Intrapulmonary Percussive Ventilation as a Lung Recruitment Strategy in Brain-Dead Organ Donors

Respiratory physiotherapy as a tool to allow and optimize lung donation

Lung donation is complex and sometimes the secretion retention makes it impossible. We report a case of a patient that was screened as potential lung donor with PaO2/FiO2 ratio below range. As in viable patients, the respiratory physiotherapist applied a ventilator-based group of techniques with removal of huge amount of secretions and consequent increase in the PaO2/FiO2 ratio that allowed the inclusion of the patient as potentially lung donor. The protocol was applied until the extraction day, with successful extraction and transplantation. We believe that respiratory physiotherapy could have a potential role in increasing lung viability.

Successful lung transplantation after prone positioning in an ineligible donor: a case report

Atelectasis is a reversible factor in hypoxemia among brain-dead donors. In ineligible donors, prone positioning reverses atelectasis and improves oxygenation. We present a successful lung transplantation after salvaging a previously unviable lung. A 37-year-old woman presented with acute pontine hemorrhage that progressed to brain death. The initial partial pressure of oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) ratio of the donor’s lung was 342 mmHg. The PaO₂/FiO₂ ratio dropped to 49 mmHg due to atelectasis. There was no improvement despite recruitment maneuvers, bronchoscopy, and chest percussion. After placing the donor in the prone position for four hours, electrical impedance tomography showed improved atelectasis. The donor did not experience hemodynamic instability. The lung was transplanted into a patient with Kartagener’s syndrome with situs inversus. The surgical procedure was uneventful. He was successfully weaned from the mechanical ventilator on the second-day post-transplantation and was discharged from the hospital after 4 weeks.

A Randomized Controlled Trial of Naloxone for Optimization of Hypoxemia in Lung Donors After Brain Death

BACKGROUND

Persistent hypoxemia is the principal reason lungs from otherwise eligible brain dead (BD) organ donors are not transplanted. Experimental models and retrospective studies have suggested that naloxone attenuates neurogenic pulmonary edema and reverses hypoxemia after brain death. We undertook a multisite, randomized, placebo-controlled trial to evaluate whether naloxone is able to improve oxygenation in BD donors with hypoxemia.

METHODS

BD organ donors at 4 organ procurement organizations were randomized in a blinded manner to naloxone 8 mg or saline placebo if lung were being considered for allocation but exhibited hypoxemia (partial pressure of oxygen in arterial blood to fraction of inspired oxygen ratio [PFR] below 300 mm Hg). The primary outcome was change in PFR from baseline to final arterial blood gas. Secondary outcomes included early improvement in PFR and proportion of lungs transplanted.

RESULTS

A total of 199 lung-eligible BD donors were randomized to naloxone (n = 98) or placebo (n = 101). Groups were comparable at baseline. Both groups exhibited similar improvements in oxygenation (median improvement in PFR of 81 with naloxone versus 80 with saline, P = 0.68), with 37 (39%) versus 38 (40%) exhibiting reversal of hypoxemia. There was no difference in the rate of lungs transplanted (19% in both groups, P = 0.97) although it was significantly higher in those with reversal of hypoxemia (32/69 versus 2/111, P < 0.001).

CONCLUSIONS

Naloxone does not improve oxygenation more than placebo in hypoxemic organ donors. However, reversal of hypoxemia was a powerful predictor of lung utilization regardless of drug therapy. Further organ procurement organization-led research is needed to assess optimal interventions to improve oxygenation in BD donors with hypoxemia.