Prone Ventilation in Brain-Dead Organ Donors Acutely Increases Oxygenation and Results in More Lungs Transplanted

Purpose A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterion for lung transplantation. Absence of cough and respiratory drive in the brain-dead (BD) donor results in basilar atelectasis, contributing to V/Q mismatching and hypoxemia. We hypothesized that ventilating BD donors in the prone position would result in better V/Q matching, increased PFR, and more lungs transplanted. Methods All BD donors at our OPO are treated with a lung-protective ventilation strategy, recruitment maneuvers and repeated fiberoptic bronchoscopy (FOB). Since June 2018, a prone ventilation protocol was instituted for donors meeting the eligibility criteria: 12-70 years old, basilar atelectasis on X-ray or CT, and a PFR Results In 14 months, 27 donors met eligibility criteria and were enrolled. Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187 (116-250) in controls (p=0.06). PFR increased more after four hours of prone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409) versus 264 (156-339) with supine ventilation. At 12-hours, there was a trend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13). Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09) although ∆PO2 was comparable. However, more lungs were transplanted in the prone group (14 of 27 donors, 52%) compared to 23% in the control group, an effect persisting after adjusting for baseline PFR (OR 3.0, 95% CI: 1.2-7.8, p=0.02). Conclusion Prone ventilation acutely improved oxygenation in hypoxemic BD organ donors with basilar atelectasis relative to those managed in the supine position and resulted in more lungs transplanted.