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Year : 2019  |  Volume : 52  |  Issue : 1  |  Page : 37-38

Low-tidal-volume ventilation for recipients of lung transplant: Ready for clinical use?

Department of Anesthesiology and Intensive Care, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran

Date of Web Publication18-Feb-2019

Correspondence Address:
Dr. Manijeh Yousefi Moghadam
Department of Anesthesiology and Intensive Care, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_35_18

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How to cite this article:
Moghadam MY. Low-tidal-volume ventilation for recipients of lung transplant: Ready for clinical use?. Formos J Surg 2019;52:37-8

How to cite this URL:
Moghadam MY. Low-tidal-volume ventilation for recipients of lung transplant: Ready for clinical use?. Formos J Surg [serial online] 2019 [cited 2022 Nov 26];52:37-8. Available from: https://www.e-fjs.org/text.asp?2019/52/1/37/252439

Recently, the necessity for critical care before and after lung transplantation (LT) has steadily increased. Mechanical ventilation (MV), particularly posttransplant ventilation, is an important aspect of critical care for patients undergoing LT. Therefore, preventing and managing ventilator-associated complications, following LT is one of the important challenges ahead of intensivists for selecting MV strategies.[1] Primary graft dysfunction (PGD), a syndrome of acute lung injury, is one of the important complications of LT, which occurs within the first 72 h following LT.[2] PGD is associated with substantial postoperative morbidity and mortality.[2] Estimates suggest that up to 57% of LT recipients experience PGD.[3] It is assumed that PGD and acute respiratory distress syndrome (ARDS) have similar underlying pathophysiology. Hence, it seems theoretically that any preventive or therapeutic approaches that diminish the rates of ARDS might improve the outcomes for recipients of LT.[3] The etiology of PGD following LT is multifaceted, and it is the result of multiple pathways. It is supposed that ischemia-reperfusion injury within 24 h of LT is an important factor that contributes to the PGD.[4] In this regards, several approaches have been used to early diagnose or prevent this complication by intensivists including MV with low-tidal-volume ventilation (LTVV), inhibition of oxidative injury, anti-inflammatory mediators, N-acetyl cysteine, extracorporeal lung perfusion, activator of epithelial sodium channel-mediated Na+ uptake, inhaled nitric oxide, and venoarterial extracorporeal membrane oxygenation.[5],[6] The last three approaches are more commonly used to treat this condition. It should be noted that one preventative strategy will not be effective for all recipients of LT, and a well-personalized approach is required that involves the consideration of donor and recipient characteristics and clinical risk factors.

Currently, there is limited evidence to provide conclusive guideline regarding the optimal strategy for MV following LT.[1] Some intensivists select the MV strategy based on donor properties rather than recipient properties; however, there is no supporting evidence for this selection.[3] To prevent ischemia-reperfusion injury, several research findings suggest that lung-protective MV with LTVV in addition to positive end-expiratory pressure (PEEP) for the recipients of LT.[3],[7] In addition to the tidal volume, several research findings showed that fine adjusting of the fraction of inspired oxygen (FiO2) and respiratory rate in ventilators are two of the important issues that intensivists must be considered to prevent PGD.[8] Nevertheless, this suggestion also requires further validation in prospective clinical studies. Importantly, the optimal level of PEEP, respiratory rate, and FiO2 has not been well defined in recipients of LT yet. Therefore, because of a lack of clear evidence on how to optimally ventilate and manage patients, the current practices of MV strategy following LT are highly based on intensivists' preferences rather than on rigorous evidence.[1]

Current evidence shows that LTVV with PEEP has beneficial effects on ARDS-induced PGD.[8] Considering the high risk of PGD following LT, it seems that the use of protective ventilation strategies, such as LTVV immediately after implantation of the lung, may be beneficial.[8] However, there is a lack of evidence regarding the application of LTVV in recipients of LT, and no guidelines specific to this setting exist. In addition, there are no universal practice guidelines for the anesthetic management of these patients. Based on the aforementioned issues, it is difficult to define the optimal ventilation strategy for recipients of LT including the optimal tidal volume, respiratory rate, and FiO2. These issues highlight the need for further research, and therefore, definitive well-designed trials are needed.

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  References Top

Fuehner T, Kuehn C, Welte T, Gottlieb J. ICU care before and after lung transplantation. Chest 2016;150:442-50.  Back to cited text no. 1
Gilliland S, Brainard J. Postoperative noninvasive ventilation following cardiothoracic surgery: A clinical primer and review of the literature. Semin Cardiothorac Vasc Anesth 2015;19:302-8.  Back to cited text no. 2
Barnes L, Reed RM, Parekh KR, Bhama JK, Pena T, Rajagopal S, et al. Mechanical ventilation for the lung transplant recipient. Curr Pulmonol Rep 2015;4:88-96.  Back to cited text no. 3
Meade MO, Granton JT, Matte-Martyn A, McRae K, Weaver B, Cripps P, et al. Arandomized trial of inhaled nitric oxide to prevent ischemia-reperfusion injury after lung transplantation. Am J Respir Crit Care Med 2003;167:1483-9.  Back to cited text no. 4
Porteous MK, Lee JC. Primary graft dysfunction after lung transplantation. Clin Chest Med 2017;38:641-54.  Back to cited text no. 5
Aigner C, Slama A, Barta M, Mitterbauer A, Lang G, Taghavi S, et al. Treatment of primary graft dysfunction after lung transplantation with orally inhaled AP301: A prospective, randomized pilot study. J Heart Lung Transplant 2017. pii: S1053-2498 (17) 32036-3.  Back to cited text no. 6
Beer A, Reed RM, Bölükbas S, Budev M, Chaux G, Zamora MR, et al. Mechanical ventilation after lung transplantation. An international survey of practices and preferences. Ann Am Thorac Soc 2014;11:546-53.  Back to cited text no. 7
Guo L, Wang W, Zhao N, Guo L, Chi C, Hou W, et al. Mechanical ventilation strategies for Intensive Care Unit patients without acute lung injury or acute respiratory distress syndrome: A systematic review and network meta-analysis. Crit Care 2016;20:226.  Back to cited text no. 8


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