What is included in postoperative respiratory management following lung transplantation?

Updated: Aug 19, 2019
  • Author: Bryan A Whitson, MD, PhD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Answer

Patients should be maintained on a nontoxic fraction of inspired oxygen, and barotrauma should be minimized. Volume control ventilation with a tidal volume of 8-10 mL/kg and a peak end-expiratory pressure (PEEP) of 5 cm H2 O generally is instituted. The transplanted lung is susceptible to capillary leak in the postoperative period. Therefore, the pulmonary capillary wedge pressure should be kept lower to minimize the formation of low-pressure pulmonary edema. Aggressive diuresis while maintaining adequate cardiac output and tissue perfusion is recommended.

Attention to bronchial hygiene is important. Frequent suctioning and bronchoscopy may be necessary for postoperative atelectasis in patients who have undergone lung transplant. Hyperinflation of the native lung may occur in patients with emphysema. This may lead to barotrauma and the development of air leaks that require chest tube placement. Phrenic nerve injury is known to occur in a significant number of patients. Unilateral phrenic nerve paralysis may compromise respiratory status to some extent, and bilateral phrenic nerve injury certainly would result in prolonged mechanical ventilation. In most patients, phrenic nerve palsy is transient and generally improves over the following weeks to months.

Adequate postoperative analgesia is helpful in weaning these patients from the ventilator. An epidural is normally placed in most patients. Extubation is performed when the patient's mental status is normal and when the patient has achieved reasonable spontaneous ventilation and gas exchange, generally 24-48 hours following the procedure. In patients with significant pulmonary hypertension who undergo transplantation, a risk exists for the development of pulmonary edema in the donor lung.


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