Airway pressure release ventilation during ex vivo lung perfusion attenuates injury

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 153; no. 1; pp. 197 - 204
• Main Authors: Mehaffey, J. Hunter, MD, Charles, Eric J., MD, Sharma, Ashish K., MBBS, PhD, Money, Dustin T., RRT-ACCS, Zhao, Yunge, MD, PhD, Stoler, Mark H., MD, Lau, Christine L., MD, MBA, Tribble, Curtis G., MD, Laubach, Victor E., PhD, Roeser, Mark E., MD, Kron, Irving L., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-01-2017
• Subjects: airway pressure release ventilation; Animals; APRV; Barotrauma - etiology; Barotrauma - pathology; Barotrauma - physiopathology; Barotrauma - prevention & control; Cardiothoracic Surgery; Continuous Positive Airway Pressure - adverse effects; Cytokines - metabolism; EVLP; ex vivo lung perfusion; Female; Graft Survival; ischemia reperfusion; Lung - metabolism; Lung - pathology; Lung - physiopathology; Lung - surgery; Lung Compliance; lung injury; Lung Injury - etiology; Lung Injury - pathology; Lung Injury - physiopathology; Lung Injury - prevention & control; lung transplant; Lung Transplantation - adverse effects; Lung Transplantation - methods; Male; Neutrophil Infiltration; Perfusion - adverse effects; Perfusion - methods; Pneumonectomy; Pressure; Pulmonary Edema - etiology; Pulmonary Edema - pathology; Pulmonary Edema - physiopathology; Pulmonary Edema - prevention & control; Reperfusion Injury - etiology; Reperfusion Injury - pathology; Reperfusion Injury - physiopathology; Reperfusion Injury - prevention & control; Respiration; Sus scrofa; Time Factors; Warm Ischemia; pulmonary artery; IL; positive end-expiratory pressure; DCD; lung transplant; PEEP; ischemia reperfusion; left atrial; APRV; ex vivo lung perfusion; inspired oxygen fraction; death after cardiac death donor; PA; lung injury; EVLP; F io 2; LA; Pa o 2; ex vivo lung perfusion; interleukin; partial pressure of oxygen; airway pressure release ventilation; Fio2; Pao2
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2016.09.029

Abstract Objective Critical organ shortages have resulted in ex vivo lung perfusion gaining clinical acceptance for lung evaluation and rehabilitation to expand the use of donation after circulatory death organs for lung transplantation. We hypothesized that an innovative use of airway pressure release ventilation during ex vivo lung perfusion improves lung function after transplantation. Methods Two groups (n = 4 animals/group) of porcine donation after circulatory death donor lungs were procured after hypoxic cardiac arrest and a 2-hour period of warm ischemia, followed by a 4-hour period of ex vivo lung perfusion rehabilitation with standard conventional volume-based ventilation or pressure-based airway pressure release ventilation. Left lungs were subsequently transplanted into recipient animals and reperfused for 4 hours. Blood gases for partial pressure of oxygen/inspired oxygen fraction ratios, airway pressures for calculation of compliance, and percent wet weight gain during ex vivo lung perfusion and reperfusion were measured. Results Airway pressure release ventilation during ex vivo lung perfusion significantly improved left lung oxygenation at 2 hours (561.5 ± 83.9 mm Hg vs 341.1 ± 136.1 mm Hg) and 4 hours (569.1 ± 18.3 mm Hg vs 463.5 ± 78.4 mm Hg). Likewise, compliance was significantly higher at 2 hours (26.0 ± 5.2 mL/cm H2 O vs 15.0 ± 4.6 mL/cm H2 O) and 4 hours (30.6 ± 1.3 mL/cm H2 O vs 17.7 ± 5.9 mL/cm H2 O) after transplantation. Finally, airway pressure release ventilation significantly reduced lung edema development on ex vivo lung perfusion on the basis of percentage of weight gain (36.9% ± 14.6% vs 73.9% ± 4.9%). There was no difference in additional edema accumulation 4 hours after reperfusion. Conclusions Pressure-directed airway pressure release ventilation strategy during ex vivo lung perfusion improves the rehabilitation of severely injured donation after circulatory death lungs. After transplant, these lungs demonstrate superior lung-specific oxygenation and dynamic compliance compared with lungs ventilated with standard conventional ventilation. This strategy, if implemented into clinical ex vivo lung perfusion protocols, could advance the field of donation after circulatory death lung rehabilitation to expand the lung donor pool.