Mechanical Ventilation after Lung Transplantation. An International Survey of Practices and Preferences

Abstract

Between 10% and 57% of lung transplant (LTx) recipients develop primary graft dysfunction (PGD) within 72 hours of LTx. PGD is clinically and histologically analogous to the acute respiratory distress syndrome. In patients at risk for or with acute respiratory distress syndrome, lung-protective ventilation strategies (low tidal volume and positive end-expiratory pressure) improve outcomes. There is, however, little information available on mechanical ventilation strategies after LTx. Our aim in this international survey was to describe the current practices of mechanical ventilation immediately after LTx. An electronic survey was sent to the medical and surgical directors of U.S. LTx programs (n = 111) and to members of the Pulmonary Council of the International Society for Heart and Lung Transplantation (n = 470). A total of 149 individuals from 18 countries responded to the questionnaire. The most common modes of ventilation were pressure assist/control (37%) and volume assist/control (35%). Tidal volumes were most often determined by recipient characteristics. Donor characteristics were rarely considered (35%) and were infrequently known by the team managing the ventilator (42%). When presented with a choice of ideal tidal volumes, a majority of respondents selected 6 ml/kg recipient predicted body weight (58%), fewer selected 10 ml/kg (21%), and none selected 15 ml/kg. A majority preferred limiting the fraction of inspired oxygen rather than positive end-expiratory pressure (PEEP) (69% versus 31%, P = 0.006). The median minimum PEEP was 5 cm H2O, and the median maximum PEEP was 11.5 cm H2O. The presence of PGD increased the perceived importance of monitoring plateau pressure to adjust tidal volumes. The median plateau pressure limit perceived as a threshold triggering reduction in tidal volume was 30 cm H2O. Most respondents reported using lung-protective approaches to mechanical ventilation after lung transplantation. Low tidal volumes based on recipient characteristics were frequently chosen. Donor characteristics often were not considered and frequently were not known by the team managing mechanical ventilation after LTx.