Expert Webinar Series: Bronchoscopy and Donor Management

[00:00:00] Laura Carroll: Hi, I’m Laura Carol with CompuMed, and on behalf of the entire team at CompuMed, welcome to our expert webinar series, where the feature topic today, as you all know, is Bronchoscopy and Donor Management. CompuMed is really honored to have Dr. Lewis Angel to present this really important topic Dr. Angel’s in-depth knowledge and expertise really helps in assessing, managing, improving the recovery of donor lungs and resulting in an increase in the number transplanted into the needy recipients.

[00:00:33] We’re really grateful for his passion to share his knowledge and expertise with the entire OPO and transplant community. We also real quick wanted to let you know that Carrie Cadrick, who is currently a VP at Southwest Transplant Alliance is on with us today. Carrie was just recently with the CompuMed team for over two and a half years.

[00:00:53] And prior to that was with, TOSA for, (sorry, Carrie!) 20 plus years – that dates both of us. And she actually was instrumental in introducing us to Dr. Angel, as she worked with Dr. Angel when he was based in San Antonio. And both of their passion. They talked to each other and knew that this was a right thing to bring to the entire OPO and transplant team.

[00:01:17] So this is where we are now, and we’re excited to have you, and again, welcome on behalf of the entire CompuMed team.

[00:01:23] Dr. Luis Angel, MD: Right. Thank you very much – welcome to everybody that is participating in this webinar, uh, as Laura nicely introduced me. I’m a pulmonary and critical care physician. Currently, the Director of the Lung Transplant Program at NYU. And before that, I was in San Antonio with the university of Texas lung transplant program, where we work very closely with, uh, TOSA in implementing some donor management protocols.

[00:01:55] While some of you may have heard before at the San Antonio lung transplant protocol or the SALT, uh, protocol, which again has been implemented by many of the OPOs in the management or donors. And it is something in which I have a lot of passion and have done a lot of work and research in trying to improve the availability of organs for our patients.

[00:02:22] So what we’ll try to do is, I give an overview of lung transplantation and organ donation, and then focus a little bit more on detail of the role of bronchoscopy in some of the challenges that we have in the management of potential lung donors. I will try to spend 25 minutes or so on the presentation.

[00:02:42] Because I think that is more important to leave an open forum for many questions and, and try to answer topics related to lung donation. So always I like to start with giving a big picture of where lung donation is and to me, something that I try to describe to most of the OPOs, if they say I, I was a person that is giving a task to review an OPO.

[00:03:16] And there are, again, multiple things that you can measure the performance of an OPO, uh, from the clinical point of view, I will say that my choice will be, let me check at this OPO and see how are they doing with lungs, because that will give me a good indication of how is the management of the donors that they have and how complicated it is.

[00:03:41] So this graph shows a little bit of that data and you see different colors in here. So in this line here is total disease. Organ donors, uh, here is skin. Liver heart and lungs. So you, first of all, you can see, again, few things that are interesting. Again, obviously since 2014 and 2015, we have a significant increase in the total of organ donors available.

[00:04:09] Uh, as you can imagine again, you see these two lines here, the kidney and the, and the total organ donation, they really match almost perfectly all the time, which is basically telling you that you have an organ donor. You have a good chance to be able to procure the kidneys. And, and in some way, there is not a lot of management that you can do.

[00:04:34] There’s not a way to measure again, you’re monitoring because most of the OPOs do relatively well with kidneys. With livers. It was almost the same story, but I think that because some of the donors that we are taking are a lot more extended, uh, the curve is a little bit different, but also the chances, if you have an organ donor that you’re gonna get again, a kidney or liver, and truly again, different that the hypernatremia and the overall good management of donors is not much that you can do also for the liver.

[00:05:07] Then down here, you start seeing again, just the heart and the lungs, and you can see, again, the numbers here, how they start increasing over the years and here in 2019 and 2020, probably some of this is related to COVID and all the things we just kind of see that, that kind of plateau. But this is almost like a different way to look at the same graph.

[00:05:30] Again, purple here will be all the donor skins and livers. So you see how, again, as you increase donors, you’re always gonna increase skins, livers, but for lungs, again, the numbers increase some way. And, but even if the number doesn’t seem to be a huge number, For organ donation and lungs is very, very significant because in 2007, we were doing 1,300 donors and this is start increasing in 2015, we crossed 2,000 donors for the first time.

[00:06:03] And then in 2019, and then for the last three years, we are doing 2,700 donors. So this is a significant increase in the number of donors that we are doing. And a lot of this is related to better donor management, which I think that is most of it, but also to some of the programs that are becoming more aggressive and more comfortable taking extended, uh, donors.

[00:06:27] So some of the reasons why it’s so difficult to procure lungs and it’s so difficult to go into different hospitals and manage this is because there is this kind of confusion on what is important in terms of lung donation. And even if this criteria has been established is for a long time, most of them are really mixing a bag when our coordinators, when we are taking care of the patients and more importantly, the ICU teams, they have no idea what is required for a transplant and program to take some lungs.

[00:07:04] One of the first examples is when you make a lung offer and usually they come again in the middle of the night to a transplant center. The first things that the … or the pulmonologist were, are taking the operator going to ask is what is this? PFR this ratio between the PaO2 and the FIO2. And you want to be more than 300.

[00:07:26] So you are measuring blood gases in a hundred percent. That is my recommendation. In that way, you have consistent numbers to look when you are reviewing and donor net and not all of these different PaO2. Cause again, people don’t make the effort to look at the PFR. They look at the PaO2, but you look at this number.

[00:07:44] You want to be more than 300. This is a goal that none of the ICUs that is taking care of living patients in mechanical ventilation has, and which very often make a difficulty for the coordinators when they go to somebody that is starting 98% with a PaO2 or FIO 0f 200 and everybody’s as happy as they can be on the ICU.

[00:08:11] And you start saying, we need to do a lot of stuff. We need to, again, do changes of the bronch code. Do recruitment, get new, x-rays do a bronchoscopy because we have these sense, like, okay, these lungs are not good for us, but up to the point that the patient became an organ organ donor, I can almost guarantee that the ICU team was super happy because they have a PaO2 above 150.

[00:08:35] So this is an absolute criteria that is very important. Uh, it’s not to say that we have take patients with PaO2s below 300, uh, but for the most part, you want to be offering lungs. You need to improve the Pa02 and, and the five, two ratio, uh, to about three. Uh, the second criteria is about the x-rays. It’s almost impossible to have a completely normal x-rays, but some of the things that you see on the x-rays on these patients can be improved again by management of the donor, like ASIS with cleaning up mucus plugging, or there is again, a minor contusion that we know about the trauma.

[00:09:15] I think that we can live with those things, but we want to improve the x-rays. And there are very few, two ways to improve the x-rays, but most of them are very successful and I will go over those in a few seconds, but they may include the bronchoscopy too. And finally, you want to have a clear bronchoscopy with no evidence of aspiration of pure and secretions, and also you want to have a negative gram stain, and now a negative COVID test for those things.

[00:09:45] You are, you are required to have a bronchoscopy. All things are why we consider extended criteria. And many of those things are things that you really cannot do anything for the donor. So for me, almost the absolute criteria, there are the things that are required are things that we can work on, but the extended criteria very often, we just cannot do anything because a lot of this is the history of the patient.

[00:10:11] We cannot make them younger. They were heavy smokers. We cannot. Can make them non-smokers. Uh, they have history of pulmonary diseases in particular asthma or something like that. Or COPD. We cannot take it away. If they came with a major chest trauma, it just happened. And this, again, big pressures, we can make some changes and the negative gram stain, that one is not like criteria anymore.

[00:10:38] Most of the gram stay in our paces are positive, but what is very important is that we start antibiotics really early in all the donors. And my personal recommendation is every donor regardless should be on antibiotics. Because the argument I always tell our coordinators when we do simulation and training courses.

[00:10:59] So when we take care of our donors here in New York, and when I was in Texas is those same lungs immediately when they go into the, or we are gonna give antibiotic to our recipient. So there is no reason not to give it before, because they are gonna be getting these antibiotics now to make things very simple and realistic.

[00:11:24] When we have this, what I call the three biggest enemies on lung donation is when you are looking into these absolute criteria of getting like a very good PFR or Pa02, about 300, and you want to have a relatively clear x-ray, the things that give you this type of trouble are pulmonary edema, ASIS, mostly of the lower lobes.

[00:11:49] And pneumonias. So those are the three things that you need to look into and bronchoscopy. We have a significant role in the management of the ASIS, and then also in the diagnosis of pneumonia and looking into the pure secretions, getting the cultures and providing some information that show you again, how important it’s to do a good BAL to reassure the trust and center that regardless, even if there is a little bit of an infiltrate, the airways are looking good.

[00:12:20] There is not a lot of pure lens when you do a good BAL, you clear up the airways and then you see the return are coming clear and the secretions are not reaccumulating. And also it’s very important to do this fairly early, because we always want the patients to be on good antibiotic coverage, at least for 24 hours, ideally for 48 hours.

[00:12:44] So you tell me that you have a donor with a single lobe pneumonia. And we say, we documented what the bacteria is. And we having antibiotics for at least 24-36 hours and the bronchoscopy good, this type of donor, we will take it here. And we have done many donors with these characteristics, but again, the results of the early bronchoscopy, very, very important for us to know that this is getting better.

[00:13:11] So because we know that the x-rays take longer to improve compared to the pure length on the airways. So you can start cleaning the airways and the x-ray may lag behind. So that part is very important for us and the ASIS of the lung. There is mucus plug in. You can do all the recruitment that you want by the secretions or plug with there, with mucus, the, all the recruitment is gonna go to the other areas and you cannot expand those unless that you clean up their waste.

[00:13:43] So from these messages, I think that you can infer at this point of, you can start saying it’s very clear that again a doctor feels that the bronch could, should be done as early as possible. To clarify again, this enemies of organ donation, the role of ale is a mucus plugging and define it. They have a pneumonia based on the x-rays and the bronchoscopic findings.

[00:14:09] Remember, again, hypoxemia for us when we are taking of organ donors is 300. And if you leave that message to the bedside nurses in the ICU, specifically to the respiratory therapies and even more to the ICU attendings there, because this is why I see all the time they question, why are we doing this?

[00:14:32] When somebody has a saturation on 97% and appeal tube, 150. And because we say for organ donation, hypoxemia is a PF far less than 300 and this abnormal pulmonary infiltrates, again, we can help with this with very good donor management. So one of the first things that we can do is obviously, uh, we can spend another time in a different meeting about the management of pulmonary edema, but it is probably one of the most common things I see on most of the donors, these patients, they have been resuscitated very heavily, very often when they arrive into the hospital, once they determine that the patient is very, very sick and probably going to die, they just stop the resuscitation office, but they forget that they have the patient 10 or 15 liters up.

[00:15:28] Then we need to diuresis them. And very often they just not forget that they give the 10 liters of the resuscitation. They keep giving fluids for three or four more days. So I assume that most of our patients are volume overload and trying to diuresis here. What we are trying to show in this graph is that at some point, and he’s usually getting two, three days into the resuscitation of the patient that is around the time that we have the pronunciation of brain death, giving more fluids usually does not help improving of the cardiac capital and the hemos.

[00:16:02] All he does is increase the vascular lung water. And unfortunately the most leaky of all the organs that we have when we are taking care of organ, donors are the lungs. And so I will say the calculation that you need to make is for every lit that you give of fluids, approximately 5 to 600 of those fluids are gonna find a way to get into the lungs.

[00:16:26] So it’s a significant amount. So we have to be very judicious with not giving a lot of fluids and in patient that we can diarrhea or dialyze in some of those, we have to do that. The pneumonia is, is a very important thing. There is no much that we can do again if they already have a pneumonia, but there is some things that we can do to prevent pneumonias.

[00:16:48] So we always have need to have the head of the bed elevated. We, I always tell all of our coordinators inflate the cuff to the point that the respiratory therapist is uncomfortable, that they feels really hard because we don’t care about creating any kind of tracheal issues. We don’t do tracheal transplants yet, and indeed, and that will be extremely rare.

[00:17:12] And we want to avoid that. Any aspiration, especially patients with trauma when they are bleeding from the face, from the head or patients with gunshots to the head or major trauma that they are and having brain particles, even staying on the back of the mouth, they can aspirate these things into the lungs.

[00:17:30] So just over inflate the cuff. And then we go into the question with the antibiotics. Our recommendation is for most of the patients with certain medications but you can usually, but all of these patients should be on antibiotics. Uh, is my recommendation. The one that we missed the most is this, uh, is the atelectasis.

[00:17:54] And, and unfortunately, uh, this, this idea by critical care physicians and by most of the people taking care of these patients that having a little bit of atelectasis is okay, and especially the PIO2 is fine. And because they look at an x-ray like, When you can see the diaphragm very clearly here again on the left side, but you lose the diaphragm on the right side and you see this area collapse here, and then you say, okay, there is some atelectasis is in the right lower lung truly when you have a right lower lung collapse, you are missing at least 50% of the right lung function.

[00:18:32] So even you just say, ah, it looks fine again. I see this x-ray looks fine here. And this is mostly okay. You are giving a significant amount on the lung function there. And even again, you see a complete collapse on this. X-ray here on the left side. Again, the same thing, you see this dense retro cardiac area, and, and then it’s complete collapse of the left lower lobe, and then again, you are giving 50% of your lung function and that can make the difference between a Pa02, 280 and 350.

[00:19:05] Which makes like a front port donor to a good donor. And often the atelectasis , like this are deal that the patients are being on, on the ventilator with low pressures because this RDS ventilation is why everybody use with extremely low tidal volumes, high respiratory rates. And they don’t have a lot of people.

[00:19:26] This is the patient is staying in the bed for three or four days, uh, is basically dying. Nobody is rounding, nobody is suctioning and doing all of those things. So the most common problem in donors is that elective is the lower lobe, and if you have both lower lobe, then you are giving easily a hundred points on your PFR.

[00:19:50] And now most of these AEs are due to mucus. Secretions are plugging. The recruitment can help a lot, but the secretions are very significant and the Broncos are included with secret Christians. It doesn’t matter how much people you’ll use and how much recruitment you will not be able to open those away.

[00:20:09] So when the reports say that there is a SIS, then it’s very important to look into the airways, just to be sure that they are clear because if not, and the recruitment will not work. If they are clear, then the lower recruitment has a better chance to help us in opening those, uh, lower loads. So some of this x-ray, this is the problem very often that we just see, again, these reports by anesthesia, Hey, by radiology.

[00:20:43] After the patient has been there for three or four days, first of all, they say no significant changes and they always gonna describe the, some pulmonary infiltration on the basis can define that SIS versus pneumonia versus fluid overload. So we, we really need to look at the x-rays and it’s always something that we would teach in our simulation courses.

[00:21:04] We teach to all of our coordinators, how to read donor x-rays. Cause it’s really important that you determine, and you look into that to say, you know, there is all of this infiltrates and I’m not sure if it’s pneumonia. At SIS, the bronchoscopy will help you a lot because the bronchoscopy, you see mucus plugging, you clear the mucus and there is no pure lens probably kind of is gonna help you lean a little bit more like, okay, I think that we are dealing with that where you see that the ways are opening.

[00:21:35] You watch this scope and it’s all pure lens, then you say, okay, it’s more likely pneumonia. Let’s give the antibiotics, do lung recruitment and see we can make things better. So again, the same thing here, for example, clear, left lung on the right load. You can see the diaphragm, you see this dense infiltrate.

[00:21:54] So it’s more likely pneumonia and pneumonia like this. The bronchoscopy be should show significant periods in this area. And if you have antibiotics going for two, three days, maybe that the airways look fairly clear. So when you make the offer for some bio, maybe some interest because you say left lung is very clear.

[00:22:14] This has been treated. This is getting a little bit better. And hopefully with some recruitment, we can make this lung look a little bit better. Then this is the SIS of the left, lower lobe again, it’s completely collapsed. And that’s why, again, it’s very important when you see left lower lobe collapse or right.

[00:22:30] Lower lobe collapse, and combined you giving 50% of each one of the lungs with those lower lobe collapses. So it’s a very significant amount.

[00:22:42] So let’s focus a little bit on bronchoscopy for evaluation and management of the potential lung donors. So what is the ideal time of, for the, uh, and, and this is a very, very difficult question, uh, from the practical point of view, from the clinician point of view and from the donor management. The answer for me will be, as soon as you get into the ICU to see these patients do the things that you need to do, get your bronchoscopy done.

[00:23:11] And it’s part of our donor center here at the NYU. We have a donor procurement and recovery center at NYU, which started almost a year and a half, two years ago with a procurement rate lungs close to 40, almost 50%. So one of the highest procurement rate lungs and, and whatever time they get here, middle of the night, the ICO team knows soon as the patient is in the room and is stable.

[00:23:39] There is a bronchoscopy done. So why is that important? Because as I had been mentioning before, we need to see where the LA again, how is everything looking? What can we do? And try to answer this question. Why is that these lungs are not ventilating well, and we have the information of the x-rays. We have the information from the ventilator, and then if we add the bronchoscopy and we say, okay, these mucus plugging, we cleaned out the mucus plugging, these pure secretions, we send the gram stain.

[00:24:13] So my recommendation will be to do it. Then now the reality is most of the places are not like NYU. Most of the places don’t have the resources. Again, the, the things that we have when I was in Texas with TOSA, that we have our own bronchoscopes that we were taking to the hospital. So we always have a bedside bronchoscope and we, all we needed at that point was to get somebody there in the ICU to say, come and do the bronch.

[00:24:41] The reality that I see all the time, even here in New York, when they call me from many of our hospitals or when I was also in Texas sometimes is that they are trying to call the bronchoscopy tech and is Saturday three o’clock in the morning. Nobody’s gonna come sometime in Sunday. They don’t even come.

[00:24:59] And then the bronchoscopy is left with this idea. Okay, everything looks fine. We are gonna offer the organs. Let’s do the bronchoscopy at this point, just to kind of check box that the bronchoscopy was fine. So I think that again, obviously you do, whenever you can. But the ideal point is to do it relatively early.

[00:25:19] In that way you can again, find out if there is any abnormalities, the bronchoscopy can help you. And it has to be again, a good quality bronchoscopy to do this. Once say we have been working in training coordinators for this is a very, again, huge task by asked my opinion. I think that that will be the best way to approach this thing to have most of the coordinators train.

[00:25:44] This is a very easy procedure to do in an intubated patient. And then we can basically just do the bronchoscopy, do a videotape. We can, you guys can review with the ICU people there. We can help to review the bronchoscopies and then come up with an idea again, how to do again, the interpretation and what to look after we do the bronch.

[00:26:10] Once we do a bronchoscopy, there is obviously some minimal requirements. We need to understand the anatomy and we need to describe the anatomy locally for us. Very, very rarely. We have an anatomy that is not normally enough that can prevent us from having transplantation. And we never ask again, a coordinator to be able to define the anatomy of the lungs perfectly, but the basic stuff to say, this is a right lobe.

[00:26:37] There is a left lung. Both of the bronch seems to be okay. Uh, that’s that’s at least what we need to say. The secretions is very, very interesting. Because most of the pulmonologists of the ICU physicians or the anesthesia people that are doing the bronchoscopies, like I mentioned before, they do not understand lung donation.

[00:27:00] They think that a PaO2 150 is fine. And then they do a bronchoscopy. They place the bronchoscope, the endotrachel tube is plugged with blood and mucus the trachea has a couple of big plugs and yeah, and even at that point, they say, oh, this looks terrible. And, and, and it doesn’t mean anything to us.

[00:27:18] Again, we don’t trust the trachea. We don’t trust the end of trachea too. You have to go beyond these areas, cleared up all of those mucus we don’t care about that. Getting to the lungs, clean up all their ways, doing anatomy review. And that requires to use a fair amount of saline. Have a large therapeutic bronchoscope to clean up secretions.

[00:27:41] So don’t use that little pediatric scope with a two, three millimeter again, channel that you cannot function anything. And yes, use a very good bronchoscope. And I say, you know, again, just clean up the tracheal tube, the trachea don’t worry about that. But sometimes I have seen you basically stop. The trache, they say, there’s a lot of blood in the trachea.

[00:28:02] This looks terrible. And then they don’t make it in the effort to see how does it look? And once you clean up all of that, how things are looking, we also need to obtain samples and these samples, again, the better that we can do is obtain them as early as possible. Or again, the donor management in muscle, the OPOs is 24 to 36 hours.

[00:28:22] If we have the cultures. And by the time that we get the organs, we have the results of cultures and we help our recipients. And we help you to be able to place the organs. As you say, the cultures are negative or it’s just a regular bacteria. And nowadays, obviously we are required to evaluate for aspiration too.

[00:28:41] There is this patient that have, again, basically in trauma, very difficult intubations or patients who die with drug overdose. Many of those patients can aspirate during the process. And if you find food particles or something, you can see them, you clean it up. And then you see, but you have to document all of this.

[00:29:00] I think that it’s ideal to at least for the, uh, OPO coordinators to very carefully look at the, at the bronchoscopy when it’s being done, especially again, to avoid these things, that again, they are stopping without clearing the secretions and all they do is place 20 CCS of sailing in one lobe and that’s it?

[00:29:20] No, you need to be aggressive. Go to every lobe, clean it up, be sure that you do that. So you are there and you are present during the bronchoscope is fine. And most of the bronchoscopes now you can do a videotape and picture the documentation, even though use your smart devices, use your phone and make a video and take a picture, put it on donor net.

[00:29:41] That that will help again, uh, the SOS and the team, just to see how the airways look and also the BAL needs to be. There are some of the BIS from the smokers that looks really dark and black. So when there is a question about the smoking history and you see all of these antiotic pigment, you may say probably this guy smoke a little bit more than what we think, and you can see pure and secretions.

[00:30:05] You can see aspiring material, you can see a lot of blood in contusion. So you have to do this, an idea. You take a picture that again, because it’s hard to describe to our people, but a picture will show you very quickly, the characteristics of that, uh, fluid. So, this is a bronchoscopy that we did in a donor.

[00:30:27] Again, just last week in preparation for this talk. Uh, this is with an Ambu that doesn’t have the best images compared, but I just want to make a realistic, uh, donor. So here again, we are going, uh, from the right, we are already kind of cleared up the secretion. So you see how everything looks clear. We are going into the right side, the right.

[00:30:46] I’m never expecting that you guys will have to describe the anatomy. All you have to say, hey, I see going to every opening. I don’t see a lot of secret Christians. Now we are going into the broadcast intermediates, the middle lobe everything looks open there. Here the same thing going into the lower lobe and then once you get into the lower lobe you are gonna wedge this scope and you’re gonna place again, 50 to 100 on saline.

[00:31:10] And then when the scope is wedged, you’re gonna try to so, and need this scope is wedded properly. You should be able to. So, uh, most of the fluid back, so you won’t be losing too much. If you put the fluid in the middle of the airway, you won’t be able to get it, but you watch this scope again. You will do that.

[00:31:28] And after you clear up this equation, you see, everything is very clear. Now we are going into the left side. This is the left upper lobe again, this is the pickup posterior interior. This is the lingula. Again, you are seeing each one of the opening. You don’t see a lot of mu, so this one, if they have AEC, you say, okay, recruitment should help because there is no much secretions.

[00:31:50] And it’s important again, that the bronchs look like this, or you try to do like this in a therapeutic way. Just kind of be aggressive, clean up their ways, do these things, and then do a nice documentation on the bronch. Now the donor management protocols again are really, really important. And, and obviously, even if we are not gonna talk about all of this, I have to say that the results are really important.

[00:32:16] We have to take care of every donor. And the reason I’m showing this picture is because this is a 17 year old patient that when I was in Texas, again, it was with a major car accident. And this is the initial presentation of this patient, but we were working and we are gonna take care of every donor.

[00:32:35] We are gonna be very consistent. We are gonna do our bronchoscopies. We’re gonna do the fluid monitoring. We’re gonna do the lung recruitment and, and interesting this donor, the P2o, the PFR was around 220, 230 with this type of x-ray. So that kind of gave me the information that maybe that most of this was kind of significant Neurogen pulmonary edema, and that with good donor management, we should be able to clear this both lower lungs were completely completely collapsed, but the airways were open.

[00:33:05] So we knew that recruitment and diuresis could make a difference. And we start working on that and with the recruitment, as you see, compared to these dense areas here, Now we start opening the lungs and it still has significant pulmonary edema. This is again, eight to 10 hours later, and we were able to take again these lungs and as you see them, so donor management is extremely, extremely rewarding in what you can do and from lungs and look really poorly.

[00:33:32] You implement all the things that we are saying about fluid management, ventilator management, and bronchoscopy. It can make a big difference. We do have time, again, most of the donors, if you see the average of time that they take again, 34, 36 hours is the time that you have to take donors. So if you implement these changes, as quickly as we get there, in terms of donor management, we can make a significant difference.

[00:34:00] There is some again, criteria for mechanical ventilation. There is some again, recommendations for the use of peep. Now, one of the reasons that I want to. Again, I have such a passion for this it’s because it is really, really important to get more lungs, to get everybody transplanted for lungs. And here is again, a little bit of the story.

[00:34:24] This is looking at the OPOs from 2021, and I divided this in two different groups. So I don’t know anybody that is in the column, what OPO they are. Uh, you can quickly try to look at your number here, but to me, I will say, okay, opioids that procure 20% and above we call this like at the top performing OPOs.

[00:34:48] I think that we should be 25 and above in most of this. So again, kudos to all of these opioids that are doing around this number. I have to say when I was working in Texas, I was pretty sad when I, again, prepared this slide for 16 years when I was there and we were working very hard with organ donation.

[00:35:06] Our OPO was number one to five every single year for 16 years. And now I’m seeing it back to where we start again. Uh, again, almost 20 years ago there doing 11%. So it is, again, it is so important to do it. And there is a lot of underperforming opioids that are doing these extremely low numbers. Why? I think that is very important for us.

[00:35:31] You see, you look at the number of donors and the number of transplants. You see how many lung transplants are added to the transplant list. So you start looking over the years, again from 2010 to three, uh, 2021. So we are adding around 3000 patients again here and miss here to the transplant list right now, this is the number of lung donors that we are currently doing.

[00:35:56] So the difference as you start seeing again, what’s very significant. We have like a 45% gap to close, but this gap is getting smaller. And all we have to do is get this again, 400, 500 more donors. And if we change these numbers here from these underperforming, 15% donors. To this average overperforming 24%.

[00:36:20] So a 9% improvement on this. We basically wipe out the transplant list and this deficit will be only a hundred patients, which will mean that every single patient that needs transplantation for lung will be transplanted the same year when they are list. And there is no any other organ that we could be able to say that even if they procure so many kidneys and livers, those transplant leads are huge.

[00:36:46] 80,000 patients waiting for kidneys, again, 20,000 waiting for, for liver. So we will never get there, but we lungs, we are very, very close and all we have to do is everybody just need to commit to make a better job, to take a better care, to move from this group to this. It’s not huge. The effort that you have to make is just being very consistent in donor management, passionate about, and always incorporate the volume management, the ventilator.

[00:37:16] And hopefully again, after this understand that incorporating the bronchoscopy is very, very important. So in conclusion, again, lung transplantation again is vital for our patients. The best option to improve organ donation is I’m. In particular, lung donation is started at the arrival of the potential organ donors at the hospital.

[00:37:38] Like I mentioned before, uh, many of the hospitals, they completely neglect lung donation until the patient becomes an organ donor. And then it’s the opioid responsibility to do everything that they can. But you use wisely those 36 hours that you have in average to 34 hours. I think that you can move your oppo from the underperforming to the, uh, good performing opioids, this good communication in the transplant centers and OPOs is very important.

[00:38:08] Uh, and that’s one of the things that happen in Texas, too. The lung transplant program that was very active now is a very small program. So between, uh, a small non program and the lack of commitment and communication things can be again weakening, uh, that, so it’s very important. And I think, again, people keep hearing about these XBS and every time that I get an offer, let’s say this donor qualify for XB one and stuff like that.

[00:38:35] I don’t have any issues with XVI, but I don’t use it very often because I strongly believe the Inbivo donor management when the donor, the Naloxone is still in the, in the. Donor that has a heart that is beating and the lungs start breathing with the ventilator is the best opportunity to manage these lungs.

[00:38:55] And we do have time to make it better. So these donor management protocols to me is the best thing. So with that, unfortunately again, I went a little bit longer that I was supposed by 10 minutes, but I’m happy to take any questions and I really appreciate your participation and being present on this.

[00:39:13] My appreciation for the coordinators is always the biggest I can have. Your work is very hard, your work and the very difficult circumstances with many times, unfortunately, house style environments, and every night, every weekend, every special holiday, you can count this, uh, coordinator there. So you guys have a, all my sympathy for your work and, and anything that we can help to make this better.

[00:39:39] Uh, that will be our mission. Thank you so much.

[00:39:44] Deanna Host: Thank you, Dr. Angel, and thank you to all 140 of you joining us for Dr. Angel’s presentation. It’s amazing to see so many of you interested in donor management and bronchoscopy. Now we’re gonna move into our Q&A. So if you haven’t submitted your question yet, the Q&A section of Zoom is filling up fast.

[00:40:01] We’re gonna try to get all of your questions in some of you sent yours in early. So Dr. Angel will be taking those first and yes. Dr. Nicholas Henry says hello from Texas. Okay. Thank you. So Dr. Angel, this is a question from Donor Network West and they asked what are the indications for serial bronch?

[00:40:21] Dr. Luis Angel, MD: Oh, excellent.

[00:40:23] Excellent point because I did mention this on my presentation. Uh, and this is something that we do here. And that’s the reason that the first bronchoscopy is so important because if you have a first bronchoscopy, when you say, ah, I’m kind of unhappy with this, it’s a lot of secretions. We keep again, getting a little bit of appeal and secret was so much mucus plugging.

[00:40:47] That will be the type of patient that would say, okay, we’re gonna decide our bronchoscopy. We did this tonight. Tomorrow morning, I’m gonna repeat and see how these things are looking in. That way you can don’t have the report about by bronchoscopy only you can say, this is the things that the way that things were looking, we suction everything like that.

[00:41:06] We started the patient on antibiotics. We did some lung recruitment. We suction all of these mucus block. And then our second bronchoscopy be 12 hours later. Hopefully looks a lot better when you are still dealing withs with equation or things like that, you can clear up. So I think that it depends on your face.

[00:41:22] Bronchoscopy, your face bronchoscopy looks pristine. The blood gases are great. The x-rays are good. You don’t have to do more bronchoscopies. Uh, and, and this is why I see the value of this. You know, don’t want to promote any company, but when you have these and we were taking with our OPO in Texas and you leave it.

[00:41:41] Uh, the bronchoscopy is always there. So it’s not like you need to call again the team of the ICU come, the bronchoscopy team and all of those things because then becomes a production and it’s a lot more expensive too. So I would recommend according to the findings of the first bronchoscopy, but your first bronchoscopy is not ideal.

[00:42:01] Very likely the transplant center is gonna require that you have another bronchoscopy, uh, before you again, go for the final location. And as you know, again, the SOS, when they go there, they like to do their own bronchoscopy. So again, you get the benefit of having your own scopes and doing all of these things. Um, multiple times in the same case.

[00:42:19] Okay, thank you very much. We’ve got another question from Donor Network West, and they’re asking what’s the best way to begin lung management on a donor. I know it’s not a one size fits all, but a good starting point or parameters, a good direction for OPOs to begin proper management.

[00:42:40] Yeah. So I think I had raised a little bit some of these issues during the presentation and obviously that’s a course that we have here at the NYU for organ donation, with simulation, that we have all the live on New York coordinators and some of the app state coordinators coming to take and go where all of those things, obviously to me, is understanding better what is required knowing that our fight is against pulmonary EMN pneumonia at SIS. And we have to do again, fluid management, ventilator management, and bronchoscopic evaluation, assessment, and management of the airways. Now you ask me ways you have an opportunity to say, what is the best thing to do is you start these things as soon as you have time and you get there also, you need to get situated. You need to, again, fill all the paperwork, meet with everybody in the ICU, talk to their family, do all of those things. I do understand. But once you settle those things, you review your again, donor criteria for lung donation. You recognize they are not ideal.

[00:43:45] And I say, I need to start working into this immediate very often. I see that they call me at two in the morning and the x-ray was done. Again, six o’clock in the morning or even the night before the blood gas was from 18 hours before. And you just need to say, okay, this is where we go. We are gonna implement management.

[00:44:05] Let’s get a recent x-ray good blood gas, get our bronchoscopy, see where we are and start management early, implement protocols. This again, multiple publications. This is a consensus statement, which I work again. And I was the outer of that consensus statement on donor management for the launch section and need you start implementing all of the things that we discussed briefly today as early as possible.

[00:44:30] That would be the most important thing I would recommend.

[00:44:34] Deanna Host: Okay, thank you. Now we’ve got two questions from Finger Lakes Donor Recovery Network. First question is what is the best advice you can offer for getting a thorough grinch without causing significant derecruitment and residual fluid being left in lungs after BAL samples that look like pneumonia on imaging?

[00:44:55] Dr. Luis Angel, MD: Okay. Very good. So, uh, couple of things once is when we are doing the bronchoscopy, uh, don’t ever disconnect the patient from the ventilator to do the bronchoscopy, uh, that will create problems because then you will lose all the recruitment, especially you have done it for hours. So always try to do it through the adapter that you use, that that minimize the leak, but still you will have some leak, but it won’t be as.

[00:45:21] The second part that you will do in terms of the BALs. And this is important to do. Just try to wedge the scope when you are doing the BAL in the way you have a better chance to recover 50 or 60% of the fluid that you give to the patient. And also you see you wed it again. It will be going into a more focal area that will be when you’re looking into the x-ray saying yes, we did a lower lung batch in the lateral segment, and you are seeing a little bit of an infiltrate on diuresis.

[00:45:50] That’s what you need to do now. The fluid into the lung scale Resor very, very quickly from a BAL. So my recommendation is you just don’t send a, an x-ray 20 minutes after the bronch. You just try to do it again. Two, three hours later. And most of that fluid, even if you lead two, 300 cc behind. Probably will be gone, uh, about that time.

[00:46:14] Now, very often after I finish the bronchoscopy, I do a little bit of recruitment again. So what you can try to do is one of those, again, 30, over 30 in the way, all the recruitment you lose on recruitment, you can rerecruit, and that will take care of that part. Uh, if you want to do that or increase the peep again for a few minutes, again, go the peep then to 1215 in some cases.

[00:46:37] And that will kind rerecruit the lungs after the bronchoscopy. And I do this very often, not just for donors, for my lung trust recipients, after we do the bronchoscopy and we are trying to get them excavated or something, just not to lose the recruitment and kind of rerecruit them very shortly for again, few minutes, couple of minutes, and that she’ll do it because it’s a very loss of recruitment during the bronchoscopy.

[00:47:02] Deanna Host: Thank you. Can you go ahead and move to the next slide before we ask this other question? Thank you. Significant PMH of smoking. How significant is it really? If the gasses look good?

[00:47:16] Dr. Luis Angel, MD: That one, you are gonna have a hundred different answers from a hundred programs. Uh, I personally feel that somebody that has a smoking history that is more than 20 packs per year, and especially is getting into the older category.

[00:47:34] The donors are getting over 60 or close to 60 and they have a smoking history of 40 or 50 packs per year. You are just not taking the risk that they may have some early emphysema and things like that. But also the reason malignancy with those patient, they may have an increased risk of tumors. And then with the immunosuppression, there is a little bit of additional risk.

[00:47:57] So our program, again, when we have somebody that is fairly young, 25, 30 years old, and they say that they smoke a lot by the most gonna be 50 to 20 I’m okay. With those, with the older donors, I’m a little bit more concerned. And even if it’s not the right way to do this, it’s just the smoking history.

[00:48:17] It’s very sketchy on these donors. Sometimes it’s just, there’s nobody to document clearly or the whoever is with them and say, oh, I have been with them the last three or four years. I was smoking only half a pack per day, but, but they are 60 years old. And, and so they give us a story that he smoked 10 packs per year.

[00:48:37] I have a lot of questions about those. And when you have older smoker, I always ask at some point, what is the most that you smoke? And I’m assuming that they smoke that for most of the years, but then also you have to have a C. The CT scan is completely normal with no pulmonary, no annoying fem. I think that I feel a little bit more comfortable in somebody that I, 35 or 40 years with a smoking history of 25 or 30 packs per year.

[00:49:05] If I really have a very sick recipient that is dying and we need to get organs, I may be comfortable with us. However, if I, if, if the donor is fairly, the recipient is fairly stable, I, I would say I’m not very comfortable with that being said. They are very transparent, again, very often very aggressive, transparent programs that they really don’t seem to care much about the smoking history.

[00:49:30] As far as they have good mechanics on the ventilator are good bronchoscopy and the CT scan looks fine. They use it. And the reality is, with information that I don’t like to share with any patient, but even if you are a heavy smoker, the chance that you develop pulmonary diseases is less than 20%. So most of the smokers can smoke most of their life and they don’t develop emphysema or COPD is a percentage between 16 to 20%.

[00:49:58] So, so you can argue both ways. I say you have a normal CT, even if they smoke, you say, this is one of those places that smoking didn’t affect their lungs. Cause not everybody who smoke has bad lungs. Now the bronchoscopy, again, as I mentioned shortly, the presentation and you have somebody with a heavy smoking history and you get all of these black, B L uh, I can say probably they smoke a lot more than what you were told and in significant TRAC, obviously you can see that on heavily polluted areas with high contamination.

[00:50:29] You can see that, but somebody that is smoker, I will be careful with those ones. Okay, thank you very much.

[00:50:37] Deanna Host: Should donors automatically be covered in antifungals and antibiotics?

[00:50:42] Dr. Luis Angel, MD: Uh, my answer is again, and people can argue this, but I, I think that is a no brainer, antibiotics for sure. And my argument to everybody say, okay, these same lungs that you are just giving me.

[00:50:54] As soon as I received them, I’m gonna have them on antibiotics and you will help me if we have antibiotics in there. Many of these patients develop again, some type of pneumonias at the time of death, again, as a result of aspiration or as a result of being on the ventilator for few days, uh, if they have any infiltrate on the x-rays, the definitions and the recommendations from the critical society.

[00:51:20] And the infectious disease societies is, is that that’s a definition of ventilator associated pneumonia and all of them should be on antibiotics. So to me, everybody, unless that you say that has a pristine, absolutely clear chest x-ray that was intubated electively in the, or for some type of surgical resection and any reason, and that the x-rays are pristine.

[00:51:46] You may say, you know, again, probably there is no reason for antibiotics in that, but that’s where minority of patients, most of them are gonna have an abnormal x-ray when the report is gonna say, we cannot define, but it is pneumonia. And if you see a report like that, all of those should be an antimicrobials.

[00:52:06] Antifungus is a different situation. That’s the value. The bronchoscopy be too. If you don’t find fungal particles again, or your ear like candy was per or crypto, any other type of fungus on the B, there is no reason for the actual donors to be on antifungal.

[00:52:24] Deanna Host: Thank you so much. Another question asks, what are your thoughts on proning all donors?

[00:52:30] Dr. Luis Angel, MD: Okay. Uh, many of you may not like this answer, but I’m gonna explain my argument about this. My answer is, and my answer is no, uh, because I’m never gonna prone one of my recipients. And if I need to get lungs that have to be promoted to function, uh, those lungs have a significant problem. And my goal, when I go through all of these education, uh, sessions about organ donation for lungs, our goal, when we do all of these donor management is to provide good lungs.

[00:53:07] To a donor effort to our recipient from a donor. So we want to give this recipient lungs that we feel that are good lungs. And to me, good lungs are lungs that have this good PFR ratio that are fairly compliant on the ventilator. Relatively easy to ventilate. Maybe that we’re hard to ventilate when we start the case, but the end, when we diuresis the pacing release, all the mucus plugin, improve the SIS to carry some of the pneumonia.

[00:53:37] At the end, you have lungs that with a tidal volume of 500, 550 have peak pressures in the low twenties and the nine again, 1819 with a peep of eight to 10, you have great API tube. Those are no prone lungs. So if in some point again, you want to be very aggressive at the early management of the donor and do some proning and stuff like that.

[00:54:01] You are welcome to do it, but by the time that you are offering these lungs, you have to say, these lungs do extremely well under supine conditions because that’s the way that our receiving is gonna be. And this again goes into this, APRB and all of those that, again, we receive a lot of donors from one of the OPOs that does a lot of APRB and they cannot change the model to do APRB.

[00:54:25] Our recipients are not on APRB. Our recipients are in conventional ventilation with pressure control, with normal settings or volume control. And there is standard ventilation because that’s what we want to provide them, lungs are easy to ventilate. And if you need to do PRB reverse ratios one to one and things like that, it is not the idea.

[00:54:48] So I’m not trying to just make a bylaw, looks good to get a transplant program, to take it for the, just for the point to just place in organs. All we are trying to do is say this lung has the potential to be a good donor. Let’s do all of these things that we are mentioning in fluid management, recruitment, ventilator management, bronchoscopy, put all together to be at the end, when we are offering these lungs – lungs, that we feel fairly comfortable for that.

[00:55:15] So, unfortunately, again, I just give you a very long answer, but to me, I don’t like it, unless when, if you want to do it early, it’s fine. If the way doing protein before is fine. But by the time that you are offering these lungs, patients should be under relatively standard mechanical ventilation. We prefer pressure controlling our OPOs.

[00:55:35] You want to do volume control. You can still do it with a good peep, minimal peep of eight. And if you have good lungs with that, all the numbers should be looking okay. The x-ray should be acceptable. And none of these reverses proning and things like that, there is somebody again from the OPOs that do PRB, I’m sure that they a hundred percent disagree with me, but that’s okay too.

[00:55:58] We don’t have to agree in every aspect of organ.

[00:56:02] Deanna Host: Thank you so much. I think we have time for one more question. And so if we didn’t get to your question today, don’t worry. We’ll be sure to answer all of those in a follow up email or blog post. So for our last question, Dr. Angel, do you perform bronchoscopy on only brain dead donors or DCD cases as well?

[00:56:24] Dr. Luis Angel, MD: That again, obviously, we do in the disease donors, that’s what we do. And we try to do multiple bronchoscopies as possible. Uh, the, the DCS are a little bit more complicated because, this is a different philosophy in, in different hospitals. Again, our lung donor management, uh, donor management center here at the NYU, we have a lot of patients who are transferred.

[00:56:52] Some of those patients are being transferred for DCD organ donation when there is a family or somebody that is fully committed to organ donation, even on DCDs. So when they come here, we implement all the donor management protocols and we do bronchoscopies in those. And we don’t have any issue because we understand they come to our center because they really want to maximize the potential of organ donation.

[00:57:18] And when we talk to the families, we say, we’re gonna do some procedure. They are not gonna affect a lot of the care, and it’s not gonna again, change the fact that we are gonna do the, again, remove all the support to the patient, but we want to maximize these things. So we bronchoscopy is on those patients on those DCS.

[00:57:36] However, in many of our hospitals, even in our same OPO, uh, we are not even allowed to touch those donors even to do any recruitment, to do again, any management. And then in those we don’t do, bronchoscopy.

[00:58:09] Laura Carroll: Great. Well, thank you everyone, especially Dr. Angel. Absolutely incredible information. The presentation, the data, absolutely everything I think we could stay on with you for hours and hours. I just want to echo what Dr. Angel says of all of you after doing the, all the really hard work in organ donation.

[00:58:29] I know that the other group of our doctors that work with many of you have probably talked to many of you in the middle of the night, holidays, weekends. So just, you know, remember we’re all here to assist you. A quick programming note, if you will, we’re gonna continue these series. The next one is gonna be heart caths and the importance of donor management.

[00:58:51] So any of you that are on this list will make sure you get the invite. That’ll be towards the end of August. But again, we will continue the whole bronchoscopy conversation following up in more webinars like this with Dr. Angel. And again, we just can’t thank you enough for joining us, everyone in, in all the work that you do.

[00:59:10] And, and again, thank you so much, Dr. Angel and we’ll send out the information soon. Thank you.

[00:59:16] Dr. Luis Angel, MD: Well, thank you. And it’s incredible to have so many people listening to this, which is very encouraging. Uh, again, it’s so important lung management. Uh, I, I think that for all of your organizations, this always this feeling of accomplishment, when you have a donor in which you can procure lungs and seeing again, so many of you just willing to listen and hear my presentation is very encouraging and best luck to everybody.