Mechanical ventilation after lung transplantation.

INTRODUCTION: To explore the hypothesis that early ventilation strategies influence clinical outcomes in lung transplantation, we have examined our routine ventilation practices in terms of tidal volumes (Vt) and inflation pressures. METHODS: A total of 124 bilateral lung transplants between 2010 and 2013 were retrospectively assigned to low (<6 mL/kg), medium (6-8 mL/kg), and high (>8 mL/kg) Vt groups based on ventilation characteristics during the first 6 hours after surgery. Those same 124 patients were also stratified to low-pressure (<25 cm H2O) and high-pressure (≥25 cm H2O) groups. RESULTS: Eighty percent of patients were ventilated using pressure control mode. Low, medium, and high Vt were applied to 10%, 43%, and 47% of patients, respectively. After correcting for patients requiring extracorporeal support, there was no difference in short-term to midterm outcomes among the different Vt groups. Low inflation pressures were applied to 61% of patients, who had a shorter length of intensive care unit stay (5 vs 12 days; P = .012), higher forced expiratory volume in 1 second at 3 months (77.8% vs 60.3%; P < .001), and increased 6-month survival rate (95% vs 77%; P = .008). CONCLUSION: Low Vt ventilation has not been fully adopted in our practice. Ventilation with higher inflation pressures, but not Vt, was significantly associated with poorer outcomes after lung transplantation.

Fungal infection in cardiothoracic transplant recipients: outcome without systemic amphotericin therapy.

Transplant recipients require immunosuppression to prevent allograft rejection, placing them at risk of opportunistic infections including fungal infection. Difficulties in managing fungal infections include: establishing diagnosis, poor treatment response, drug interactions and toxicity. We report our single centre experience of treating fungal infections using systemic non-Amphotericin current generation antifungals. Patients receiving inpatient antifungal therapy from September 2005 to December 2010 were identified from pharmacy records. Fungal infections were retrospectively classified according to European Organization for Research and Treatment of Cancer (EORTC) criteria. Treatment outcomes were classified in a manner similar to those used in clinical trials. Two hundred and forty-nine recipients received antifungal treatment, 204 lungs and 45 hearts. One hundred and one patients received Voriconazole, 82 Caspofungin and 65 received both agents. One patient was unsuccessfully treated with additional Amphotericin. Treatment duration varied from 1.5 to 12 weeks. One hundred and sixty-five patients had a complete response, 24 had a partial response and in 60 patients treatment was unsuccessful. The response to systemic non-Amphotericin based antifungal therapy was high. We propose that diagnostic criteria without positive identification of a fungus allow treatment to be started early with few clinically relevant side effects.

Gastroesophageal reflux in bronchiolitis obliterans syndrome: a new perspective.

BACKGROUND: Long-term survival after lung transplantation (LTx) is limited largely by bronchiolitis obliterans syndrome (BOS). Gastroesophageal reflux disease (GERD) is proposed as a risk factor for BOS development. This study investigates the relationship between BOS and GERD measured by esophageal impedance. METHODS: After the initiation of routine screening for GERD, 59 LTx recipients underwent ambulatory esophageal impedance monitoring. Exposure to acid reflux and non-acid liquid reflux was recorded. Clinical outcomes were reviewed to analyze any effect of reflux on the time to development of BOS. RESULTS: Thirty-seven (65%) had abnormal acid reflux and 16 (27%) had abnormal non-acid reflux. There was no relationship between acid reflux and BOS. The hazard ratio (HR) for development of BOS in the presence of abnormal non-acid reflux was 2.8 (p = 0.043). The HR for development of BOS increased to 3.6 (p = 0.022) when the number of acute rejection episodes was also taken into account. CONCLUSIONS: GERD is prevalent in LTx recipients and may represent a modifiable risk factor for BOS. This study found non-acid reflux, measured by esophageal impedance to be associated with the development of BOS. Prospective studies are now required to investigate a causal association between GERD and the development of BOS and to establish the role of surgery for GERD in preventing progression to BOS. The methods used to identify GERD in future studies may be important.

Native valve Aspergillus endocarditis complicating lung transplantation.

We present 2 cases of Aspergillus endocarditis occurring in lung transplant recipients, both of whom were treated with early surgical intervention and triazole anti-fungal agents. Neither had evidence of airway colonization/infection with Aspergillus post-transplant, suggesting hematogenous spread of fungi at the time of surgery as a possible mechanism of infection. One case was successfully treated and discharged from the hospital, but, despite initial recovery, death occurred 10 months later due to a recurrence of Aspergillus endocarditis. Aspergillus endocarditis should be considered a relapsing disease and survivors of the condition should receive ongoing anti-fungal therapy.

Refractory pulmonary aspergillosis treated with caspofungin after heart-lung transplantation.

Invasive pulmonary aspergillosis (IPA) is a serious complication of lung transplantation. Pre-mortem diagnosis is difficult and is made according to defined criteria. Most patients with a post mortem diagnosis of IPA only reach the possible or probable levels of diagnostic certainty during life. Here, we report a case of probable IPA that was refractory to conventional treatment, including amphotericin, but which responded to therapy with caspofungin. A 23-year-old man underwent heart-lung transplantation for cystic fibrosis. Ten years after transplantation he developed IPA. His condition continued to deteriorate despite treatment with itraconazole, liposomal amphotericin and flucytosine together with treatment of a concomitant infection with Pseudomonas aeruginosa. Following treatment with caspofungin there was progressive and sustained clinical and radiological improvement. No adverse reaction occurred during treatment. Caspofungin should be considered as an alternative treatment for IPA in lung transplant recipients who fail to respond to other therapy.