Editorial
High-flow Oxygen Therapy in Post-Lung Transplant Patients
Alto flujo en pacientes postrasplantados de pulmón
a Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain
b Grupo de Investigación en Patología Crítica (GREPAC), IMIM, Barcelona, Spain
c Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III (CIBERES-ISCIII), Spain
d Universitat Pompeu Fabra (DCEX), Barcelona, Spain
e Coordinación de Trasplantes, Parc de Salut Mar, Barcelona, Spain
f Servicio de Medicina Intensiva, Hospital Vall d’Hebron, Barcelona, Spain
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Nevertheless, lung transplant patients have particular characteristics, due not only to their differing degrees of immunosuppression, but also to the characteristics of the organ itself and the ribcage. These factors not only delay mechanical ventilation weaning in the immediate postoperative period, but can also lead to mid-to-long-term respiratory failure after transplantation. This is often due to infection, which, together with bronchiolitis obliterans syndrome associated with chronic rejection, limits life expectancy.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Both delayed withdrawal of mechanical ventilation and acute hypoxemic respiratory failure, generally associated with infectious complications, lead to prolonged intensive care unit (ICU) stays, both in the immediate post-operative period and in subsequent re-admissions. These complications are associated with a grimmer prognosis and prolonged mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this setting, high flow nasal cannula (HFNC) therapy can be of particular use. HFNC is a system of administration of medicinal gas based on the principle that the flow delivered must be equal to or greater than the inspiratory flow demands of the patient, with flows of up to 60<span class="elsevierStyleHsp" style=""></span>lpm and the F<span class="elsevierStyleInf">I</span>O<span class="elsevierStyleInf">2</span> required to achieve correct oxygenation (0.21–1). The key point is that the patient can tolerate such high flows because the system delivers adequately heated and humidified gas, i.e., 37<span class="elsevierStyleHsp" style=""></span>°C and 44<span class="elsevierStyleHsp" style=""></span>mg/l.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The HFNC system improves respiratory failure in some patients<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> by minimizing the dilution with ambient air and thus optimizing F<span class="elsevierStyleInf">I</span>O<span class="elsevierStyleInf">2</span> values, and reducing dead space and airway resistance, which in turn reduce work of breathing and the metabolic cost of gas conditioning. All this, in addition to changing the ventilatory pattern and generating a certain level of continuous positive airway pressure, lead to an improvement in the hemodynamic profile. All this is achieved with the use of a very comfortable and well tolerated system. Although the active humidifier used in this system no doubt has a major role in the management of bronchial secretions and in the maintenance of cell structure and ciliary function, its real impact in unventilated patients compared with the administration of poorly conditioned oxygen has yet to be determined.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Extubation problems in patients after lung transplantation are generally due either to symptoms associated with primary graft dysfunction, causing severe hypoxemia, or else to disorders caused by diaphragmatic paralysis. In the latter situation, if the standard criteria for mechanical ventilation weaning are applied, patients may continue to need some level of airway pressure, and non-invasive strategies (non-invasive ventilation or HFNC) may play a useful role, provided the patient does not present complete diaphragmatic paralysis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Although no specific studies have been conducted on the role of HFNC in the extubation of transplant recipients, some studies support the utility of this system in optimizing extubation outcomes in critical patients (some of whom had undergone thoracic surgery),<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> or in patients with a high risk of extubation failure. A comparison of non-invasive ventilation with HFNC showed a lower incidence of reintubation among patients receiving HFNC.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A recent French multicenter study of the role of HFNC in the treatment of patients with acute hypoxemic respiratory failure found that it improved mortality in the most hypoxemic patients compared to conventional oxygen therapy or non-invasive ventilation.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> A subanalysis of that study, conducted in immunosuppressed patients (as is the case for lung transplant recipients), found that the benefit of HFNC remained superior to that of non-invasive ventilation.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> No conclusive studies have been published on the potential role of this technique in the prevention of atelectasis in these patients, although it is clear that loosening secretions must have some impact.</p><p id="par0035" class="elsevierStylePara elsevierViewall">More specifically, our group was able to show, for the first time in a non-randomized retrospective single-center study of transplanted patients readmitted to an ICU with symptoms of acute respiratory failure, generally due to infection, that HFNC reduced the need for invasive mechanical ventilation in up to one third of patients, thus improving survival.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It is clear that HFNC is a well-tolerated non-invasive respiratory support system.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In lung transplant recipients particularly, it may be useful for expediting extubation in some patients and for providing support to those who are readmitted with hypoxemia, thus avoiding intubation and invasive ventilation and the associated impact on prognosis. Nevertheless, more studies must be performed in both situations in lung transplant recipients, since we should not forget that delaying intubation and invasive ventilation in cases in which the technique fails can in itself worsen a patient's prognosis.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Masclans J-R, Zapatero A, Sacanell J. Alto flujo en pacientes postrasplantados de pulmón. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 93 | 27 | 120 |
| 2024 September | 70 | 22 | 92 |
| 2024 August | 101 | 63 | 164 |
| 2024 July | 66 | 27 | 93 |
| 2024 June | 89 | 46 | 135 |
| 2024 May | 98 | 32 | 130 |
| 2024 April | 55 | 45 | 100 |
| 2024 March | 54 | 29 | 83 |
| 2024 February | 34 | 28 | 62 |
| 2023 September | 2 | 2 | 4 |
| 2023 August | 1 | 1 | 2 |
| 2023 March | 14 | 4 | 18 |
| 2023 February | 63 | 24 | 87 |
| 2023 January | 44 | 46 | 90 |
| 2022 December | 65 | 36 | 101 |
| 2022 November | 82 | 44 | 126 |
| 2022 October | 88 | 38 | 126 |
| 2022 September | 52 | 31 | 83 |
| 2022 August | 60 | 48 | 108 |
| 2022 July | 41 | 47 | 88 |
| 2022 June | 45 | 38 | 83 |
| 2022 May | 55 | 56 | 111 |
| 2022 April | 44 | 38 | 82 |
| 2022 March | 48 | 47 | 95 |
| 2022 February | 70 | 36 | 106 |
| 2022 January | 96 | 56 | 152 |
| 2021 December | 87 | 58 | 145 |
| 2021 November | 84 | 48 | 132 |
| 2021 October | 90 | 62 | 152 |
| 2021 September | 47 | 47 | 94 |
| 2021 August | 52 | 37 | 89 |
| 2021 July | 42 | 35 | 77 |
| 2021 June | 61 | 40 | 101 |
| 2021 May | 68 | 46 | 114 |
| 2021 April | 99 | 84 | 183 |
| 2021 March | 96 | 29 | 125 |
| 2021 February | 58 | 23 | 81 |
| 2021 January | 44 | 22 | 66 |
| 2020 December | 46 | 15 | 61 |
| 2020 November | 40 | 21 | 61 |
| 2020 October | 65 | 14 | 79 |
| 2020 September | 37 | 14 | 51 |
| 2020 August | 41 | 14 | 55 |
| 2020 July | 41 | 23 | 64 |
| 2020 June | 30 | 9 | 39 |
| 2020 May | 49 | 13 | 62 |
| 2020 April | 46 | 26 | 72 |
| 2020 March | 30 | 10 | 40 |
| 2020 February | 46 | 13 | 59 |
| 2020 January | 54 | 19 | 73 |
| 2019 December | 48 | 22 | 70 |
| 2019 November | 36 | 24 | 60 |
| 2019 October | 43 | 18 | 61 |
| 2019 September | 33 | 12 | 45 |
| 2019 August | 43 | 22 | 65 |
| 2019 July | 28 | 25 | 53 |
| 2019 June | 36 | 22 | 58 |
| 2019 May | 59 | 27 | 86 |
| 2019 April | 67 | 37 | 104 |
| 2019 March | 48 | 21 | 69 |
| 2019 February | 34 | 23 | 57 |
| 2019 January | 21 | 17 | 38 |
| 2018 December | 44 | 17 | 61 |
| 2018 November | 104 | 25 | 129 |
| 2018 October | 128 | 31 | 159 |
| 2018 September | 66 | 8 | 74 |
| 2018 May | 54 | 1 | 55 |
| 2018 April | 25 | 7 | 32 |
| 2018 March | 31 | 12 | 43 |
| 2018 February | 29 | 10 | 39 |
| 2018 January | 132 | 6 | 138 |
| 2017 December | 122 | 10 | 132 |
| 2017 November | 40 | 7 | 47 |
| 2017 October | 21 | 15 | 36 |
| 2017 September | 31 | 12 | 43 |
| 2017 August | 25 | 17 | 42 |
| 2017 July | 33 | 16 | 49 |
| 2017 April | 2 | 1 | 3 |
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