Donor Lung Availability Research Articles

The Intensive Care Unit Oxygen Challenge Should Not Be Used for Donor Lung Function Decision-making

The intensive care unit oxygen challenge is a routine screening test for donor lung function. An arterial PO2 of <300 mm Hg is generally considered evidence of inadequate pulmonary function that contraindicates the use of the lungs for transplantation. Between December 1, 2001 and January 24, 2004, the intensive care unit oxygen challenge was compared with the PO2 in samples drawn from each pulmonary vein confluence in the operating room in 91 donors (182 donor lungs) after the lungs were fully inflated (FIO2 1.0). There were 62 males and 29 females, with a median age of 27.5 years (13.6 to 55.4 years). In 40 lungs, the pulmonary vein PO2 was >300 mm Hg, whereas the PO2 was <300 mm Hg on the last intensive care unit O2 challenge. The difference between the intensive care unit PO2 and the operating room pulmonary vein PO2 was greatest for donors with the lowest intensive care unit PO2. Of these 40 lungs, 8 were transplanted, all of whom had excellent graft function with a median intubation of 14.2 hours (6.1 to 23.8 hours). No patient sustained primary graft failure or an airway complication. The intensive care unit PO2 is an unreliable screening test for donor lung function, particularly when one lung is clear and the other is unclear radiographically. In this setting, intraoperative surgical assessment and pulmonary venous PO2 should be the basis for determining donor lung suitability. This strategy may provide an opportunity to increase donor lung availability.

Bilateral lobar transplantation utilizing living related donors.

As the recipient list for patients requiring lung transplantation continues to increase, cadaveric donor lung availability has remained static. Our experience with utilizing lobes from living related donors for bilateral pulmonary transplantation in 20 patients has yielded a 75% survival at 1 year follow-up. Morbidity and mortality have been predominately due to infection. Rejection episodes have been mild and unilateral and have responded to augmented corticosteroids. Pulmonary function tests in the recipients tend to improve steadily during the first year postoperatively, and the patients have excellent functional capacity. There have been no significant complications in the donors. On the basis of our clinical experience, we have found that bilateral lobar transplantation utilizing living related donors has resulted in organ availability that can be lifesaving in critically ill patients and can provide a good alternative in certain noncritical, deteriorating patients.

Double lung replacement: The options in 1993

L ung transplantation is the solid-organ transplantation procedure which has undergone the greatest evolution over recent years, both with respect to surgical developments and population servicing. The history of lung transplantation spans 10 years. Landmarks in its evolution are listed in Table 1. The spectrum of available lung transplant procedures has necessitated rationalisation of those procedures to optimise both recipient outcomes and the utilisation of pulmonary allografts. Despite improvements in pulmonary preservation and the successful use of suboptimal or “non-traditional” donors, the limited availability of donor lungs continues to restrict population servicing. The “internal milieu” of the brain-dead donor is hostile to the lungs, which are compromised by a combination of direct injury from trauma, neurogenic pulmonary oedema, and a propensity to secondary bacterial infections. As a consequence, only 30-40% of all brain dead donors are a potential source of suitable lungs.

Morbidity, mortality, and early results of single versus bilateral lung transplantation for emphysema

Both single lung transplantation and bilateral lung transplantation have been successful in patients with chronic obstructive pulmonary disease. Limited availability of donor lungs dictates wider use of single lung transplantation as long as this procedure provides a comparable functional result at less risk. Early morbidity, mortality rates, and functional results were compared in 32 consecutive patients undergoing either single or bilateral lung transplantation for end-stage chronic obstructive pulmonary disease. When pretransplantation and posttransplantation values of forced expiratory volume in 1 second, single breath diffusing capacity, total lung capacity, arterial oxygen tension, and 6-minute walking distance were compared, statistically significant improvement (p less than 0.01) was seen in both groups. However, significantly higher values (p less than 0.01) were attained for forced expiratory volume in 1 second, single breath diffusing capacity, and arterial oxygen tension in the bilateral transplantation group than in the single lung transplantation group. Patients receiving bilateral lung transplants were at greater risk for postoperative complications, especially cardiac arrhythmias and bronchial anastomotic defects. Actuarial survival for the single lung transplantation group was 93% at 1 year, versus 87% at 6 months and 71% at 1 year for the bilateral lung transplantation group. The optimal transplantation procedure for patients with chronic obstructive pulmonary disease has not been determined. Longer follow-up periods are needed to define better the roles of bilateral and single lung transplantation in this group of patients.

Lung Transplantation

Over the past 20 years, many advances in surgical methods, transplantation immunology, donor organ procurement and preservation techniques, and postsurgical care regimens have influenced greatly the field of lung transplantation. The single remaining obstacle to widespread clinical success is donor lung availability. Improved methods of ex vivo lung preservation, organ donor maintenance, and donor lung retrieval after the completion of cardiac donation should help to ameliorate this problem.