Acute Respiratory Failure and Pulmonary Complications in End-Stage Liver Disease

Nida Qadir, MD; Tisha Wang, MD; Igor Barjaktarevic, MD, PhD; Steven Y. Chang, MD, PhD


Semin Respir Crit Care Med. 2018;39(5):546-555. 

In This Article

Acute Respiratory Distress Syndrome

Chronic liver failure is associated with increased mortality in ARDS.[70,71] Thus, adherence to evidence-based ARDS management in patients with ESLD is essential. The benefits of lung protective ventilation for patients with ARDS are well established, and mechanical ventilation with a tidal volume of 6 mL/kg predicted body weight is recommended for the management of ARDS patients.[72–74] The use of higher positive end-expiratory pressure (PEEP) has also been shown to be beneficial in patients with moderate-to-severe ARDS.[74–76] Although concerns exist about the effects of PEEP on hepatic blood flow, particularly in the posttransplant setting, transplanted patients have demonstrated tolerance of moderate levels of PEEP.[77–79] Optimal fluid management in ARDS patients is also crucial. In the FACTT (fluids and catheters treatment) trial, patients randomized to a conservative fluid management strategy had fewer ventilator and ICU days than patients randomized to liberal fluids.[80] In addition to ventilator and fluid management, adjunctive therapies should be considered in cases of moderate–severe ARDS (PaO2/FiO2 ≤ 150). These include early neuromuscular blockade and prone positioning. Early systemic neuromuscular blockade is the most frequently used adjunctive therapy for ARDS.[81] The use of neuromuscular blockade may have a mortality benefit when compared with heavy sedation;[82] however, it is unknown if it provides any improvement in outcomes when compared with light sedation. Similarly, prone positioning is associated with a reduction in mortality and days of IMV[83] but is severely underutilized. Only 16% of patients with severe ARDS are placed in the prone position.[81]

Although ARDS is associated with high mortality, in the absence of situations requiring maximal ventilator support, it is generally not considered a contraindication to transplant. Audimoolam et al demonstrated that the preoperative presence of ARDS in patients with acute liver failure had no impact on mortality or ICU days.[84] Additionally, case reports and series have been published showing successful outcomes and resolution of ARDS following transplant.[85–87]