Mechanical ventilation and extracorporeal membrane oxygenation as a bridge to lung transplantation: Closing the gap

Utilization and outcomes of nonintubated extracorporeal membrane oxygenation as a bridge to lung transplant

BACKGROUND

Nonintubated extracorporeal membrane oxygenation (ECMO) has been increasingly utilized for patients with severe respiratory failure. Since data on its use as a bridge to lung transplant remain limited, we evaluated its use in a national cohort.

METHODS

Adult lung-only transplant recipients bridged with ECMO May 4, 2005 to March 8, 2023 in the United Network for Organ Sharing database were categorized by use of ECMO and mechanical ventilation (MV) at transplant (ECMO+MV vs ECMO-only). We compared post-transplant intubation and ECMO at 72 hours, length of stay, and survival.

RESULTS

The 1,599 transplants identified included 902 (56.4%) bridged with ECMO+MV and 697 (43.6%) bridged with ECMO-only. ECMO-only recipients had higher median age (52 vs 49 years, p < 0.001), shorter ischemic times (5.7 vs 6.0 hours, p = 0.003), and similar lung allocation scores (89.5 vs 89.6, p = 0.11). ECMO-only recipients had lower likelihood of intubation at 72 hours (56.5% vs 77.5%; adjusted odds ratio 0.33 [95% confidence interval (CI): 0.25, 0.42], p < 0.001) and shorter lengths of stay (28 vs 35 days; coefficient -0.19 [95% CI: -0.27, -0.11], p < 0.001). ECMO-only recipients had higher 90-day survival (92.1% vs 89.1%; adjusted hazards ratio (aHR) 0.69 [95% CI: 0.48, 0.99], p = 0.04) but similar 1-year (83.1% vs 81.5%; aHR 0.87 [95% CI: 0.67, 1.12], p = 0.27) and 5-year (54.6% vs 54.7%; aHR 0.98 [95% CI: 0.82, 1.17], p = 0.83) survival.

CONCLUSIONS

Nonintubated ECMO bridge to lung transplant was associated with improved perioperative outcomes and short-term survival and should be considered for candidates requiring ECMO.

ECMO for bridging lung transplantation

BACKGROUND

With the shift in donor lung allocation from blood type and waiting order to the use of the lung allocation score (LAS) system, there are increasingly more cases of ECMO bridging lung transplantation. However, there are still some problems in case selection, implementation, and management.

METHODS

We analyzed and summarized a series of data on ECMO bridging lung transplantation through an extensive literature review.

RESULTS

The improvement of the lung transplant allocation system and the progress of ECMO technology have made the ECMO bridge to lung transplant more widely used in clinical practice. The selection of bridge patients is a crucial link in the success of transplantation, and accurate assessment of the patient before transplantation is necessary. The advantages and disadvantages of different bridge strategies exist, and the appropriate bridge strategy should be selected based on the patient's situation. Bleeding and thrombosis complications often occur during ECMO circulation, and there is currently no optimal anticoagulation strategy. The predictive score for bridge post-outcome is still subject to certain limitations.

CONCLUSIONS

ECMO bridging lung transplantation is suitable for patients waiting for lung transplantation when other respiratory support is ineffective or when hemodynamic instability occurs the disease is severe and the donor organ is easily obtainable. Patients aged 65 years or older, or have reversible multiple organ dysfunction should not be included as contraindications for ECMO bridging lung transplantation.

Cannulation Configuration and Its Effects on Bridging to Lung Transplant: Analysis of the Extracorporeal Life Support Organization Registry

BACKGROUND

Donor stagnation and modification of lung allocation scores has resulted in a higher acuity of patient presentation before lung transplantation. Extracorporeal membrane oxygenation (ECMO) has been used as a bridge to lung transplant (BTT), although the effect of cannulation strategy on outcomes has not been well investigated. We analyzed contemporary data on ECMO BTT by using a large, international registry of patients.

METHODS

We used the Extracorporeal Life Support Organization registry to identify all adult patients from 2010 to 2022 undergoing ECMO as a BTT. Patients were stratified by venovenous or venoarterial support type.

RESULTS

A total of 1066 patients were identified. ECMO BTT increased over the study period (P < .001), as did survival to hospital discharge (P < .001), with an overall survival of 87.7%. Venovenous patients experienced fewer complications on ECMO, including dialysis (16.7% vs 25.3%, P = .006), stroke (1.4% vs 5.1%, P = .004), and limb ischemia (0.2% vs 3.4%, P < .001) and required ECMO less frequently in the postoperative period (41.0% vs 53.4%, P = .002) and for less time (4 days [interquartile range, 2-7 days] vs 5 days [interquartile range, 3-9 days], P = .01). In-hospital mortality was significantly lower for venovenous patients compared with venoarterial patients (11.0% vs 18.5%, P = .005). Increasing center volume of ECMO BTT was protective of in-hospital mortality (P < .001), with benefit observed after ∼45 total BTT intent cannulations.

CONCLUSIONS

ECMO BTT has resulted in improved posttransplant survival to discharge. Owing to a higher rate of complications and worsened mortality, thoughtful implementation of venoarterial ECMO in BTT should be undertaken when assessing patient candidacy.

Non-intensive care unit feasibility for ambulatory veno-venous extracorporeal membrane oxygenation patients

INTRODUCTION

Veno-venous extracorporeal membrane oxygenation has increasingly been utilized to support patients in respiratory failure as a bridge to recovery or lung transplantation. As patients progress from cannulation to recovery or transplantation, it has been shown that physical therapy and ambulation are possible and beneficial for patient outcomes.

METHODS

We sought to evaluate the feasibility of managing these ambulatory VV-ECMO patients in a non-ICU setting by conducting a single-center, retrospective cohort study to characterize the daily data collection (i.e., CXRs, blood draws, etc.) and ICU and ECMO interventions and events (i.e., oxygenator/cannula exchange, sweep or flow adjustments, etc.).

RESULTS

A total of 28 ECMO runs from patients ≥18 years of age who ambulated ≥100 feet while on VV ECMO between 2014 and 2020 were included for analysis. Patients were supported on ECMO a median of 33 [18-79.5] days with a mean of 4.0 (3.8,4.1) data collections per day. There was a mean of 1.1 (1.0,1.2) anticoagulation changes, 1.5 (1.4,1.6) ECMO interventions, and 0.40 (0.34,0.46) ICU interventions per day. There were very few instances of cannula repositioning or oxygenator exchanges - 0.05 (CI 0.04, 0.06) per day.

CONCLUSION

Our data suggests that ambulatory VV-ECMO patients may tolerate less than ICU level of care and may even progress to outpatient management as ECMO technology continues to advance.

Lessons Learned From Extracorporeal Life Support Practice and Outcomes During the COVID-19 Pandemic

Extracorporeal membrane oxygenation is increasingly being used to support patients with hypoxemic respiratory failure and cardiogenic shock. During the COVID-19 pandemic, consensus guidance recommended extracorporeal life support for patients with COVID-19-related cardiopulmonary disease refractory to optimal conventional therapy, prompting a substantial expansion in the use of this support modality. Extracorporeal membrane oxygenation was particularly integral to the bridging of COVID-19 patients to heart or lung transplantation. Limited human and physical resources precluded widespread utilization of mechanical support during the COVID-19 pandemic, necessitating careful patient selection and optimal management by expert healthcare teams for judicious extracorporeal membrane oxygenation use. This review outlines the evidence supporting the use of extracorporeal life support in COVID-19, describes the practice and outcomes of extracorporeal membrane oxygenation for COVID-19-related respiratory failure and cardiogenic shock, and proposes lessons learned for the implementation of extracorporeal membrane oxygenation as a bridge to transplantation in future public health emergencies.

Postoperative conditions of rehabilitative interest in lung transplantation: a systematic review

Lung transplantation is an elective treatment option for end-stage respiratory diseases in which all medical therapy options have been exhausted. The current study aimed to identify updated information on the postoperative conditions that may impair rehabilitation after lung transplantation and to provide specific considerations of their clinical relevance during the recovery process. The present study is a systematic review conducted by searching three primary databases: the United States National Library of Medicine PubMed system, Scopus, and the Cochrane Library. The databases were searched for articles published from database inception until May 2024; at the end of the selection process, 27 documents were included in the final analysis. The retrieved material identified 19 conditions of rehabilitative interest that potentially affect the postoperative course: graft dysfunction, dysphagia, postsurgical pain, cognitive impairment, chronic lung allograft dysfunction-bronchiolitis obliterans syndrome, phrenic nerve injury, delayed extracorporeal membrane oxygenation weaning, airway clearance, refractory hypoxemia, mediastinitis, reduced oxidative capacity, sternal dehiscence, coronavirus disease 2019 (COVID-19), gastroparesis, ossification of the elbow, Takotsubo cardiomyopathy, airway dehiscence, recurrent pleural effusion, and scapular prolapse. Although some patients are not amenable to rehabilitation techniques, others can significantly improve with rehabilitation.

Ambulatory Extracorporeal Membrane Oxygenation Use in Patients Listed for Lung Transplant

There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) to bridge critically ill patients to lung transplant (LTX). This study evaluates how ambulatory status on ECMO affected waitlist and post-LTX outcomes. The United Network of Organ Sharing (UNOS) database was queried for patients aged of greater than or equal to 18 years and between 2016 and 2021 to identify pre-LTX patients supported by ECMO. The patients were classified in venous-arterial (VA) ECMO and veno-venous (VV) ECMO cohorts and further classified as ambulatory (AMB) and non-AMB (nAMB). Each cohort was controlled against the non-ECMO patients. Univariate statistical tests, as well as Kaplan-Meier survival curves, were used for analysis. The 90 day waitlist survival was the highest among the non-ECMO group (96%), but both AMB VV and VA groups had superior survival compared to the nAMB group (85% vs. 75%, 78% vs. 65%, p < 0.01). After adjusting for the median lung allocation score (LAS) (88) in the VV ECMO group, the waitlist survival was superior in the AMB VV ECMO compared to those not on ECMO (86% vs. 78%, p > 0.01). The 1 year post-LTX survival between non-ECMO and AMB VV ECMO was comparable (88% vs. 88%, p = 0.66). Ambulating patients or use of physical therapy while on ECMO can help improve lung transplant outcomes.

Percutaneous Mechanical Circulatory Support in Acute Heart Failure Complicated with Cardiogenic Shock

Despite advancements in algorithms concerning the management of cardiogenic shock, current guidelines still lack the adequate integration of mechanical circulatory support devices. In recent years, more and more devices have been developed to provide circulatory with or without respiratory support, when conservative treatment with inotropic agents and vasopressors has failed. Mechanical circulatory support can be contemplated for patients with severe, refractory, or acute-coronary-syndrome-related cardiogenic shock. Through this narrative review, we delve into the differences among the types of currently used devices by presenting their notable advantages and inconveniences. We address the technical issues emerging while choosing the best possible device, temporarily as a bridge to another treatment plan or as a destination therapy, in the optimal timing for each type of patient. We also highlight the diverse implantation and removal techniques to avoid major complications such as bleeding and limb ischemia. Ultimately, we hope to shed some light in the gaps of evidence and the importance of conducting further organized studies around the topic of mechanical circulatory support when dealing with such a high mortality rate.

Which strategy is better for lung transplantation: Cardiopulmonary bypass or extracorporeal membrane oxygenation?

Background: In lung transplantation surgery, extracorporeal life support (ECLS) is essential for safety. Various support methods, including cardiopulmonary bypass (CPB) and off-pump techniques, are used, with extracorporeal membrane oxygenation (ECMO) gaining prominence. However, consensus on the best support strategy is lacking.Purpose: This article reviews risks, benefits, and outcomes of different support strategies in lung transplantation. By consolidating knowledge, it aims to clarify selecting the most appropriate ECLS modality.Research Design: A comprehensive literature review examined CPB, off-pump techniques, and ECMO outcomes in lung transplantation, including surgical results and complications.Study Sample: Studies, including clinical trials and observational research, focused on ECLS in lung transplantation, both retrospective and prospective, providing a broad evidence base.Data Collection and/or Analysis: Selected studies were analyzed for surgical outcomes, complications, and survival rates associated with CPB, off-pump techniques, and ECMO to assess safety and effectiveness.Results: Off-pump techniques are preferred, with ECMO increasingly vital as a bridge to transplant, overshadowing CPB. However, ECMO entails hidden risks and higher costs. While safer than CPB, optimizing ECMO postoperative use and monitoring is crucial for success.Conclusions: Off-pump techniques are standard, but ECMO's role is expanding. Despite advantages, careful ECMO management is crucial due to hidden risks and costs. Future research should focus on refining ECMO use and monitoring to improve outcomes, emphasizing individualized approaches for LT recipients.

Outcomes of Recipients Aged 65 Years and Older Bridged to Lung Transplant With Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (BTT) has been used for critically ill candidates with excellent outcomes, but data on this strategy in older recipients remain limited. We compared outcomes of no BTT, mechanical ventilation (MV)-only BTT, and ECMO BTT in recipients of greater than or equal to 65 years. Lung-only recipients of greater than or equal to 65 years in the United Network for Organ Sharing database between 2008 and 2022 were included and stratified by bridging strategy. Of the 9,936 transplants included, 226 (2.3%) were MV-only BTT and 159 (1.6%) were ECMO BTT. Extracorporeal membrane oxygenation BTT recipients were more likely to have restrictive disease pathology, had higher median lung allocation score, and spent fewer days on the waitlist (all p < 0.001). Compared to no-BTT recipients, ECMO BTT recipients were more likely to be intubated or on ECMO at 72 hours posttransplant and had longer hospital lengths of stay (all p < 0.001). Extracorporeal membrane oxygenation BTT recipients had increased risk of 3 years mortality compared to both no-BTT (adjusted hazard ratio [aHR] = 1.48 [95% confidence interval {CI}: 1.14-1.91], p = 0.003) and MV-only recipients (aHR = 1.50 [95% CI: 1.08-2.07], p = 0.02). Overall, we found that ECMO BTT in older recipients is associated with inferior posttransplant outcomes compared to MV-only or no BTT, but over half of recipients remained alive at 3 years posttransplant.

Nurses' Interventions in Minimizing Adult Patient Vulnerability During Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation: An Integrative Review

Introduction

People during extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation find themselves in a high degree of physical and psychological vulnerability, which could cause additional problems for their health status. Therefore, this review aims to identify the interventions that shape critical nursing care to minimize patient vulnerability during ECMO as a bridge to lung transplantation.

Method

A literature review was performed using CINAHL, MEDLINE, PubMed, Scopus and Web of Science databases with searches conducted in March 2023, with temporal restriction of articles published between 2013 and 2023. After selecting articles involving adults in critical situations on ECMO, their quality was assessed using the critical appraisal tools from the Joanna Briggs Institute. Articles with the pediatric population, reviews, and opinion articles were excluded. A spreadsheet was built for data extraction and a narrative analysis was performed.

Results

Three articles were included involving 40 participants in total. Interventions that shape critical nursing care to minimize a person's vulnerability are in the physical domain (basic precautions to prevent infection) and in the psychological domain (trusting relationships, consistent and clear communication, physical presence of nurses and family members and the use of advocacy). The Awake ECMO strategy was identified as beneficial for reducing vulnerability.

Conclusion

By recognizing and identifying the person's vulnerability during ECMO as a bridge to lung transplantation, nurses can implement effective interventions to minimize vulnerability in this population, thus contributing to the person's well-being through personalization and individualization of care. Additionally, the results of this review could be useful for developing tools to assess the degree of vulnerability and for implementing person-centered care measures and policies. However, further research is warranted given the scarcity of literature on these topics.

Waitlist Mortality and Extracorporeal Membrane Oxygenation Bridge to Lung Transplant

BACKGROUND

Use of extracorporeal membrane oxygenation (ECMO) as bridge to lung transplant has increased. However, little is known about patients placed on ECMO who die while on the waiting list. Using a national lung transplant data set, we investigated variables associated with waitlist mortality of patients bridged to lung transplant.

METHODS

All patients supported on ECMO at time of listing were identified using the United Network for Organ Sharing database. Univariable analyses were performed using bias-reduced logistic regression. Cause-specific hazard models were used to determine the effect of variables of interest on hazard of outcomes.

RESULTS

From April 2016 to December 2021, 634 patients met inclusion criteria. Of these, 445 (70%) were successfully bridged to transplant, 148 (23%) died on the waitlist, and 41 (6.5%) were removed for other reasons. Univariable analysis found associations between waitlist mortality and blood group, age, body mass index, serum creatinine, lung allocation score, days on waitlist, United Network for Organ Sharing region, and being listed at a lower-volume center. Cause-specific hazard models demonstrated that patients at high-volume centers were 24% more likely to survive to transplant and 44% less likely to die on the waitlist. Among patients who were successfully bridged to transplant, there was no difference in survival between low- and high-volume centers.

CONCLUSIONS

ECMO is an appropriate strategy to bridge selected high-risk patients to lung transplant. Of those placed on ECMO with intent to transplant, about one quarter may not survive to transplantation. High-risk patients requiring advanced support strategies may be more likely to survive to transplant when bridged at a high-volume center.

Critical Care Management of the Lung Transplant Recipient

Lung transplantation is often the only treatment option for patients with severe irreversible lung disease. Improvements in donor and recipient selection, organ allocation, surgical techniques, and immunosuppression have all contributed to better survival outcomes after lung transplantation. Nonetheless, lung transplant recipients still experience frequent complications, often necessitating treatment in an intensive care setting. In addition, the use of extracorporeal life support as a means of bridging critically ill patients to lung transplantation has become more widespread. This review focuses on the critical care aspects of lung transplantation, both before and after surgery.

New Aspects of Lung Transplantation: A Narrative Overview Covering Important Aspects of Perioperative Management

The management of lung transplant patients has continued to evolve in recent years. The year 2021 was marked by the publication of the International Consensus Recommendations for Anesthetic and Intensive Care Management of Lung Transplantation. There have been major changes in lung transplant programs over the last few years. This review will summarize the knowledge in anesthesia management of lung transplantation with the most recent data. It will highlight the following aspects which concern anesthesiologists more specifically: (1) impact of COVID-19, (2) future of transplantation for cystic fibrosis patients, (3) hemostasis management, (4) extracorporeal membrane oxygenation management, (5) early prediction of primary graft dysfunction, and (6) pain management.

Critical Care of the Lung Transplant Patient

Lung transplantation is a therapeutic option for end-stage lung disease that improves survival and quality of life. Prelung transplant admission to the intensive care unit (ICU) for bridge to transplant with mechanical ventilation and extracorporeal membrane oxygenation (ECMO) is common. Primary graft dysfunction is an important immediate complication of lung transplantation with short- and long-term morbidity and mortality. Later transplant-related causes of respiratory failure necessitating ICU admission include acute cellular rejection, atypical infections, and chronic lung allograft dysfunction. Lung transplantation for COVID-19-related ARDS is increasingly common..

Allocation of Donor Lungs in Korea

The expansion of indications for lung transplantation, the growth of the waiting list, and donor shortages are increasing the waiting list mortality rate in Korea. The current lung allocation system in Korea is based mainly on urgency, but outcomes should also be considered to avoid futile transplantation. This review describes the current status of, and issues with, the lung allocation system in Korea including donors, the waiting list, and transplant outcomes in the context of an aging society, in which the frequency of end-stage pulmonary disease is increasing.

Extracorporeal membrane oxygenation support for lung transplantation: Initial experience in a single center in China and a literature review

Background

Extracorporeal membrane oxygenation (ECMO) is a versatile tool associated with favorable outcomes in the field of lung transplantation (LTx). Here, the clinical outcomes and complications of patients who underwent LTx with ECMO support, mainly prophylactically both intraoperatively and post-operatively, in a single center in China are reviewed.

Methods

The study cohort included all consecutive patients who underwent LTx between January 2020 and January 2022. Demographics and LTx data were retrospectively reviewed. Perioperative results, including complications and survival outcomes, were assessed.

Results

Of 86 patients included in the study, 32 received ECMO support, including 21 who received prophylactic intraoperative use of ECMO with or without prolonged post-operative use (pro-ECMO group), while the remaining 54 (62.8%) received no external support (non-ECMO group). There were no significant differences in the incidence of grade 3 primary graft dysfunction (PGD), short-term survival, or perioperative outcomes and complications between the non-ECMO and pro-ECMO groups. However, the estimated 1- and 2-year survival were superior in the pro-ECMO group, although this difference was not statistically significant (64.1% vs. 82.4%, log-rank P = 0.152; 46.5% vs. 72.1%, log-rank P = 0.182, respectively). After regrouping based on the reason for ECMO support, 30-day survival was satisfactory, while 90-day survival was poor in patients who received ECMO as a bridge to transplantation. However, prophylactic intraoperative use of ECMO and post-operative ECMO prolongation demonstrated promising survival and acceptable complication rates. In particular, patients who initially received venovenous (VV) ECMO intraoperatively with the same configuration post-operatively achieved excellent outcomes. The use of ECMO to salvage a graft affected by severe PGD also achieved acceptable survival in the rescue group.

Conclusions

Prophylactic intraoperative ECMO support and post-operative ECMO prolongation demonstrated promising survival outcomes and acceptable complications in LTx patients. Particularly, VV ECMO provided safe and effective support intraoperatively and prophylactic prolongation reduced the incidence of PGD in selected patients. However, since this study was conducted in a relatively low-volume transplant center, further studies are needed to validate the results.

Taking a Deep Breath: an Examination of Current Controversies in Surgical Procedures in Lung Transplantation

Purpose of Review

This article reviews controversial questions within the field of lung transplantation, with a focus on data generated within the last 3 years. We aim to summarize differing opinions on a selection of topics, including bridge-to-transplantation, intraoperative machine circulatory support, bronchial anastomosis, size mismatch, delayed chest closure, and ex vivo lung perfusion.

Recent Findings

With the growing rate of lung transplantations worldwide and increasing numbers of patients placed on waiting lists, the importance of determining best practices has only increased in recent years. Factors which promote successful outcomes have been identified across all the topics, with certain approaches promoted, such as ambulation in bridge-to-transplant and widespread intraoperative ECMO as machine support.

Summary

While great strides have been made in the operative procedures involved in lung transplantation, there are still key questions to be answered. The consensus which can be reached will be instrumental in further improving outcomes in recipients.

Anesthetic Management During Lung Transplantation - What's New in 2021?

As outcomes of lung transplantation (LTx) are improving transplant centers are pushing boundaries. There has been a steady increase in the medical complexity of lung transplant candidates. Many transplant centers are listing older patients with comorbidities, and there has been a steady rise in the number of candidates supported with extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation. There has been a growing appreciation of the importance intraoperative management of potentially modifiable risk factors has on postoperative outcomes. Evidence suggests that LTx even in high-risk patients requiring perioperative ECMO can offer excellent results. This article outlines the current state-of-the-art intraoperative management of LTx.

Inpatient Management of the Acutely Decompensating Lung Transplant Candidate

Lung allocation in the US changed nearly 15 years ago from time accrued on the waiting list to disease severity and likelihood of posttransplant survival, represented by the lung allocation score (LAS). Notably, the risk of death within a year plays a stronger role on the score calculation than posttransplant survival. While this change was associated with the intended decrease in waitlist mortality (most recently reported at 14.6%), it was predictable that transplant teams would have to care for increasingly older and complex candidates and recipients. This urgency-based allocation also led centers to routinely consider transplanting patients with higher acuity, often hospitalized and, not infrequently, in the intensive care unit (ICU). According to the Scientific Registry for Transplant Recipients, from 2009 to 2019, the proportion of lung recipients hospitalized and those admitted to the ICU at the time of transplant increased from 18.9% to 26.8% and from 9.2% to 16.5%, respectively..

Lung Transplantation for Acute Respiratory Distress Syndrome

In this review, we discuss the outcomes of patients with severe acute respiratory distress syndrome (ARDS). We discuss evidence that suggests that a significant proportion of patients with ARDS develop end-stage lung disease and die of pulmonary complications. In carefully selected patients with permanent lung damage, lung transplant can be a life-saving treatment.

Awakening in extracorporeal membrane oxygenation as a bridge to lung transplantation

Although the rate of lung transplantation (LTx), the last treatment option for end-stage lung disease, is increasing, some patients waiting for LTx need a bridging strategy for LTx due to the limited number of available donor lungs. For a long time, mechanical ventilation has been employed as a bridge to LTx because the outcome of using extracorporeal membrane oxygenation (ECMO) as a bridging strategy has been poor. However, the outcome after mechanical ventilation as a bridge to LTx was poor compared with that in patients without bridges. With advances in technology and the accumulation of experience, the outcome of ECMO as a bridge to LTx has improved, and the rate of ECMO use as a bridging strategy has increased over time. However, whether the use of ECMO as a bridge to LTx can achieve survival rates similar to those of non-bridged LTx patients remains controversial. In 2010, one center introduced awake ECMO strategy for LTx bridging, and its use as a bridge to LTx has been showing favorable outcomes to date. Awake ECMO has several advantages, such as maintenance of physical activity, spontaneous breathing, avoidance of endotracheal intubation, and reduced use of sedatives and analgesics, but it may cause serious problems. Nonetheless, several studies have shown that awake ECMO performed by a multidisciplinary team is safe. In cases where ECMO or mechanical ventilation is required due to unavoidable exacerbation in patients awaiting LTx, the application of awake ECMO performed by an appropriately trained ECMO multi-disciplinary team can be useful.

Anesthetic considerations in lung transplantation: past, present and future

Lung transplantation is a very complex surgical procedure with many implications for the anesthetic care of these patients. Comprehensive preoperative evaluation is an important component of the transplant evaluation as it informs many of the decisions made perioperatively to manage these complex patients effectively and appropriately. These decisions may involve pre-emptive actions like pre-habilitation and nutrition optimization of these patients before they arrive for their transplant procedure. Appropriate airway and ventilation management of these patients needs to be performed in a manner that provides an optimal operating conditions and protection from ventilatory injury of these fragile post-transplant lungs. Pain management can be challenging and should be managed in a multi-modal fashion with or without the use of an epidural catheter while recognizing the risk of neuraxial technique in patients who will possibly be systemically anticoagulated. Complex monitoring is required for these patients involving both invasive and non-invasive including the use of transesophageal echocardiography (TEE) and continuous cardiac output monitoring. Management of the patient's hemodynamics can be challenging and involves managing the systemic and pulmonary vascular systems. Some patients may require extra-corporeal lung support as a planned part of the procedure or as a rescue technique and centers need to be proficient in instituting and managing this sophisticated method of hemodynamic support.

Outcomes following lung re-transplantation in patients with cystic fibrosis

PURPOSE

We examined cystic fibrosis (CF) patients and compared their clinical status at the time of primary versus double lung re-transplantation (re-DLTx) in order to better understand lung retransplant practice patterns.

METHODS

We performed a retrospective analysis of the UNOS Database identifying CF patients ≥18 years old undergoing re-DLTx (5/4/2005 and 12/4/2020). Baseline and clinical variables at the primary and re-DLTx were compared utilizing the paired student t-test. Graft survival was defined as time from surgery to retransplant and analyzed using Kaplan-Meier estimates.

RESULTS

277 CF patients who underwent re-DLTx experienced a significantly worse 5-year survival when compared to the primary DLTx cohort (47.9% vs 58.8%, p = 0.00012). The following differences were observed comparing CF re-DLTx group to their primary DLTx: higher LAS score at the time of listing (50.66 vs 42.15, p < 0.001) and transplant (62.19 vs 48.20, p < 0.001), and increase LAS from the time of listing to transplant (+12.22 vs +7.23, p = 0.002). While serum albumin and total bilirubin were similar, CF patients had a higher creatinine (1.05 vs 0.74, p < 0.001), dialysis (4.4% vs 0.6%, p < 0.001), ECMO bridge to transplant rates (7.6% vs 4.0%, p < 0.001), and higher oxygen requirements (5.95 vs 3.93, p < 0.001) at the time of listing for a re-DLTx.

CONCLUSION

Compared to their initial transplant, CF patients experience significant clinical decline in renal, cardiac, and pulmonary function at the time of lung retransplantation. This may indicate that an earlier evaluation and rehabilitation process may be necessary to identify patients earlier for lung retransplantation prior significant clinical decline.

Lung transplantation for acute respiratory distress syndrome - a retrospective European Cohort Study

BACKGROUND

The published experience of lung transplantation (LTX) in acute respiratory distress syndrome (ARDS) is limited. The aim of this study was to investigate the contemporary results of LTX attempts in ARDS in major European centers.

METHODS

We conducted a retrospective multicenter cohort study of all patients listed for LTX between 2011 and 2019. We surveyed 68 centers in 22 European countries. All patients admitted to the waitlist for lung transplantation with a diagnosis of "ARDS//pneumonia" were included. Patients without extracorporeal membrane oxygenation (ECMO) or mechanical ventilation were excluded. Patients were followed until October 1st 2020 or death. Multivariable analysis for 1-year survival after listing and lung transplantation were performed.

RESULTS

Forty-eight centers (74%) with a total transplant activity of 12 438 lung transplants during the 9-year period gave feedback. Forty patients with a median age of 35 years were identified. Patients were listed for LTX in 18 different centers in 10 countries. Thirty-one-patients underwent LTX (0·25% of all indications) and 9 patients died on the waitlist. Ninety percent of transplanted patients were on ECMO in combination with mechanical ventilation before LTX. On multivariable analysis, transplantation during 2015 until 2019 was independently associated with better 1-year survival after LTX (odds ratio 10.493, 95% CI 1.977, 55.705, p=0.006). Sixteen survivors out of 23 patients with known status (70%) returned to work after LTX.

CONCLUSION

LTX in highly selected ARDS patients is feasible and outcome has improved in the modern era. The selection process remains ethically and technically challenging.

Mortality after Lung Transplantation for Children Bridged with Extracorporeal Membrane Oxygenation

RATIONALE

Extracorporeal membrane oxygenation (ECMO) is increasingly used to bridge waitlisted children failing conventional respiratory support to lung transplantation.

OBJECTIVES

To compare in-hospital mortality and a composite outcome of 1-year mortality or re-transplantation in children bridged with ECMO with those on mechanical ventilation (MV), and neither support.

METHODS

The United Network for Organ Sharing (UNOS) was used to analyze lung transplant recipients, aged ≤ 20 y, from January 2004 to August 2019. Recipients were categorized according to level of respiratory support at time of transplant, including ECMO, MV, or neither. Multivariable analysis was used to evaluate support type and in-hospital mortality.

RESULTS

Of 1,014 children undergoing lung transplant, 68 (6.7%) required ECMO as a bridge-to-transplant, 144 (14.2%) MV, and 802 (79.1%) neither. Primary diagnosis in the ECMO cohort included cystic fibrosis (43%), pneumonia/ARDS (10.3%), interstitial pulmonary fibrosis (7.4%) and pulmonary hypertension (5.9%). Number of patients bridged with ECMO increased throughout the study period from none in 2004 to 16.7% in 2018. Multivariable analysis showed bridging with both ECMO (aOR = 3.57; 95% CI: 1.42, 8.97) and MV (aOR = 2.67; 95% CI: 1.26, 5.57) increased in-hospital mortality after lung transplantation. However, there was no difference in composite outcome of mortality and re-transplantation at 1-year between the three groups.

CONCLUSIONS

ECMO to bridge children to lung transplantation has increased. Despite this, ECMO is a high-risk bridge strategy for children awaiting lung transplantation. Future research should target interventions that can be focused on improving survival in these patients.

Frailty in Lung Transplantation: Candidate Assessment and Optimization

The concept of frailty has gained considerable interest in clinical solid-organ transplantation over the past decade. Frailty as a phenotypic construct to describe a patient's risk from biologic stresses has an impact on posttransplant survival. There is keen interest in characterizing frailty in lung transplantation, both to determine which patients are suitable candidates for listing and also to prepare for their care in the aftermath of lung transplantation. Here, we review the current status of research on frailty in lung transplant candidates and recipients. This review will highlight areas of uncertainty for frailty in clinical lung transplantation that are likely to impact the state-of-the-art in the field for the next decade.

Lung transplantation disparities based on diagnosis for patients bridging to transplant on extracorporeal membrane oxygenation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly utilized as a bridge to lung transplantation, but ECMO status is not explicitly accounted for in the Lung Allocation Score (LAS). We hypothesized that among waitlist patients on ECMO, patients with pulmonary arterial hypertension (PAH) would have lower transplantation rates.

METHODS

Using United Network for Organ Sharing data, we conducted a retrospective cohort study of patients who were ≥12 years old, active on the lung transplant waitlist, and required ECMO support from June 1, 2015 through June 12, 2020. Multivariable competing risk analysis was used to examine waitlist outcomes.

RESULTS

1064 waitlist subjects required ECMO support; 40 (3.8%) had obstructive lung disease (OLD), 97 (9.1%) had PAH,138 (13.0%) had cystic fibrosis (CF), and 789 (74.1%) had interstitial lung disease (ILD). Ultimately, 671 (63.1%) underwent transplant, while 334 (31.4%) died or were delisted. The transplant rate per person-years on the waitlist on ECMO was 15.41 for OLD, 6.05 for PAH, 15.66 for CF, and 15.62 for ILD. Compared to PAH patients, OLD, CF, and ILD patients were 78%, 69%, and 62% more likely to undergo transplant throughout the study period, respectively (adjusted SHRs 1.78 p = 0.007, 1.69 p = 0.002, and 1.62 p = 0.001). The median LAS at waitlist removal for transplantation, death, or delisting were 75.1 for OLD, 79.6 for PAH, 91.0 for CF, and 88.3 for ILD (p < 0.001).

CONCLUSIONS

Among patients bridging to transplant on ECMO, patients with PAH had a lower transplantation rate than patients with OLD, CF, and ILD.

Ambulatory extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation

Ambulatory extracorporeal membrane oxygenation (ECMO) has shown promise as a bridge to lung transplantation. The primary goal of ambulatory ECMO is to provide enough gas exchange to allow patients to participate in preoperative physical therapy. Various strategies of ambulatory ECMO are utilized depending upon patients’ need. A wide spectrum of ECMO configurations is available to tackle this situation. We discuss those configurations in this article.

Lung transplantation for interstitial lung disease

Lung transplantation (LTx) can be a life-extending treatment option for patients with advanced and/or progressive fibrotic interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, sarcoidosis and connective tissue disease-associated ILD. IPF is now the most common indication for LTx worldwide. Several unique features in patients with ILD can impact optimal timing of referral or listing for LTx, pre- or post-transplant risks, candidacy and post-transplant management. As the epidemiology of LTx and community practices have evolved, recent literature describes outcomes and approaches in higher-risk candidates. In this review, we discuss the unique and important clinical findings, course, monitoring and management of patients with IPF and other progressive fibrotic ILDs during pre-LTx evaluation and up to the day of transplantation; the need for co-management with clinical experts in ILD and LTx is emphasised. Some post-LTx complications are unique in these patient cohorts, which require prompt detection and appropriate management by experts in multiple disciplines familiar with telomere biology disorders and infectious, haematological, oncological and cardiac complications to enhance the likelihood of improved outcomes and survival of LTx recipients with IPF and other ILDs.

Advances in lung transplantation for interstitial lung diseases

PURPOSE OF REVIEW

Lung transplantation (LTx) is increasingly used as ultimate treatment modality in end-stage interstitial lung diseases (ILDs). This review aims to give an overview of the latest evolutions in this field.

RECENT FINDINGS

In the last two years, important new findings regarding LTx outcomes in specific ILD entities have been reported. More data are available on optimization of pre-LTx management of ILD patients especially with regard to pretransplant antifibrotic treatment.

SUMMARY

LTx is the only treatment option with curative intent for ILDs and is increasingly used for this indication. Several studies have now reported adequate outcomes in different ILD entities, although outcome is shown to be affected by underlying telomeropathies. As new studies could not replicate inferior survival with single compared with double LTx, both options remain acceptable. ILD specialists can beneficially impact on post-LTx outcome by optimizing pre-LTx management: corticosteroids should be avoided, antifibrotics should be initiated whenever possible and BMI and nutritional status optimized, rehabilitation and depression-screening strategies should be implemented in all LTx candidates, as these interventions may all improve postlung transplant survival.

Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant

Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary technology capable of supporting cardiac and respiratory function in the presence of end-stage lung disease. Initial experiences using ECMO as a bridge to lung transplant (ECMO-BTLT) were characterized by high rates of ECMO-associated complications and poor posttransplant outcomes. More recently, ECMO-BTLT has garnered success in preserving patients' physiologic condition and candidacy prior to lung transplant due to technological advances and improved management. Despite recent growth, clinical practice surrounding use of ECMO-BTLT remains variable, with little data to inform optimal patient selection and management. Although many questions remain, the use of ECMO-BTLT has shown promising outcomes suggesting that ECMO-BTLT can be an effective strategy to ensure that complex and rapidly decompensating patients with end-stage lung disease can be safely transplanted with good outcomes. Further studies are needed to refine and inform practice patterns, management, and lung allocation in this high-risk and fragile patient population.

Lung transplantation: candidate selection and timing of transplant

PURPOSE OF REVIEW

Over the past two decades, lung transplant has become the mainstay of treatment for several end-stage lung diseases. As the field continues to evolve, the criteria for referral and listing have also changed. The last update to these guidelines was in 2014 and several studies since then have changed how patients are transplanted. Our article aims to briefly discuss these updates in lung transplantation.

RECENT FINDINGS

This article discusses the importance of early referral of patients for lung transplantation and the concept of the 'transplant window'. We review the referral and listing criteria for some common pulmonary diseases and also cite the updated literature surrounding the absolute and relative contraindications keeping in mind that they are a constantly moving target. Frailty and psychosocial barriers are difficult to assess with the current assessment tools but continue to impact posttransplant outcomes. Finally, we discuss the limited data on transplantation in acute respiratory distress syndrome (ARDS) due to COVID19 as well as extracorporeal membrane oxygenation bridge to transplantation.

SUMMARY

The findings discussed in this article will strongly impact, if not already, how we select candidates for lung transplantation. It also addresses some aspects of lung transplant such as frailty and ARDS, which need better assessment tools and clinical data.

Extracorporeal membrane oxygenation as a bridge vs. non-bridging for lung transplantation: A systematic review and meta-analysis

Whether extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) can achieve a similar survival to non-BTT remains controversial. We conducted this meta-analysis to compare the outcomes between ECMO BTT and non-BTT to facilitate better clinical decision-making. Seven databases were searched for eligible studies comparing ECMO BTT and non-BTT. The primary endpoints included survival, intraoperative indicators, postoperative hospitalization indicators, and postoperative complications. Nineteen studies (involving 7061 participants) were included in the final analysis. The outcomes of overall survival, overall survival rate, graft survival rate, in-hospital mortality, postoperative hospital days, postoperative intensive care unit days, postoperative ventilation time, blood transfusion volume, and postoperative complications were all better in the non-BTT group. The total mortality in ECMO bridging was 23.03%, in which the top five causes of death were right heart failure (8.03%), multiple organ failure (7.03%), bleeding (not cranial) (4.67%), cranial bleeding (3.15%), and sepsis (2.90%). In summary, Non-BTT is associated with better survival and fewer complications compared to BTT. When ECMO may be the only option, the patient and medical team need to realize the increased risk of ECMO by complications and survival.

Preoperative risk factors for successful extubation or not after lung transplantation

Background

The purpose of this study was to uncover preoperative risk factors for extubation failure or re-intubation for patients undergoing lung transplant (LTx).

Methods

We performed a retrospective case-control study of LTx from our center between January 2017 and March 2019. Demographic and preoperative characteristics were collected for all included patients. Univariable analysis and multivariable logistic regression were used to analyze risk factors of postoperative unsuccessful extubation following LTx.

Results

Among 107 patients undergoing first LTx investigated, 74 (69.16%) patients who were successfully liberated from mechanical ventilation (MV), and 33 (30.84%) patients who were unsuccessful extubation, which 18 (16.82%) patients suffered from reintubation. associated preoperative factors for unsuccessful extubation following LTx included preoperative extracorporeal membrane oxygenation (ECMO) support [OR =4.631, 95% confidence interval (CI): 1.403–15.286, P=0.012], the preoperative ability of independent expectoration (OR =4.517, 95% CI: 1.498–13.625, P=0.007), the age older than 65-year-old (OR =4.039, 95% CI: 1.154–14.139, P=0.029), and receiving the double lung and heart-LTx (OR =3.390, 95% CI: 0.873–13.162, P=0.078; and OR =16.579, 95% CI: 2.586–106.287, P=0.012, respectively). Further, we investigated the preoperative predicted factors for reintubation. Only the preoperative ECMO remained a significant predictor of re-intubation (OR =4.69, 95% CI: 1.56–15.286, P=0.012).

Conclusions

Preoperative independent sputum clearance, preoperative ECMO, older than 65-year-old, and double lung or heart-LTx were four independent risk factors for unsuccessful extubation. Moreover, preoperative ECMO was the only independent risk factor for reintubation.

Outcome of Bridge to Lung Transplantation With Extracorporeal Membrane Oxygenation in Pediatric Patients 12 Years and Older

BACKGROUND

There is a reluctance to using extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation in the pediatric population. Pediatric patients between ages 12 and 18 years are eligible for acuity-based lung transplantation using the Lung Allocation Score and may be suitable for adult allografts, increasing the donor pool and thus leading to a successful bridge to lung transplantation.

METHODS

The United Network for Organ Sharing dataset was queried for primary lung transplantation in pediatric patients (12-18 years) from 2005 to 2016. Groups were divided into those who were on ECMO (bridged [BG]) and not on ECMO (nonbridged [NBG]) at the time of listing for lung transplant.

RESULTS

The groups comprised 16 BG and 375 NBG patients. Fourteen BG patients (88%) survived the first 30 days. One-year (83.3% vs 86.2%, P = .78) and 3-year (66.7% vs 55.1%, P = .57) survivals were similar in the BG and NBG groups, respectively. Donors in the BG group were more likely to be adults. The median wait-list times were shorter (10.5 [interquartile range {IQR}, 11] vs 93 [IQR, 221] days, P < .001), with a higher Lung Allocation Score (89.8 vs 36.6, P < .001) and similar median ischemic times (5.19 [IQR, 2.32] vs 5.34 [IQR, 1.92] hours, P = .85) in the BG group compared with the NBG group. The median post-transplant length of stay was longer in the BG group (33 [IQR, 31] vs 17 [IQR, 12] days, P = .007) and was the only factor predictive of 3-year mortality. Longer wait-list time had a higher mortality in the BG group.

CONCLUSIONS

ECMO as a bridge to lung transplantation is a reasonable strategy in pediatric patients aged ≥ 12 years with acceptable operative mortality and similar 1- and 3-year survival compared with nonbridged patients despite higher acuity. Bridged patients were more likely to receive adult donor lungs.

Advances in Human Lung Transplantation

Lung transplantation improves survival and quality of life in patients with advanced pulmonary disease. Over the past several decades, the volume of lung transplants has grown substantially, with increasing transplantation of older and acutely ill individuals facilitated by improved utilization and preservation of available donor organs. Other advances include improvements in the diagnosis and mechanistic understanding of frequent post-transplant complications, such as primary graft dysfunction, acute rejection, and chronic lung allograft dysfunction (CLAD). CLAD occurs as a result of the host immune response to the allograft and is the principal factor limiting long-term survival after lung transplantation. Two distinct clinical phenotypes of CLAD have emerged, bronchiolitis obliterans syndrome and restrictive allograft syndrome, and this distinction has enabled further understanding of underlying immune mechanisms. Building on these advances, ongoing studies are exploring novel approaches to diagnose, prevent, and treat CLAD. Such studies are necessary to improve long-term outcomes for lung transplant recipients.

Population Pharmacokinetics of Caspofungin among Extracorporeal Membrane Oxygenation Patients during the Postoperative Period of Lung Transplantation

Little is known about the influence of extracorporeal membrane oxygenation (ECMO) on the pharmacokinetics (PK) of caspofungin. The aim of this study was to describe population PK of caspofungin in patients with and without ECMO during the postoperative period of lung transplantation (LTx) and to investigate covariates influencing caspofungin PK. We compared ECMO patients with non-ECMO patients, and patients before and after ECMO weaning as self-controls, to analyzed changes in caspofungin PK. Eight serial blood samples were collected from each patient for PK analysis. The population PK of caspofungin was described using nonlinear mixed-effects modeling. Twelve ECMO and 7 non-ECMO lung transplant recipients were enrolled in this study. None of the patients received renal replacement therapy during any part of the study period. The PK of caspofungin was best described by a two-compartment model. There were no significant differences in the PK parameters and concentrations of caspofungin among the ECMO, non-ECMO, and self-control group. In the final covariate model, we found that there was a significant association between the male gender and increased distribution volume, that a higher sequential organ failure assessment score was related to an increase in intercompartmental clearance, and that a longer operative time was related to an increase in clearance and the volume of distribution. ECMO did not have a significant impact on the PK of caspofungin in patients after LTx. Some factors were identified as statistically significant covariates related to the PK of caspofungin; however, their impact on clinical practice of caspofungin needs to be investigated further in more studies. (This study has been registered at ClinicalTrials.gov under identifier NCT03766282.).

Negative pressure ventilation as a bridge to lung transplant

Recent years have witnessed evolution of lung allocation strategies to prioritize sicker recipients. In the pre-transplant period, this has translated into increased utilization of invasive extracorporeal or mechanical ventilatory support as a bridge to lung transplantation. The morbidity associated with these strategies warrants consideration to less invasive respiratory support modalities. Herein, we present a case highlighting successful bridge to lung transplantation with a relatively non-invasive negative pressure ventilator.