Theoretical and practical perioperative considerations protective ventilation in lung transplantation

IF 5.1 2区 医学 Q1 ANESTHESIOLOGY
Julien Fessler , Wenting Ma , Archer K. Martin , Brandi Bottiger , Arne Neyrinck , Sebastien Jacqmin , Morgan Le Guen , Nandor Marczin
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Abstract

Protective ventilation is a cornerstone of perioperative management during lung transplantation. However, its current clinical approach is mainly based on literature from intensive care and elective surgery with one-lung ventilation. This review summarizes the pathophysiology of each of the four main end-stage lung diseases and how mechanical power affects the energy exerted on the lungs during the different surgical steps, first on the host and then on the grafts. Each pathology presents specific parenchymal characteristics, and there is great heterogeneity in pulmonary compliance within and between patients. Recognizing these regional heterogeneities in compliance is fundamental to personalizing ventilator settings and avoiding increasing ventilator-induced lung injury.
Furthermore, we explored the concept of the multiple-hits model of lung allograft injury. It highlights the consequences over time (additive or synergic) of all the risk factors cumulated on allograft injury, from the donor before harvesting, to the transport, and finally after implantation. Additionally, we discussed the novel opportunity that ex-vivo lung perfusion offers in the assessment of graft quality using various parameters, as well as mechanical power to guide different modes and settings to optimize ventilation. This experimental model could be used to develop new specific ventilation strategies to optimize the mechanical energy exerted on the lungs without a chest wall. Finally, we advocate for early extubation to reduce ventilation-induced lung injury and promote early rehabilitation.
肺移植围手术期保护性通气的理论与实践考虑
保护性通气是肺移植围手术期管理的基础。然而,目前的临床方法主要基于重症监护和选择性单肺通气手术的文献。本文综述了四种主要终末期肺部疾病的病理生理学,以及机械动力如何影响在不同手术步骤中施加在肺上的能量,首先是宿主,然后是移植物。每种病理表现出特定的实质特征,患者内部和患者之间的肺顺应性存在很大的异质性。认识到这些区域依从性的异质性是个性化呼吸机设置和避免增加呼吸机引起的肺损伤的基础。此外,我们还探讨了同种异体肺移植损伤的多重命中模型的概念。它强调了同种异体移植物损伤的所有风险因素随着时间的推移(加性或协同性)累积的后果,从供体在收获前,到运输,最后在植入后。此外,我们讨论了体外肺灌注在使用各种参数评估移植物质量方面提供的新机会,以及指导不同模式和设置以优化通气的机械功率。该实验模型可用于开发新的特定通气策略,以优化施加在无胸壁肺上的机械能。最后,我们提倡尽早拔管,以减少通气引起的肺损伤,促进早期康复。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
7.40
自引率
4.50%
发文量
346
审稿时长
23 days
期刊介绍: The Journal of Clinical Anesthesia (JCA) addresses all aspects of anesthesia practice, including anesthetic administration, pharmacokinetics, preoperative and postoperative considerations, coexisting disease and other complicating factors, cost issues, and similar concerns anesthesiologists contend with daily. Exceptionally high standards of presentation and accuracy are maintained. The core of the journal is original contributions on subjects relevant to clinical practice, and rigorously peer-reviewed. Highly respected international experts have joined together to form the Editorial Board, sharing their years of experience and clinical expertise. Specialized section editors cover the various subspecialties within the field. To keep your practical clinical skills current, the journal bridges the gap between the laboratory and the clinical practice of anesthesiology and critical care to clarify how new insights can improve daily practice.
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