The Alliance

Spotlight Series

The executive insight series is designed for healthcare senior executives. These brief, bi-annual issues focus on topics relevant to top-tier hospital leadership. For each topic, you can find related references, resources, and tools.

Spotlight Series Past Issues

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In the United States, there are currently over 1,400 people in need of a donor lung, 20% of whom will die awaiting transplantation.

Lung Donor Selection and Management

Strategies for Optimizing Organ Function to Increase Lung Utilization

In the United States, there are currently over 1,400 people in need of a donor lung, 20% of whom will die awaiting transplantation. A suggested strategy for increasing donor lung utilization involves an aggressive lung management protocol that incorporates Extreme Pressure Control Inverse Ratio Ventilation (PCIRV). This lung recruitment protocol has resulted in significantly improved donor lung outcomes with no apparent effect on the recipient population.

The Ideal Lung Donor

  • PaO2/ FiO2 (P/F) ratio > 300 mmHg
  • A clear chest radiograph
  • Minimal, non-infected tracheal secretions

*In 2018, there were 36, 530 organ transplants. Only 2,530 of those transplants were lung. Of the 10, 721 donors, only 23.7% of them were lung donors. (OPTN Data)

Reasons for Suboptimal Donor Lung Function

  • Pre-existing conditions such as asthma, smoking, infections, etc.
  • Death-related causes including:
    • Aspiration, Contusions, Fractures, Pneumothorax
    • Head Injury (i.e. Neurogenic Pulmonary Edema)
    • Ventilator induced injury/infection
  • Brain-Death physiology

Optimizing Lung Function

The implementation of lung management protocols lasting longer than 10 hours result in better lung recipient survival.

General Respiratory Goals:

  • Head elevated 30 degrees with the Endotracheal Tube (ETT) cuff inflated to prevent aspiration
  • Early and repeated bronchoscopy (with minimal saline lavage)
  • Utilization of Albuterol and Mucomyst as needed for mucus clearance
  • Chest physiotherapy, suctioning, and positioning every 4 hours
  • Use of adjunct medications such as corticosteroids
  • Maintaining a fluid balance

Ventilator, Blood Gas Goals

  • Normal ventilation and oxygenation
    • pH 7.35-7.45, PaCO2 35-45, O2 sats >95%
  • Limit Ventilator Associated Complications
    • Oxygen Toxicity
      • <= 40% oxygen, the lower the better
    • Barotrauma
      • Plateau <30-35, PIP<35-40, MAPs<20-25
      • Generally, need PIPs in mid 20s for acceptance for transplantation
    • Volutrauma • TV 6-8 ml/kg of ideal body weight

Airway Pressure Release Ventilation (APRV) Settings

  1.  Set P High using the peak inspiratory pressure (PIP) of the previous PC mode or at the peak plateau pressure (pPlat) of the previous VC mode
    1. A plateau pressure is obtained by performing an inspiratory hold
    2. Set to a minimum of 20 cmH20 but avoid exceeding 35 cmH20
    3. Make adjustments in 2 cmH20 increments to maintain MAP 25-28
  2. Set P Low to 0
  3. Set T High initially between 4-6 seconds
  4. Set T Low initially between 0.5-0.8 seconds
    1. Set to achieve an expiratory flow rate termination that is 50% of the peak expiratory flow
    2. Consult RT for assistance
  5. Recheck ABG in 2 hours after initial change and then every 4 hours and make adjustments as need to obtain optimal oxygenation and a normal pH

*The first ABG in APRV may be worse than the baseline. Keep in mind that full recruitment may take 4-6 hrs.

The content of this issue is based on a webinar presentation by Samir Latifi, MBBS, FRCPH, FAAP (Chair Department of Pediatric Critical Care, Cleveland Clinic; Associate Medical Director, Lifebanc, Cleveland, OH). A special thanks to Dr. Latifi for his contributions to this in-service. We’d also like to extend a sincere thanks to Dan Lebovitz, MD (Medical Director, LIfebanc) for his contributions to this educational offering.

Helpful Resources

  • Lung Donation
  • Organ Procurement and Transplantation Network Data
  • Nalk PM, Angel LF: Special Issues in the Management and Selection of the Donor for Lung Transplantation. Semin Immunopath; 2011,33(2) 201-210
  • Dhar R et al: A Randomized Controlled Trial of Naloxone for Optimization of Hypoxemia in Lung Donors after Brain Death. Transplantation; 2018, Nov epub • Wauters et al. Eur J Cardiothoracic surgery 2011; 39; e 68-e76

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A Special Thanks to This Series’ Contributors

Corey Bryant
About the Editor |
Corey Bryant

Corey Bryant brings nearly 15 years of communications experience to The Alliance, having served in communications and public relations roles for Disney Parks and Resorts, Disney Cruise Line and TransLife (now OurLegacy), the OPO serving East Central Florida. He has also been an active board member of Donate Life Florida, having served as state team leader for Driver License Outreach. Corey is a proud alum of The University of Alabama and serves on the board of directors for Come Out With Pride Orlando as well as Five Horizons Health Services, a not-for-profit organization providing access to progressive HIV testing, prevention and LGBT+ focused healthcare throughout West Alabama and East Mississippi.

Deanna Fenton
About the Editor |
Deanna Fenton

Deanna is a knowledgeable and versatile professional with diverse experiences in healthcare, client relations, marketing, project management and demonstrated skills in leadership and advocacy. Prior to joining The Alliance, she worked in Hospital Development at her local OPO in the state of New Jersey where she served as the clinical liaison to a number of Level 1 Trauma & Neuroscience centers as well as community hospitals. Her personal connection as a donor family and friend fuels her passion to support her colleagues across the donation-transplantation continuum through the development of valuable educational resources that ultimately boost performance and improve outcome measures. Deanna holds a Bachelor of Arts in Psychology and a minor degree in Public Health from Montclair State University. In her spare time, Deanna enjoys visiting vineyards, spending time with her family, and traveling in hopes of visiting all seven wonders of the world.

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