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Lung Protective Ventilation in DonorsLung Protective Ventilation in Donors: An Ounce of Prevention FREE TO VIEW

Julia A. Klesney-Tait, MD, PhD; Michael Eberlein, MD, PhD
Author and Funding Information

From the Department of Internal Medicine, Division of Pulmonary and Critical Care, and Occupational Medicine, University of Iowa Carver College of Medicine.

CORRESPONDENCE TO: Julia Klesney-Tait, MD, PhD, Department of Internal Medicine, Division of Pulmonary and Critical Care, and Occupational Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Dr, C34-12 GH, Iowa City, IA 52242; e-mail: julia-klesney-tait@uiowa.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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):4-6. doi:10.1378/chest.14-0163
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The evaluation, maintenance, and ultimate transplant of donor lungs remain one of the most challenging areas in transplantation. Donor lungs are often concomitantly injured at the time of donor death through infection, trauma, aspiration, and/or excessive smoking history. Although some progress has been made in terms of placing more organs over the past decade, lung use remains well below 50% of donors.1,2 There are a number of barriers to improving organ recovery in lung transplantation, including (1) the limited ability to accurately assess donor quality based on currently available preprocurement testing and (2) the limited evidence-based guidance regarding best practice in the ventilator management of potential donors.

The United Network for Organ Sharing (UNOS) database, which records select donor and recipient characteristics along with recipient survival, has been analyzed to try to identify preprocurement predicators of organ suitability. These retrospective studies have examined the safety of ideal donors and extended donors in terms of their impact on recipient survival, assessed the importance of various preprocurement lung characteristics identified by conventional wisdom, and examined the impact of recipient factors on recipient outcomes.3 Historically, Pao2/Fio2 has been perhaps the most heavily weighted component of the pretransplant analysis to define organ quality. While it may make intuitive sense that this component is important, there is no strong evidence validating it as an isolated marker of organ quality. Moreover, a review of 12,054 lung allograft recipients from the UNOS database reported similar survival in recipients who received lungs that had Pao2/Fio2 of < 200 and recipients who received lungs with Pao2/Fio2 > 300, suggesting that, as a single characteristic, Pao2/Fio2 is not an accurate reflection of donor lung quality, recipient outcome, or both.4

In this issue of CHEST (see page 220), Bansal et al5 discuss another mechanism to improve overall donor lung use: optimal mechanical ventilation of donor lungs. This is a challenging topic because there is a paucity of rigorous donor trial data available to guide physicians. In fact, to our knowledge, only one published study provides randomized control trial data involving donor lung management. In this study, by Mascia et al,6 potential lung donors were randomized to protective lung ventilation (6-8 mL/kg donor ideal body weight; positive end-expiratory pressure [PEEP], 8-10 cm H2O; and maneuvers to avoid derecruitment of lung units) vs conventional donor management (10-12 mL/kg and PEEP 3-5 cm H2O). Protective ventilation resulted in the placement of 54% of potential lungs vs 25% of lungs from the conventional ventilation arm (95% CI, 10%-44.5%; P = .004). Importantly, this study bases donor lung management on the much larger body of work that has shown clearly that lung protective ventilation results in improved survival in patients with ARDS.7 The concept of managing lung donors as one would any other critically ill patient has gained attention recently, and there is much to be garnered from the critical care literature on this subject.

For those skeptical that donor lungs are in need of protection from ventilator-associated lung injury, there is a growing body of literature to suggest that all lungs benefit from lung protective ventilation. A meta-analysis of lung protective ventilation in patients at risk of developing ARDS demonstrated that low tidal volume ventilation is associated with a significant reduction in the risk of developing the disease (relative risk [RR], 0.33; 95% CI, 0.23-0.47) and reduced pulmonary infection risk (RR, 0.45; 95% CI, 0.22-0.92), also important issues in donor lung use.8 The question then becomes should we be using lung protective ventilation on “normal lungs” during short-term operative ventilation? The recent multicenter, double-blind, randomized Intraoperative Protective Ventilation in Abdominal Surgery (IMPROVE) trial examined the use of protective ventilation (6-8 mL/kg ideal body weight; PEEP, 6-8 cm H2O) and scheduled 30-s recruitment maneuvers during operative ventilation in elective abdominal surgery patients.9 Patients in the lung protective group had an adjusted RR of 0.40 (95% CI, 0.24-0.68; P = .001) for the primary outcome, a composite of major pulmonary and extrapulmonary complications occurring within the first 7 days after surgery, suggesting even short-term exposure to nonprotective ventilation causes lung injury. Taken together, these data support the use of lung protective strategies in all settings of mechanical ventilation, including donor lung management.

Donor lungs, like all ventilated lungs, are at risk of developing atelectasis. The second lung management pearl gleaned from the critical care literature discussed in Bansal et al’s5 review of donor lung management is lung recruitment and the importance of PEEP. Lung protective strategies have the potential to lead to lung derecruitment, and, thus, recruitment maneuvers and optimal PEEP settings are components of many ventilator management strategies in the ICU.10,11 These maneuvers potentially increase aerated lung units, which may decrease ventilator-associated lung injury and improve oxygenation by decreasing shunt. However, this benefit may be counterbalanced by the risk of alveolar overdistention caused by excessive pressures, volumes, or both.12 One potential way to mitigate this risk is by measuring the stress index at the bedside.13 Although the stress index has not been validated as a clinical marker to prevent injury, it has been examined as a tool to assess lung overdistention in patients who have been mechanically ventilated.14 The stress index can be measured using the pressure-time display at the bedside, providing real-time clinically useful information to screen for overdistension. Thus, although addressing atelectasis/recruitability is important and potentially beneficial in the management algorithm of potential donors, one must concomitantly avoid unrecognized lung injury. Optimal recruitment maneuvers and PEEP levels in donors have not been identified at this point, and some care should be taken to avoid excessive pressures and/or volumes because lung heterogeneity is well described.

Efforts to expand the donor lung pool must be focused on both protecting potential organs and defining accurate preprocurement measurements of donor quality. It is time for donor ventilation strategies to adopt the principles of lung-protective ventilation by limiting tidal distention, reducing peak distending pressures, and abandoning routine recruitment maneuvers. Retrospective analysis of the UNOS database suggests that suitable lungs are being discarded, and randomized controlled trials are needed to expand the current criteria for donor lung suitability. Addressing these challenges will allow more patients with end-stage lung disease access to a lung transplant.

References

Sung RS, Galloway J, Tuttle-Newhall JE, et al. Organ donation and utilization in the United States, 1997-2006. Am J Transplant. 2008;8(4 pt 2):922-934. [CrossRef] [PubMed]
 
Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR). OPTN/SRTR 2011 Annual Data Report. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; 2012.
 
Snell GI, Westall GP, Oto T. Donor risk prediction: how ‘extended’ is safe? Curr Opin Organ Transplant. 2013;18(5):507-512. [CrossRef]
 
Zafar F, Khan MS, Heinle JS, et al. Does donor arterial partial pressure of oxygen affect outcomes after lung transplantation? A review of more than 12,000 lung transplants. J Thorac Cardiovasc Surg. 2012;143(4):919-925. [CrossRef] [PubMed]
 
Bansal R, Esan A, Hess D, et al. Mechanical ventilatory support in potential lung donor patients. Chest. 2014;146(1):220-227.
 
Mascia L, Pasero D, Slutsky AS, et al. Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation: a randomized controlled trial. JAMA. 2010;304(23):2620-2627. [CrossRef] [PubMed]
 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308. [CrossRef] [PubMed]
 
Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012;308(16):1651-1659. [CrossRef] [PubMed]
 
Futier E, Constantin J-M, Paugam-Burtz C, et al; IMPROVE Study Group. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013;369(5):428-437. [CrossRef] [PubMed]
 
Keenan JC, Formenti P, Marini JJ. Lung recruitment in acute respiratory distress syndrome: what is the best strategy? Curr Opin Crit Care. 2014;20(1):63-68. [CrossRef] [PubMed]
 
Borges JB, Okamoto VN, Matos GFJ, et al. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med. 2006;174(3):268-278. [CrossRef] [PubMed]
 
Marini JJ. Recruitment by sustained inflation: time for a change. Intensive Care Med. 2011;37(10):1572-1574. [CrossRef] [PubMed]
 
Grasso S, Stripoli T, De Michele M, et al. ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am J Respir Crit Care Med. 2007;176(8):761-767. [CrossRef] [PubMed]
 
Schmidt GA. Rebuttal from Dr Schmidt. Chest. 2012;141(6):1386-1387. [CrossRef]
 

Figures

Tables

References

Sung RS, Galloway J, Tuttle-Newhall JE, et al. Organ donation and utilization in the United States, 1997-2006. Am J Transplant. 2008;8(4 pt 2):922-934. [CrossRef] [PubMed]
 
Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR). OPTN/SRTR 2011 Annual Data Report. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; 2012.
 
Snell GI, Westall GP, Oto T. Donor risk prediction: how ‘extended’ is safe? Curr Opin Organ Transplant. 2013;18(5):507-512. [CrossRef]
 
Zafar F, Khan MS, Heinle JS, et al. Does donor arterial partial pressure of oxygen affect outcomes after lung transplantation? A review of more than 12,000 lung transplants. J Thorac Cardiovasc Surg. 2012;143(4):919-925. [CrossRef] [PubMed]
 
Bansal R, Esan A, Hess D, et al. Mechanical ventilatory support in potential lung donor patients. Chest. 2014;146(1):220-227.
 
Mascia L, Pasero D, Slutsky AS, et al. Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation: a randomized controlled trial. JAMA. 2010;304(23):2620-2627. [CrossRef] [PubMed]
 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308. [CrossRef] [PubMed]
 
Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012;308(16):1651-1659. [CrossRef] [PubMed]
 
Futier E, Constantin J-M, Paugam-Burtz C, et al; IMPROVE Study Group. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013;369(5):428-437. [CrossRef] [PubMed]
 
Keenan JC, Formenti P, Marini JJ. Lung recruitment in acute respiratory distress syndrome: what is the best strategy? Curr Opin Crit Care. 2014;20(1):63-68. [CrossRef] [PubMed]
 
Borges JB, Okamoto VN, Matos GFJ, et al. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med. 2006;174(3):268-278. [CrossRef] [PubMed]
 
Marini JJ. Recruitment by sustained inflation: time for a change. Intensive Care Med. 2011;37(10):1572-1574. [CrossRef] [PubMed]
 
Grasso S, Stripoli T, De Michele M, et al. ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am J Respir Crit Care Med. 2007;176(8):761-767. [CrossRef] [PubMed]
 
Schmidt GA. Rebuttal from Dr Schmidt. Chest. 2012;141(6):1386-1387. [CrossRef]
 
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