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Thomas Fuehner, MD; Christian Kuehn, MD; Tobias Welte, MD; Jen Gottlieb, MD
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FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

aDepartment of Respiratory Medicine, Hannover Medical School, Hannover, Germany

bDepartment of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany

CORRESPONDENCE TO: Thomas Fuehner, MD, Hannover Medical School, Department of Respiratory Medicine OE6870, Carl-NeubergStr. 1, 30625 Hannover, Germany


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


Chest. 2017;151(2):517-518. doi:10.1016/j.chest.2016.11.048
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We thank Thakuria and colleagues for their interest in our article recently published in CHEST and their comments. Although limited data are available, lung-protective ventilation strategies are gaining increased awareness in the early postoperative period following lung transplantation. Most of the recommendations have been extrapolated from literature recommendations for ARDS. Verbeek and Myles concluded that a combination of low tidal volume (< 6 mL/kg), moderate positive end-expiratory pressure (PEEP), and inspiratory pressure < 20 cm H2O above PEEP would be beneficial in lung transplantation ventilation.

Thakuria and colleagues reiterate the importance of pressure definitions. Plateau pressures are measured when there is no airflow in the ventilation circuit at end-inspiration. This pressure is supposed to be mainly determined according to lung compliance. Peak inspiratory pressure by definition is applied when there is airflow in the circuit (ie, during inspiration) and therefore primarily determined by airway resistance.

In the survey by Beer et al, both plateau and inspiratory pressures were mentioned. The median upper limit response in 51 participants was 35 cm H2O for peak inspiratory pressure and 30 cm H2O for the plateau pressure.

The Harefield group recently published a retrospective analysis of ventilator settings in 124 bilateral lung transplant recipients. The median inflation pressure was 24 cm H2O, median PEEP was 6 cm H2O, and median driving pressure (usually defined as the plateau pressure – PEEP) was 17 cm H2O. Low inflation pressures (< 25 cm H2O) within the first 6 hours following surgery were associated with significantly better outcomes. Higher inflation pressures were associated with prolonged mechanical ventilation and increased length of ICU stay. We agree that this paper stresses the importance of lung-protective ventilation after lung transplantation, but unfortunately this research was not published until after our literature search was concluded.

We agree with the authors that further studies are mandatory to understand the best mode of ventilator settings or even the place value of temporary extracorporeal support early after lung transplantation recipients and in lung donors.

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]
 
Verbeek G.L. .Myles P.S. . Intraoperative protective ventilation strategies in lung transplantation. Transplant Rev (Orlando). 2013;27:30-35 [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]
 
Thakuria L. .Davey R. .Romano R. .et al Mechanical ventilation after lung transplantation. J Crit Care. 2016;31:110-118 [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]
 
Verbeek G.L. .Myles P.S. . Intraoperative protective ventilation strategies in lung transplantation. Transplant Rev (Orlando). 2013;27:30-35 [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]
 
Thakuria L. .Davey R. .Romano R. .et al Mechanical ventilation after lung transplantation. J Crit Care. 2016;31:110-118 [PubMed]journal. [CrossRef] [PubMed]
 
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