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Lung allocation in the US changed nearly 15 years ago from time accrued on the waiting list to disease severity and likelihood of posttransplant survival, represented by the lung allocation score (LAS). Notably, the risk of death within a year plays a stronger role on the score calculation than posttransplant survival. While this change was associated with the intended decrease in waitlist mortality (most recently reported at 14.6%), it was predictable that transplant teams would have to care for increasingly older and complex candidates and recipients. This urgency-based allocation also led centers to routinely consider transplanting patients with higher acuity, often hospitalized and, not infrequently, in the intensive care unit (ICU). According to the Scientific Registry for Transplant Recipients, from 2009 to 2019, the proportion of lung recipients hospitalized and those admitted to the ICU at the time of transplant increased from 18.9% to 26.8% and from 9.2% to 16.5%, respectively..

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BACKGROUND: Persistent pulmonary air leak is the most frequent complication after lung resection, resulting in an increase in postoperative morbidity and mortality. We evaluated the viability, integration, and efficacy of a free peritoneal fat graft as a method for controlling air leak in normal and emphysematous rat lungs. METHODS: Sixty Wistar rats were divided into two groups: elastase-produced lung emphysema (n=30) and control (normal) lungs (n=30). Pulmonary air leak was produced by puncture of the right lower lobe, and aerostasis was attempted by means of intrapulmonary injection of autologous free peritoneal fat graft. Rats in each group (n=6) were randomly allocated to subgroups and were sacrificed at 7, 14, 21, 30, and 60 days. Then, lungs were removed for histology, morphometry, vessel identification and counting, and immunohistochemistry for caspase 3, vascular endothelial growth factor, and factor VIII. RESULTS: Tissue integration of the free fat grafts was found in all animals in both groups. Vessels stained with India ink inside the fat grafts were present at all assessment periods in both groups. Vascular endothelial growth factor expression was significantly higher in all periods in the emphysema group compared with normal lungs (p<0.001). There was a significant increase in caspase 3 expression in the emphysema group at 7, 21, 30, and 60 days (p<0.001). Factor VIII showed a significant increase (p<0.001) at 30 and 60 days in emphysematous lungs. CONCLUSIONS: The use of free peritoneal fat graft was able to control the air leaks in normal and emphysematous rat lungs, with persisting graft viability for as long as 60 days after implantation.

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OBJECTIVES: To evaluate the effects of 2 different levels of positive end-expiratory pressure on pigs who had unilateral lung transplants. MATERIALS AND METHODS: A left lung transplant was performed in 12 pigs. The animals were randomized into 2 groups based on positive end-expiratory pressure: group 1 (5 cm H(2)O) and group 2 (10 cm H(2)O). Hemodynamics, gas exchange, and respiratory mechanics were measured before and after surgery. Cytokines, oxidative stress, and histologic scores were assessed in the lung tissue of each pig. RESULTS: Pigs in group 2 exhibited a significantly higher mean heart rate (P = .006), static compliance (P = .001), lower mean arterial pressure (P = .003), and airway resistance (P = .001) than did pigs in group 1. There were no postoperative differences between the groups in concentrations of thiobarbituric acid reactive substances, superoxide dismutase, and interleukin 8. At the end of the observation period, pigs in group 2 had higher levels of thiobarbituric acid reactive substances (P = .001) and interleukin 8 (P = .05), and pigs in group 1 had higher levels of superoxide dismutase (P = .05) than they did at baseline. CONCLUSIONS: After unilateral lung transplant, higher positive end-expiratory pressure was associated with improved respiratory mechanics, a negative effect on hemodynamics, a stronger inflammatory response, and increased production of reactive oxygen species, but no effect on gas exchange.

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OBJECTIVE: To evaluate the effect of lung ischemic preconditioning (IPC) on normothermic ischemia/reperfusion (I/R) injury in a rat model, quantifying the production of reactive oxygen species. METHODS: Forty-seven male Wistar rats were randomized into four groups: control, sham, I/R and IPC. Control group animals were anesthetized and killed by decapitation, after which pneumonectomy was performed and the left lungs were stored in liquid nitrogen. Sham, IPC and I/R group rats were anesthetized, tracheostomized, ventilated, anticoagulated and submitted to left thoracotomy with dissection of the left pulmonary artery for clamping. Sham group rats underwent dissection of the left pulmonary artery, I/R group rats underwent 30 min of total hilar clamping, and IPC group rats underwent 5-min clamping of the left pulmonary artery followed by 30 min of total hilar clamping. Lungs were reperfused for 90 min and ventilated with the same parameters, with additional positive end-expiratory pressure of 1 cmH2O. Hemodynamic and blood gas values were obtained prior to thoracotomy, prior to total hilar clamping, after 30 min of reperfusion and after 90 min of reperfusion. Lipid peroxidation was determined by measuring levels of thiobarbituric acid reactive substances. RESULTS: There were no significant differences among the groups in terms of the levels of thiobarbituric acid reactive substances. Nor were there any significant differences among the sham, I/R and IPC groups in terms of arterial oxygen tension, arterial carbon dioxide tension or hemodynamic values. CONCLUSIONS: In an in situ I/R rat model, 5-min IPC of the left pulmonary artery does not attenuate I/R injury.

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PURPOSE: To evaluate the effects of alveolar recruitment based on mean airway pressure (MAP) on pig lungs submitted to thoracotomy through blood gas exchange and hemodynamic parameters. METHODS: Twelve pigs weighting approximately 25Kg were intubated and ventilated on volume controlled ventilation (tidal volume 10ml/Kg, respiratory rate 16min, FiO2 1.0, inspiratory:expiratory ratio 1:2, PEEP 5cmH2O). The animals were then randomized into two groups: control and left lateral thoracotomy. The PEEP was increased at each 15-minute intervals to reach a MAP of 15, 20 and 25cmH2O, respectively. Hemodynamic, gas exchange and respiratory mechanic data were measured immediately before each PEEP change. RESULTS: There were no significant differences between both groups in all parameters analyzed (P=1.0). The PaO2, PaCO2, MAP, PAP and plateau pressure were significantly worse at MAP of 25cmH2O, when compared with the other values of MAP (P=0.001, P=0.039, P=0.001, P=0.016 e P=0.027, respectively). The best pulmonary performance according to the analyzed parameters was observed at MAP of 20cmH2O. CONCLUSION: PEEP adjusted to MAP of 20cmH2O resulted in best arterial oxygenation, without compromising the venous return, as opposed to MAP of 25cmH2O, which caused deterioration of gas exchange, hemodynamics and respiratory mechanic.

OBJETIVO: Avaliar os efeitos do recrutamento alveolar baseado na pressão média das vias aéreas (Pmédia) sobre os pulmões de porcos submetidos a toracotomia, através de dados gasométricos e hemodinâmicos. MÉTODOS: Doze porcos machos pesando em média 25Kg receberam indução anestésica, sendo intubados e ventilados a volume (FiO2=1.0, volume corrente=10 ml/kg/min, FR=16 cpm, relação I:E=1:2 e PEEP 5 mmHg). Os animais foram randomizados em dois grupos: controle e toracotomia lateral esquerda. Os valores de PEEP em cada grupo foram aumentados a cada 15 minutos para atingir valores de Pmédia de 15, 20 e 25cmH2O, sendo coletados dados hemodinâmicos, gasometria arterial e mecânica respiratória imediatamente antes de cada acréscimo do PEEP. RESULTADOS: Não houve diferença estatisticamente significativa entre os 2 grupos em todos os parâmetros analisados (P=1,0). Ocorreu piora significativa da PaO2, PaCO2, pressão arterial média, pressão da artéria pulmonar e pressão de platô com Pmédia de 25cmH2O comparado com os demais valores de Pmédia (P=0.001, P=0.039, P=0.001, P=0.016 e P=0.027, respectivamente). O melhor desempenho pulmonar pelos parâmetros analisados ocorreu com a Pmédia de 20cmH2O. CONCLUSÃO: As manobras de recrutamento alveolar alteram o desempenho pulmonar e função hemodinâmica independemente da cavidade torácica estar aberta ou fechada. O PEEP ideal para o recrutamento alveolar independente dos grupos estudados foi obtido a uma Pmédia de 20cmH2O em relação a todos os parâmetros analisados.

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OBJETIVO: Avaliar o efeito do pré-condicionamento isquêmico (PCI) em modelo de isquemia e reperfusão (I/R) pulmonar normotérmica em ratos, quantificando a produção de espécies reativas do oxigênio. MÉTODOS: Quarenta e sete ratos Wistar foram randomizados em quatro grupos: controle, sham, I/R e PCI. Após anestesia, animais do grupo controle foram sacrificados por decapitação, pneumonectomizados, e os pulmões esquerdos armazenados em nitrogênio líquido. Animais dos grupos sham, I/R e PCI foram anestesiados, traqueostomizados, ventilados, anticoagulados e submetidos a uma toracotomia esquerda com dissecção da artéria pulmonar esquerda para clampeamento. No grupo sham procedeu-se a dissecção da artéria pulmonar esquerda; no grupo I/R, clampeamento hilar total de 30 min e no grupo PCI, clampeamento da artéria pulmonar esquerda por 5 min seguido por reperfusão de 10 min e um clampeamento hilar total de 30 min. Pulmões foram reperfundidos por 90 min e ventilados com os mesmos parâmetros, acrescidos de pressão expiratória final positiva de 1 cmH2O. Foram obtidas medidas hemodinâmicas e gasométricas antes da toracotomia, antes do clampeamento hilar total, aos 30 e 90 min de reperfusão. A peroxidação lipídica foi estabelecida por meio da determinação das substâncias reativas ao ácido tiobarbitúrico. RESULTADOS: A determinação das substâncias reativas ao ácido tiobarbitúrico analisada nos grupos controle, sham, I/R, PCI não revelou diferenças significativas, o mesmo ocorrendo com a pressão parcial arterial de oxigênio, pressão parcial arterial de gás carbônico e medidas hemodinâmicas entre os grupos sham, I/R e PCI. CONCLUSÕES: O PCI de 5 min da artéria pulmonar esquerda em modelo de I/R in situ em ratos não atenua a lesão de I/R.

OBJECTIVE: To evaluate the effect of lung ischemic preconditioning (IPC) on normothermic ischemia/reperfusion (I/R) injury in a rat model, quantifying the production of reactive oxygen species. METHODS: Forty-seven male Wistar rats were randomized into four groups: control, sham, I/R and IPC. Control group animals were anesthetized and killed by decapitation, after which pneumonectomy was performed and the left lungs were stored in liquid nitrogen. Sham, IPC and I/R group rats were anesthetized, tracheostomized, ventilated, anticoagulated and submitted to left thoracotomy with dissection of the left pulmonary artery for clamping. Sham group rats underwent dissection of the left pulmonary artery, I/R group rats underwent 30 min of total hilar clamping, and IPC group rats underwent 5-min clamping of the left pulmonary artery followed by 30 min of total hilar clamping. Lungs were reperfused for 90 min and ventilated with the same parameters, with additional positive end-expiratory pressure of 1 cmH2O. Hemodynamic and blood gas values were obtained prior to thoracotomy, prior to total hilar clamping, after 30 min of reperfusion and after 90 min of reperfusion. Lipid peroxidation was determined by measuring levels of thiobarbituric acid reactive substances. RESULTS: There were no significant differences among the groups in terms of the levels of thiobarbituric acid reactive substances. Nor were there any significant differences among the sham, I/R and IPC groups in terms of arterial oxygen tension, arterial carbon dioxide tension or hemodynamic values. CONCLUSIONS: In an in situ I/R rat model, 5-min IPC of the left pulmonary artery does not attenuate I/R injury.

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PURPOSE: To evaluate the effects of alveolar recruitment based on mean airway pressure (MAP) on pig lungs submitted to thoracotomy through blood gas exchange and hemodynamic parameters. METHODS: Twelve pigs weighting approximately 25Kg were intubated and ventilated on volume controlled ventilation (tidal volume 10ml/Kg, respiratory rate 16min, FiO2 1.0, inspiratory:expiratory ratio 1:2, PEEP 5cmH2O). The animals were then randomized into two groups: control and left lateral thoracotomy. The PEEP was increased at each 15-minute intervals to reach a MAP of 15, 20 and 25cmH2O, respectively. Hemodynamic, gas exchange and respiratory mechanic data were measured immediately before each PEEP change. RESULTS: There were no significant differences between both groups in all parameters analyzed (P=1.0). The PaO2, PaCO2, MAP, PAP and plateau pressure were significantly worse at MAP of 25cmH2O, when compared with the other values of MAP (P=0.001, P=0.039, P=0.001, P=0.016 e P=0.027, respectively). The best pulmonary performance according to the analyzed parameters was observed at MAP of 20cmH2O. CONCLUSION: PEEP adjusted to MAP of 20cmH2O resulted in best arterial oxygenation, without compromising the venous return, as opposed to MAP of 25cmH2O, which caused deterioration of gas exchange, hemodynamics and respiratory mechanic.(AU)

OBJETIVO: Avaliar os efeitos do recrutamento alveolar baseado na pressão média das vias aéreas (Pmédia) sobre os pulmões de porcos submetidos a toracotomia, através de dados gasométricos e hemodinâmicos. MÉTODOS: Doze porcos machos pesando em média 25Kg receberam indução anestésica, sendo intubados e ventilados a volume (FiO2=1.0, volume corrente=10 ml/kg/min, FR=16 cpm, relação I:E=1:2 e PEEP 5 mmHg). Os animais foram randomizados em dois grupos: controle e toracotomia lateral esquerda. Os valores de PEEP em cada grupo foram aumentados a cada 15 minutos para atingir valores de Pmédia de 15, 20 e 25cmH2O, sendo coletados dados hemodinâmicos, gasometria arterial e mecânica respiratória imediatamente antes de cada acréscimo do PEEP. RESULTADOS: Não houve diferença estatisticamente significativa entre os 2 grupos em todos os parâmetros analisados (P=1,0). Ocorreu piora significativa da PaO2, PaCO2, pressão arterial média, pressão da artéria pulmonar e pressão de platô com Pmédia de 25cmH2O comparado com os demais valores de Pmédia (P=0.001, P=0.039, P=0.001, P=0.016 e P=0.027, respectivamente). O melhor desempenho pulmonar pelos parâmetros analisados ocorreu com a Pmédia de 20cmH2O. CONCLUSÃO: As manobras de recrutamento alveolar alteram o desempenho pulmonar e função hemodinâmica independemente da cavidade torácica estar aberta ou fechada. O PEEP ideal para o recrutamento alveolar independente dos grupos estudados foi obtido a uma Pmédia de 20cmH2O em relação a todos os parâmetros analisados.(AU)

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PURPOSE: To evaluate the effects of alveolar recruitment based on mean airway pressure (MAP) on pig lungs submitted to thoracotomy through blood gas exchange and hemodynamic parameters. METHODS: Twelve pigs weighting approximately 25 Kg were intubated and ventilated on volume controlled ventilation (tidal volume 10 ml/Kg, respiratory rate 16 min, FiO2 1.0, inspiratory:expiratory ratio 1:2, PEEP 5 cmH2O). The animals were then randomized into two groups: control and left lateral thoracotomy. The PEEP was increased at each 15-minute intervals to reach a MAP of 15, 20 and 25 cmH2O, respectively. Hemodynamic, gas exchange and respiratory mechanic data were measured immediately before each PEEP change. RESULTS: There were no significant differences between both groups in all parameters analyzed (P=1.0). The PaO2, PaCO2, MAP, PAP and plateau pressure were significantly worse at MAP of 25 cmH2O, when compared with the other values of MAP (P=0.001, P=0.039, P=0.001, P=0.016 e P=0.027, respectively). The best pulmonary performance according to the analyzed parameters was observed at MAP of 20 cmH2O. CONCLUSION: PEEP adjusted to MAP of 20 cmH2O resulted in best arterial oxygenation, without compromising the venous return, as opposed to MAP of 25 cmH2O, which caused deterioration of gas exchange, hemodynamics and respiratory mechanic.

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