Mechanical ventilation post-bilateral lung transplantation: A scoping review

Evidence from lung protective ventilation (LPV) in the acute respiratory distress syndrome has commonly been applied to guide periprocedural ventilation in lung transplantation. However, this approach may not adequately consider the distinctive features of respiratory failure and allograft physiology in the lung transplant recipient. This scoping review was conducted to systematically map the research describing ventilation and relevant physiological parameters post-bilateral lung transplantation with the aim to identify any associations with patient outcomes and gaps in the current knowledge base.

To identify relevant publications, comprehensive literature searches of electronic bibliographic databases were conducted with the guidance of an experienced librarian in MEDLINE, EMBASE, SCOPUS and the Cochrane Library. The search strategies were peer-reviewed using the PRESS (Peer Review of Electronic Search Strategies) checklist. The reference lists of all relevant review articles were surveyed. Publications were included in the review if they described relevant ventilation parameters in the immediate post-operative period, published between 2000 and 2022 and involved human subjects undergoing bilateral lung transplantation. Publications were excluded if they included animal models, only single-lung transplant recipients or only patients managed with extracorporeal membrane oxygenation.

A total of 1212 articles were screened, 27 were subject to full-text review and 11 were included in the analysis. The quality of the included studies was assessed to be poor with no prospective multi-centre randomised controlled trials. The frequency of reported retrospective LPV parameters was as follows: tidal volume (82%), tidal volume indexed to both donor and recipient body weight (27%) and plateau pressure (18%). Data suggest that undersized grafts are at risk of unrecognised higher tidal volume ventilation indexed to donor body weight. The most reported patient-centred outcome was graft dysfunction severity in the first 72 h.

This review has identified a significant knowledge gap that indicates uncertainty regarding the safest ventilation practice in lung transplant recipients. The risk may be greatest in patients with established high-grade primary graft dysfunction and undersized allografts, and these factors may define a sub-group that warrants further investigation.