LUNG TRANSPLANTATION FOR MECHANICALLY VENTILATED PATIENTS

As lung transplantation has become more successful, the selection crit eria have broadened; however, some relative contraindications to lung transplantation are controversial. Some programs consider mechanical v entilation to be a major contraindication to lung transplantation beca use airway colonization with bacteria may lead to nosocomial infection and respiratory muscle deconditioning may necessitate prolonged posto perative ventilatory support. We report our experience of seven double lung transplant procedures on six patients requiring mechanical venti lation. Five patients with cystic fibrosis required preoperative mecha nical ventilation for 7 to 19 days (mean, 10.7 days). One patient with acute lung injury required 115 days of preoperative mechanical ventil atory support. Only the latter patient required prolonged (27 days) po stoperative mechanical ventilation because of respiratory muscle weakn ess; the others were extubated in 1 to 19 days (mean, 7.8 days). No ea rly complications related to bacterial infection were seen. Two patien ts required temporary hemodialysis for transient kidney failure. Three patients had postoperative neurologic residua; one patient had a tran sient hemiparesis, and seizures developed in two patients. One patient died 3 months after transplantation from severe central nervous syste m complications with no evidence of pulmonary problems; and two patien ts died 17 months after transplantation, one of them receiving a secon d double lung transplant for obliterative bronchiolitis. Except for th e patient who required prolonged preoperative ventilatory support, mec hanical ventilation did not appear to play a role in the outcome of th ese patients. The posttransplantation hospital stay and hospital charg es for patients requiring pretransplantation ventilatory support were not significantly different from those for other lung transplant recip ients. Lung transplantation for patients requiring mechanical ventilat ion is technically feasible, and the previously stated reasons for wit hholding transplantation for these patients do not appear to be concer ns for the patient who requires mechanical ventilation for a short per iod (less than 2 weeks). However, the growing number of lung transplan t candidates and the limited supply of donor organs have substantially increased the average waiting time for transplants and mitigate again st the routine use of mechanical ventilation in lung transplant candid ates. Therefore mechanical ventilation for lung transplant candidates is recommended only for patients with acutely reversible deterioration or with sufficiently accrued seniority on the waiting list to make ea rly transplantation likely.