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A Recruitment Maneuver After Apnea Testing Improves Oxygenation and Reduces Atelectasis in Organ Donors After Brain Death

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Abstract

Background

Hypoxemia is the main modifiable factor preventing lungs from being transplanted from organ donors after brain death. One major contributor to impaired oxygenation in patients with brain injury is atelectasis. Apnea testing, an integral component of brain death declaration, promotes atelectasis and can worsen hypoxemia. In this study, we tested whether performing a recruitment maneuver (RM) after apnea testing could mitigate hypoxemia and atelectasis.

Methods

During the study period, an RM (positive end-expiratory pressure of 15 cm H2O for 15 s then 30 cm H2O for 30 s) was performed immediately after apnea testing. We measured partial pressure of oxygen, arterial (PaO2) before and after RM. The primary outcomes were oxygenation (PaO2 to fraction of inspired oxygen [FiO2] ratio) and the severity of radiographic atelectasis (proportion of lung without aeration on computed tomography scans after brain death, quantified using an image analysis algorithm) in those who became organ donors. Outcomes in RM patients were compared with control patients undergoing apnea testing without RM in the previous 2 years.

Results

Recruitment maneuver was performed in 54 patients after apnea testing, with a median immediate increase in PaO2 of 63 mm Hg (interquartile range 0–109, p = 0.07). Eighteen RM cases resulted in hypotension, but none were life-threatening. Of this cohort, 37 patients became organ donors, compared with 37 donors who had apnea testing without RM. The PaO2:FiO2 ratio was higher in the RM group (355 ± 129 vs. 288 ± 127, p = 0.03), and fewer had hypoxemia (PaO2:FiO2 ratio < 300 mm Hg, 22% vs. 57%; p = 0.04) at the start of donor management. The RM group showed less radiographic atelectasis (median 6% vs. 13%, p = 0.045). Although there was no difference in lungs transplanted (35% vs. 24%, p = 0.44), both better oxygenation and less atelectasis were associated with a higher likelihood of lungs being transplanted.

Conclusions

Recruitment maneuver after apnea testing reduces hypoxemia and atelectasis in organ donors after brain death. This effect may translate into more lungs being transplanted.

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Funding

This study was funded by a grant from Mid-America Transplant Foundation Clinical Innovation Fund. RD also received unrelated funding from the National Institutes of Health (K23NS099440, R01NS121218).

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Authors and Affiliations

  1. Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, 63110, USA

    Rajat Dhar, Porche Braun, Atul Kumar, Jayesh Patel, Flavia L. Lee & Baback Arshi

  2. Department of Neurology, Drexel University College of Medicine, Philadelphia, PA, USA

    Jayesh Patel

  3. Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA

    Flavia L. Lee

Authors
  1. Rajat Dhar
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  2. Porche Braun
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  4. Jayesh Patel
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  6. Baback Arshi
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Contributions

RD and JP conceived of the study. RD conducted the primary analyses. Data were collected by PB, JP, and FL. Study data were reviewed by BA. RD drafted the manuscript, tables, and figures. All authors reviewed and edited the manuscript and approved the final version.

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Correspondence to Rajat Dhar.

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Conflicts of interest

RD reports consulting fees from Marinus Pharma and Mid-America Transplant.

Ethical Approval/Informed Consent

All research was conducted under approval of the institutional ethics review board, deemed as exempt from consent given this was a study involving only deceased patients.

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Dhar, R., Braun, P., Kumar, A. et al. A Recruitment Maneuver After Apnea Testing Improves Oxygenation and Reduces Atelectasis in Organ Donors After Brain Death. Neurocrit Care (2024). https://doi.org/10.1007/s12028-024-01975-7

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  • DOI: https://doi.org/10.1007/s12028-024-01975-7

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