh

 high airway pressure

PIP

peak inspiratory pressure

Plow

low airway pressure

SALT

San Antonio Lung Transplant

VCV

volume-control ventilation

Vt

tidal volume

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Figures

Figure Jump LinkFigure 1  Algorithmic approach in lung donor candidate. IBW = ideal body weight; PC = pressure above positive end-expiratory pressure; PCV = pressure-control ventilation; PEEP = positive end-expiratory pressure; P/F = Pao2/Fio2; Pplat = plateau pressure; SpO2 = oxygen saturation by pulse oximetry; VCV = volume-control ventilation; VT = tidal volume.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1  ] Principles of Mechanical Ventilation in Potential Lung Donor Patients

IBW = ideal body weight; PEEP = positive end-expiratory pressure; Spo2 = oxygen saturation by pulse oximetry.

Table Graphic Jump Location
TABLE 2  ] Randomized Comparison of Ventilatory Strategies in Potential Lung Donor Patients28

Vt = tidal volume. See Table 1 legend for expansion of other abbreviations.

Table Graphic Jump Location
TABLE 3  ] SALT Protocol Criteria26: Absolute and Extended Criteria

SALT = San Antonio Lung Transplant.

Table Graphic Jump Location
TABLE 4  ] SALT Protocol Criteria26: Ideal, Extended, and Poor Donor Criteria

See Table 3 legend for expansion of abbreviation.

Table Graphic Jump Location
TABLE 5  ] Ventilatory Strategies and Lung Transplant Protocols in Potential Lung Donor Patients

APRV = airway pressure release ventilation; LT = lung transplantation; NR = not reported; RCT = randomized controlled trial. See Table 3 legend for expansion of other abbreviation.

References

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