Respiratory and Hemodynamic Effects of Prophylactic Alveolar Recruitment During Liver Transplant: A Randomized Controlled Trial

Objectives: Prolonged surgical retraction may cause atelectasis. We aimed to recruit collapsed alveoli, stepwise, monitored by lung dynamic compliance and observe effects on arterial oxygenation and systemic and graft hemodynamics. Secondarily, we observed alveolar recruitment effects on postoperative mechanical ventilation, international normalized ratio, and pulmonary complications. Materials and Methods: For 58 recipients (1 excluded), randomized with optimal positive end-expiratory pressure (n = 28) versus control (fixed positive end-expiratory pressure, 5 cm H2O; n = 29), alveolar recruitment was initiated (pressure-controlled ventilation guided by lung dynamic compliance) to identify optimal conditions. Ventilation shifted to volume-control mode with 0.4 fraction of inspired oxygen, 6 mL/kg tidal volume, and 1:2 inspiratory-to-expiratory ratio. Alveolar recruitment was repeated postretraction and at intensive care unit admission. Primary endpoints were changes in lung dynamic compliance, arterial oxygenation, and hemodynamics (cardiac output, invasive arterial and central venous pressures, graft portal and hepatic vein flows). Secondary endpoints were mechanical ventilation period and postoperative international normalized ratio, aspartate/alanine aminotransferases, lactate, and pulmonary complications. Results: Alveolar recruitment increased positive end-expiratory pressure, lung dynamic compliance, and arterial oxygenation (P<.01) and central venous pressure (P=.004), without effects on corrected flow time (P=.7). Cardiac output and invasive arterial pressure were stable with (P=.11) and without alveolar recruitment (P=.1), as were portal (P=.27) and hepatic vein flow (P=.30). Alveolar recruitment reduced postoperative pulmonary complications ( n = 0/28 vs 8/29; P=.001), without reduction in postoperative mechanical ventilation period (P=.08). International normalization ratio, aspartate/alanine aminotransferases, and lactate were not different from control (P>.05). Conclusions: Stepwise alveolar recruitment identified the optimal positive end-expiratory pressure to improve lung mechanics and oxygenation with minimal hemodynamic changes, without liver graft congestion/dysfunction, and was associated with significant reduction in postoperative pulmonary complications.