Improving donor lung suitability: from protective strategies to ex-vivo reconditioning

Lung transplant is a therapeutic option for end stage lung diseases, but only a limited number of lung grafts is considered suitable for transplantation. It has been recently suggested an approach to improve and maximize donor lung suitability, namely ventilation strategies to prevent lung damage and preserve function before transplantation. In potential lung donor patients, the use of lung-protective ventilatory strategies may protect against and at least partially reverse some conditions, such as ventilator-induced lung injury, atelectasis and neurogenic pulmonary edema, resulting in improved donor organ procurement. The novelty recently proposed lies in the integration of ventilatory strategies of previous studies, using an algorithmic approach for the management of potential donors, based on their clinical response and PaO2/FiO2 ratio. This approach could be further improved by using lung ultrasound (LUS) which demonstrated to be more accurate than bedside chest radiography in detecting and distinguishing different degrees of aeration loss, and could be useful in the evaluation of alveolar recruitment following the application of PEEP or after performing any recruitment maneuver. Finally, the close future is the exploration of ex-vivo reconditioning which introduces the exciting concept of both a protective ventilation and a protective perfusion, reducing the risk of ventilation associated damage, and, on the other hand, washing out potential inflammatory cytokines by low volume high oncotic pressure perfusion, managing the risk of edema by capillary leakage. Addressing these challenges will allow more patients with end-stage lung disease access to a lung transplant.