The Association Between Extravascular Lung Water and Critical Care Outcomes Following Bilateral Lung Transplantation

Laveena Munshi, MD, MSc; Marcelo Cypel, MD; Alaa Mohamed, MD; Alyaa Elhazmi, MD; Eddy Fan, MD; Damon Scales, MD; Jussi Tikkanen, MD; Lorenzo Del Sorbo, MD; Niall D. Ferguson, MD; Shaf Keshavjee, MD; John Granton, MD

doi:10.1097/TXD.0000000000001376

Transplantation Direct (Oct 2022)

The Association Between Extravascular Lung Water and Critical Care Outcomes Following Bilateral Lung Transplantation

Laveena Munshi, MD, MSc,
Marcelo Cypel, MD,
Alaa Mohamed, MD,
Alyaa Elhazmi, MD,
Eddy Fan, MD,
Damon Scales, MD,
Jussi Tikkanen, MD,
Lorenzo Del Sorbo, MD,
Niall D. Ferguson, MD,
Shaf Keshavjee, MD,
John Granton, MD

Affiliations

Laveena Munshi, MD, MSc: 1 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, ON, Canada.
Marcelo Cypel, MD: 3 Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
Alaa Mohamed, MD: 1 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, ON, Canada.
Alyaa Elhazmi, MD: 1 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, ON, Canada.
Eddy Fan, MD: 1 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, ON, Canada.
Damon Scales, MD: 2 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
Jussi Tikkanen, MD: 4 Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
Lorenzo Del Sorbo, MD: 1 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, ON, Canada.
Niall D. Ferguson, MD: 1 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, ON, Canada.
Shaf Keshavjee, MD: 3 Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
John Granton, MD: 1 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, Toronto, ON, Canada.

DOI: https://doi.org/10.1097/TXD.0000000000001376
Journal volume & issue: Vol. 8, no. 10
p. e1376

Abstract

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Background. Primary graft dysfunction (PGD) is a form of acute respiratory failure that complicates 30% of bilateral lung transplants. Higher grades of PGD correlate with higher severity of respiratory failure and unfavorable outcomes. Immediate PGD determination posttransplant‚ however, is not always predictive of PGD over subsequent days or intensive care unit outcomes. We aimed to evaluate whether extravascular lung water index (ELWI) measured immediately post bilateral lung transplant was associated with higher severity of PGD at 72 h and duration of mechanical ventilation. Methods. We conducted a prospective, observational study of bilateral lung transplant patients admitted to the intensive care unit. ELWI measurements were performed at admission, 6, 12, 24, 36, 48, 60, and 72 h following transplant or until extubation. We evaluated the association between admission ELWI and 72-h PGD grade and duration of mechanical ventilation. Results. Across 56 patients enrolled, 268 transpulmonary thermodilution measurements were conducted. At admission, median ELWI increased with PGD grade (grade 1: 9 mL/kg [interquartile range (IQR), 8–11 mL/kg]‚ grade 2 [10 mL/kg (IQR, 8–12 mL/kg)]‚ and grade 3 [17 mL/kg (IQR, 14–19 mL/kg); P < 0.001]). Using multivariable Poisson regression analysis adjusting for confounders, admission ELWI elevation was associated with higher severity of PGD at 72 h (incidence rate ratio [IRR], 1.06; 95% confidence interval, 1.01-1.12) and duration of mechanical ventilation (IRR, 1.62; 95% confidence interval, 1.23-2.14). The combination of an ELWI of ≥13 mL/kg and partial pressure of oxygen/fraction of inspired oxygen ≤ 100 within 6 h of admission had high sensitivity (75%) and specificity (100%) for grade 3 PGD at 72 h (area under the curve, 0.95) and performed better than ELWI or partial pressure of oxygen/fraction of inspired oxygen alone. Conclusions. Our exploratory study demonstrates an association between admission ELWI and high grades of PGD at 72 h and longer duration of ventilation. These results provide the impetus to study whether goal-directed ELWI algorithms can improve transplant outcomes.

Published in Transplantation Direct

ISSN: 2373-8731 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Surgery
Website: http://journals.lww.com/transplantationdirect/Pages/default.aspx

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