ORIGINAL CLINICAL SCIENCE
Ventilation in the prone position improves oxygenation and results in more lungs being transplanted from organ donors with hypoxemia and atelectasis

https://doi.org/10.1016/j.healun.2020.11.014Get rights and content

BACKGROUND

Hypoxemia is the most common barrier to lungs being transplanted from eligible organ donors who are brain dead (BD). Atelectasis is the principal reversible contributing factor to hypoxemia after brain death. We evaluated prospectively whether ventilation in the prone position in donors who are BD would reverse atelectasis, improve oxygenation, and result in more lungs being transplanted.

METHODS

Organ donors managed at the recovery center of 1 organ procurement organization over a 2-year period who exhibited hypoxemia (partial pressure of arterial oxygen [PaO2]/fraction of inspired oxygen of <300 mm Hg) and had evidence of atelectasis were ventilated in the prone position for 12 hours or longer during donor management. A subset underwent computed tomography (CT) imaging to quantify the degree of atelectasis before and after prone positioning. Outcomes were compared with those of a control group with hypoxemia and atelectasis managed similarly but in the supine position in the previous 2 years.

RESULTS

A total of 40 lung-eligible donors who were BD with hypoxemia and atelectasis were managed in a prone position and compared with 79 donors in supine position. Baseline PaO2 was similar between the prone and the supine groups (194 ± 78 vs 177 ± 77 mm Hg, p = 0.26) but increased more in the prone group at 4 hours (by 113 vs 54 mm Hg, p = 0.001) and remained 74-mm Hg higher at 12 hours (340 vs 266 mm Hg, p = 0.0006). CT-graded atelectasis was significantly reduced after ventilation in the prone position but persisted in the supine group (p = 0.001). Final PaO2 was not significantly higher (344 vs 306, p = 0.12), but lungs were more often transplanted in the prone group (45% vs 24%, p = 0.03).

CONCLUSIONS

Ventilation in the prone position reverses atelectasis and rapidly and sustainably improves oxygenation in organ donors who are BD with hypoxemia. This effect appears to translate into more lungs being transplanted.

Section snippets

Study site

This prospective study was performed at Mid-America Transplant, an organ procurement organization (OPO) with a freestanding organ recovery center (ORC). The ORC includes a 6-bed intensive care unit (ICU) for donor management; an on-site laboratory; facilities for radiography, including chest X-rays and a CT scanner; and a surgical suite for organ recovery. In total, 97% of organ donors who are BD in the Mid-America Transplant's donation service area are transferred from donor hospitals to the

Results

A total of 362 organ donors who were BD were managed at the ORC during the study period. A total of 109 donors were eligible on the basis of age, the presence of hypoxemia, and detection of basilar opacities on chest imaging (Figure 1). In total, ≥1 lung exclusions were present in 67 of these 109 donors, leaving 32 who met all the criteria. In addition, 3 donors with hepatitis C, 3 with chest tubes (but no residual pneumothorax), 1 with a history of COPD, and 1 with positive hepatitis B

Discussion

This prospective cohort study evaluated whether ventilation in the prone position of lung-eligible organ donors could reverse hypoxemia and atelectasis and result in more lungs being transplanted. We compared outcomes in this prone cohort with those in historical controls with hypoxemia and atelectasis whose data were also collected prospectively and otherwise managed identically but in the supine position. Aggressive lung management protocols, utilized similarly in both groups, improved

Conclusions

A total of 12 hours of ventilation in the prone position in donor who are BD with hypoxemia with atelectasis improves oxygenation and is associated with an increased likelihood of lungs being transplanted.

Disclosure statement

G.F.M. and C.O. are employees, and R.D. is a consultant for Mid-America Transplant, an organ procurement organization.

The authors acknowledge all the organ procurement coordinators who supported this study and cared for these organ donors.

No specific funding was provided for this study. R.D. is funded by the National Institutes of Health Grant K23NS099440.

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