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Correspondence |

Mechanical Ventilation After Lung Transplantation FREE TO VIEW

Louit Thakuria, BMBS; Anna Reed, MBChB, PhD; André R. Simon, MD, PhD; Nandor Marczin, MD, PhD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aDepartment of Cardiothoracic Transplantation, Royal Brompton & Harefield NHS Foundation Trust, London, UK

bDepartment of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK

cDepartment of Anaesthesia and Intensive Therapy, Semmelweis University, Budapest, Hungary

CORRESPONDENCE TO: Louit Thakuria, BMBS, Harefield Hospital, Hill End Rd, London, England UB9 6JH


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(2):516-517. doi:10.1016/j.chest.2016.10.064
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The recent review by Fuehner et al in an issue of CHEST (August 2016) regarding perioperative care in lung transplantation has highlighted the need for further research into the unique challenges for this special cohort. Although current guidelines on ventilation strategies for newly transplanted lungs have been extrapolated from studies in patients with ARDS and the general ICU population, these studies have specifically excluded lung transplant recipients from their analyses. Because it is difficult to define the optimal ventilation strategy for lung transplant recipients when limited data are available on their perioperative care, we share the authors’ view that large prospective studies into this field are needed.

However, we suggest that the claim by Fuehner et al to limit peak inspiratory pressures (Pinsp) to 35 cm H2O following lung transplantation is too liberal. The Acute Respiratory Distress Syndrome Clinical Network (ARDSNet) investigators actually suggested limiting plateau pressures to 30 cm H2O in their protective ventilation strategy. Our recent analysis of ventilation strategies after lung transplantation suggested a survival advantage for patients who received Pinsp < 25 cm H2O within the first few hours following surgery. Our small retrospective study reopens the debate on volume vs pressure paradigms of injurious ventilation and sets a lower pressure target for protective ventilation within this unique patient population. Recent revelations on the interplay between driving pressures, lung injury, and outcomes in both the ARDS and general perioperative populations would also advocate the aggressive limitation of inspiratory pressures, especially in the setting of lower levels of positive end-expiratory pressure (PEEP).

In the survey by Beer et al of ventilation preferences after transplantation, nearly 40% of responders advocated a maximum acceptable PEEP of 11.5 cm H2O. Presumably, this finding relates to perceived risks to the bronchial anastomoses, although experimental canine models of transplantation have paradoxically suggested that PEEP could actually increase bronchial blood flow at the anastomoses. Lower PEEP levels could come at the expense of higher driving pressures, which have been associated with dramatic increases in mortality in both patients with ARDS and even perioperative patients with uninjured lungs.

We thus call upon the lung transplant community to conduct definitive trials addressing the role of driving pressures in these patients. By doing so, we will likely need to set a trend away from our existing dogmas: either accept higher PEEP levels and/or further limit our inspiratory pressures. Predictably, a proportion of transplant recipients will fail with such strategies and may require temporary extracorporeal support. However, even invasive extracorporeal respiratory support could offer improved allograft protection compared with the alternative of battering the lung with high inspiratory and low expiratory pressures.

References

Fuehner T. .Kuehn C. .Welte T. .Gottlieb J. . ICU care before and after lung transplantation. Chest. 2016;150:442-450 [PubMed]journal. [CrossRef] [PubMed]
 
Barnes L. .Reed R.M. .Parekh K.R. .et al Mechanical ventilation for the lung transplant recipient. Curr Pulmonol Rep. 2015;4:88-96 [PubMed]journal. [CrossRef] [PubMed]
 
Thakuria L. .Davey R. .Romano R. .et al Mechanical ventilation after lung transplantation. J Crit Care. 2016;31:110-118 [PubMed]journal. [CrossRef] [PubMed]
 
Amato M.B. .Meade M.O. .Slutsky A.S. .et al Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372:747-755 [PubMed]journal. [CrossRef] [PubMed]
 
Beer A. .Reed R.M. .Bolukbas S. .et al Mechanical ventilation after lung transplantation. An international survey of practices and preferences. Ann Am Thorac Soc. 2014;11:546-553 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Fuehner T. .Kuehn C. .Welte T. .Gottlieb J. . ICU care before and after lung transplantation. Chest. 2016;150:442-450 [PubMed]journal. [CrossRef] [PubMed]
 
Barnes L. .Reed R.M. .Parekh K.R. .et al Mechanical ventilation for the lung transplant recipient. Curr Pulmonol Rep. 2015;4:88-96 [PubMed]journal. [CrossRef] [PubMed]
 
Thakuria L. .Davey R. .Romano R. .et al Mechanical ventilation after lung transplantation. J Crit Care. 2016;31:110-118 [PubMed]journal. [CrossRef] [PubMed]
 
Amato M.B. .Meade M.O. .Slutsky A.S. .et al Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372:747-755 [PubMed]journal. [CrossRef] [PubMed]
 
Beer A. .Reed R.M. .Bolukbas S. .et al Mechanical ventilation after lung transplantation. An international survey of practices and preferences. Ann Am Thorac Soc. 2014;11:546-553 [PubMed]journal. [CrossRef] [PubMed]
 
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