Organ preservation
Resolution of Severe Ischemia–Reperfusion Injury Post–Lung Transplantation After Administration of Endobronchial Surfactant

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Background

Ischemia–reperfusion injury (IRI) is a prominent cause of primary graft failure after lung transplantation and is associated with an altered surfactant profile. Experimental animal studies have found that replacement with exogenous surfactant administered via fiber-optic bronchoscopy (FOB) enhanced recovery from IRI with improved pulmonary compliance and gas exchange after lung transplantation. We report our clinical experience with FOB instillation of surfactant in severe IRI after human lung transplantation.

Methods

This study is a retrospective review of 106 consecutive lung or heart–lung transplants performed at a single institution. Severe IRI was defined as diffuse roentgenographic alveolar infiltrates, worsening hypoxemia and decreased lung compliance within 72 hours of lung transplantation. One vial of surfactant (20 mg/ml phospholipid) was instilled into each segmental bronchus upon diagnosis of IRI.

Results

Six patients (5 bilateral sequential and 1 re-do heart–lung transplant), mean age 46 years, were diagnosed with IRI and surfactant was administered at a mean of 37 hours (range 2.3 to 98) post-transplant. Mean graft ischemia time was 376 minutes (range 187 to 625) and cardiopulmonary bypass time 174 minutes (range 0 to 210). Mean Pao2 [mm Hg]/Fio2 ratio before and 48 hours after surfactant instillation was 70 and 223, respectively. Significant resolution of radiologic infiltrates was evident in all cases within 24 hours. Successful extubation occurred at a mean of 13.5 days and survival is presently 100% at 19 months (range 3 to 54).

Conclusions

Bronchoscopic instillation of surfactant improves oxygenation and prognosis after severe IRI in lung transplant recipients. It represents a cost-effective, relatively non-invasive therapeutic alternative to extracorporeal membrane oxygenation.

Section snippets

Methods

In 106 consecutive patients, 18 single-lung, 81 bilateral lung and 7 heart–lung transplants were performed between 1996 and 2004. Standard donor criteria were applied as described elsewhere.6 Donor lungs were treated with systemic heparin and the pulmonary bed flushed anterograde with Papworth preservation solution after intravenous administration of 500 μg prostacyclin. A retrograde flush via the pulmonary vein was performed after left atrial anastomosis. Donor lungs were transported in

Results

Six patients, including 5 BSSLTxs and 1 re-do heart–lung transplant, mean age 46 years (range 29 to 62), were diagnosed with severe IRI (Table 1). The mean graft ischemic time was 376 minutes (range 187 to 625); CPB time was 174 minutes (range 0 to 210). Endobronchial surfactant was administered at a mean of 37 hours post-transplant (range 2.3 to 98) and significant resolution of radiologic infiltrates was evident in all cases within 24 hours (Figure 1, Figure 2). The mean Pao2/Fio2 ratio

Discussion

Primary graft dysfunction is the end result of multiple insults occurring from the time of brainstem death through the time of lung reperfusion and post-operative ventilation. It causes significant morbidity and mortality after transplantation.1 IRI has been identified as the main cause of early allograft dysfunction. The clinical syndrome of IRI is characterized by hypoxemia, decreased pulmonary compliance, and progressive alveolar infiltrates on chest radiography within 72 hours of

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