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J Thorac Cardiovasc Surg 2003;126:2106
© 2003 The American Association for Thoracic Surgery

Letter to the editor

Lobar transplantation

^a Departments of Anesthesiology, Keck School of Medicine,University of Southern California,Los Angeles, Calif, USA
^b Department of Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA

To the Editor:

In their communication detailing their observations of the detrimental effects of hyperinflation of transplanted lungs, Kozower and colleagues¹ speculate that patients receiving lobar transplants may be at even greater risk for this complication due to the greater potential for size disparity between lobe and hemithorax. This is indeed the case as we have recently reported.² We believe the mechanism to be as described by Kozower's group. We also believe this size disparity is even greater than would otherwise be predicted as the anterior-posterior dimension in cystic fibrosis patients increases because of lung hyperinflation during the period of bony development of the thorax.³ We have observed that this physiology is more apparent and the hemodynamics are more severely affected with increasing size disparity. Early in our experience, the breath stacking occasionally became severe enough to cause severe hemodynamic depression as a result of the altered respiratory mechanics.²

These observations have led us to modify our postoperative management for lobar transplantation as follows²:

1. In the operating room, 4 chest tubes are placed (2 in each hemithorax) and connected to water-seal with no negative pressure.
   
2. Positive end-expiratory pressure is applied in the operating room (5-10 cm H₂O as tolerated) and continued in the intensive care unit.
   
3. Negative pressure is applied to the chest tubes in sequence: 5 to 10 cm H₂O to each tube, in 1-hour intervals, rotating for the first 24 hours. Later, each tube is placed on continuous suction that is gradually increased to -20 cm H₂O over the next 48 hours as tolerated.
   

Using the above procedure on all lobar transplant patients, we have minimized the hemodynamic consequences of the donor-to-recipient size discrepancies inherent in this procedure and have not seen similar acute deterioration in the last 90 to 100 lobar transplantation cases.

	References

Top References

 

1. Kozower B, Meyers B, Ciccone A, Guthrie T, Patterson G, Alexander M. Potential for detrimental hyperinflation after lung transplantation with application of negative pleural pressure to undersized lung grafts. J Thorac Cardiovasc Surg. 2003;125:430–432[Free Full Text]
   
2. Haddy SM, Bremner RM, Moore-Jefferies EW, et al. Hyperinflation resulting in hemodynamic collapse following living donor lobar transplantation. Anesthesiology. 2002;97:1315–1317[Medline]
   
3. Guignon I, Cassart M, Gevenos P, et al. Persistent hyperinflation after heart-lung transplantation for cystic fibrosis. Am J Respir Crit Care Med. 1995;151:534–540[Abstract]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Steven Haddy Vaughn A. Starnes Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Haddy, S. Articles by Starnes, V. A. Search for Related Content PubMed PubMed Citation Articles by Haddy, S. Articles by Starnes, V. A. Related Collections Lung - transplantation Related Article