Management of Severe Non-Infectious Acute Respiratory Failure in Lung Transplant Recipients

Abstract

<h3>Purpose</h3> Acute respiratory failure (ARF) necessitating mechanical ventilation (MV) is the leading cause of ICU readmission after lung transplantation and is associated with a 6-month survival of <50%. Management strategies for patients with non-infectious causes of severe ARF are under-reported. We hypothesized that aggressive, early treatment of non-infectious ARF with awake venovenous extracorporeal membrane oxygenation (VV-ECMO) and augmented immunosuppression would improve outcomes. <h3>Methods</h3> This is a retrospective, single-center case series between 1/1/2018-12/1/2020. Lung transplant recipients (LTRs) with severe ARF with diffuse allograft infiltrates on chest X-ray and PaO2/FiO2 <150 were considered for VV-ECMO. All LTRs received empiric broad antibiotics. If initial cultures were negative, augmented immunosuppression with a combination of high-dose steroids, plasma exchange, intravenous immunoglobulin, rituximab, antithymocyte globulin or alemtuzumab was initiated. VV-ECMO support was via a bicaval, dual lumen single cannula. <h3>Results</h3> Ninety-nine LTRs were re-admitted to an ICU during the study period, with 5 meeting criteria for non-infectious severe ARF. Median duration of ECMO was 21 days (IQR 7-28). Four of the five patients received antibody and/or augmented T-cell depleting therapies, and 12-month survival was 80%. (Fig 1). Lung function stabilized following the ARF insult in survivors (Fig 2). <h3>Conclusion</h3> Treatment with awake VV-ECMO and augmented immunosuppression in LTRs with severe non-infectious ARF is associated with excellent 12-month outcomes that are better than previously reported with MV.