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Ali A, Pettenuzzo T, Ramadan K, Farrell A, Di Nardo M, Liu M, Keshavjee S, Fan E, Cypel M, Del Sorbo L. Surfactant therapy in lung transplantation: A systematic review and meta-analysis. Transplant Rev (Orlando) 2021; 35:100637. [PMID: 34224988 DOI: 10.1016/j.trre.2021.100637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite numerous reports demonstrating the efficacy of exogenous surfactant therapy during lung transplantation, this strategy remains absent in routine clinical use. Here, we systematically review and meta-analyze the effect of exogenous surfactant on respiratory pathophysiological variables during lung transplantation. METHODS To identify relevant clinical and pre-clinical studies, we performed an electronic search of MEDLINE, EMBASE, and Cochrane CENTRAL from inception to June 11, 2021. In addition, research-in-progress databases were searched. Randomized and non-randomized adult and pediatric clinical studies and animal experiments that compared the use of surfactant for lung transplantation with a control group were included. The primary outcome was the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio). RESULTS From 1,041 citations, we identified 35 studies, of which 6 were clinical studies and 29 were pre-clinical. Thirty-two studies were included in the quantitative analysis. The administration of surfactant therapy during clinical lung transplantation significantly improved PaO2/FiO2 ratio in recipients (mean difference [MD] 93 mmHg, 95% confidence interval [CI] 25-160 mmHg, p < 0.01). Similar results were seen in pre-clinical settings (MD 201 mmHg, 95% CI 145-256 mmHg, p < 0.01). Moreover, surfactant benefited a range of important physiologic and biologic outcomes after preclinical lung transplantation. The overall certainty of evidence was very low. CONCLUSIONS Exogenous surfactant therapy improves post-transplant lung function; however, its effects on clinical outcomes remain uncertain. High-quality randomized controlled trials are needed to determine whether the physiologic benefits of surfactant therapy affect patient-important outcomes in lung transplant recipients.
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Affiliation(s)
- Aadil Ali
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, MaRS Discovery District, 101 College St, Toronto, Ontario M5G 1L7, Canada.
| | - Tommaso Pettenuzzo
- Interdepartmental Division of Critical Care Medicine, University Health Network, University of Toronto, 204 Victoria Street, Toronto, Ontario M5B 1T8, Canada.
| | - Khaled Ramadan
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, MaRS Discovery District, 101 College St, Toronto, Ontario M5G 1L7, Canada.
| | - Ashley Farrell
- Library & Information Services, University Health Network, 101 College St, Toronto, Ontario M5G 1L7, Canada.
| | - Matteo Di Nardo
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, MaRS Discovery District, 101 College St, Toronto, Ontario M5G 1L7, Canada.
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, MaRS Discovery District, 101 College St, Toronto, Ontario M5G 1L7, Canada.
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, MaRS Discovery District, 101 College St, Toronto, Ontario M5G 1L7, Canada; Division of Thoracic Surgery, University Health Network, University of Toronto, 200 Elizabeth St, Toronto, Ontario, M5G 2C4, Canada.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University Health Network, University of Toronto, 204 Victoria Street, Toronto, Ontario M5B 1T8, Canada.
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, MaRS Discovery District, 101 College St, Toronto, Ontario M5G 1L7, Canada; Division of Thoracic Surgery, University Health Network, University of Toronto, 200 Elizabeth St, Toronto, Ontario, M5G 2C4, Canada.
| | - Lorenzo Del Sorbo
- Latner Thoracic Surgery Research Laboratories, University Health Network, University of Toronto, MaRS Discovery District, 101 College St, Toronto, Ontario M5G 1L7, Canada; Interdepartmental Division of Critical Care Medicine, University Health Network, University of Toronto, 204 Victoria Street, Toronto, Ontario M5B 1T8, Canada.
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Ischemia-Reperfusion Injury in Lung Transplantation. Cells 2021; 10:cells10061333. [PMID: 34071255 PMCID: PMC8228304 DOI: 10.3390/cells10061333] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 02/08/2023] Open
Abstract
Lung transplantation has been established worldwide as the last treatment for end-stage respiratory failure. However, ischemia–reperfusion injury (IRI) inevitably occurs after lung transplantation. The most severe form of IRI leads to primary graft failure, which is an important cause of morbidity and mortality after lung transplantation. IRI may also induce rejection, which is the main cause of mortality in recipients. Despite advances in donor management and graft preservation, most donor grafts are still unsuitable for transplantation. Although the pulmonary endothelium is the primary target site of IRI, the pathophysiology of lung IRI remains incompletely understood. It is essential to understand the mechanism of pulmonary IRI to improve the outcomes of lung transplantation. Therefore, we reviewed the state-of-the-art in the management of pulmonary IRI after lung transplantation. Recently, the ex vivo lung perfusion (EVLP) system has been clinically introduced worldwide. Various promising therapeutic strategies for the protection of the endothelium against IRI, including EVLP, inhalation therapy with therapeutic gases and substances, fibrinolytic treatment, and mesenchymal stromal cell therapy, are awaiting clinical application. We herein review the latest advances in the field of pulmonary IRI in lung transplantation.
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Seese L, Kilic A, Turbendian HK, Sanchez PG, Diaz-Castrillon CE, Morell VO. The Impact of Donor Asphyxiation or Drowning on Pediatric Lung Transplant Recipients. Transplantation 2021; 105:620-627. [PMID: 32301909 DOI: 10.1097/tp.0000000000003262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Donors with drowning or asphyxiation (DA) as a mechanism of death (MOD) are considered high risk in pediatric lung transplantation. We sought to evaluate whether recipients of DA donors had negatively impacted outcomes. METHODS Pediatric recipients recorded in the United Network for Organ Sharing registry between 2000 and 2019 were included. Primary stratification was donor MOD. Propensity matching with a 1:1 ratio was performed to balance the DA and non-DA MOD donor cohorts. Cox multivariable regression was used to determine the risk-adjusted impact of donor MOD. A subanalysis of the effect of lung allocation score was also evaluated. RESULTS A total of 1016 patients underwent bilateral lung transplantation during the study period, including 888 (85.6%) from non-DA donors and 128 (14.4%) from DA donors. Survival at 90 days, 1 year, and 2 years were similar in the matched and unmatched cohorts regardless of the donor MOD. Moreover, separate risk-adjusted analysis of drowning and asphyxiated donors was similar to other MOD donors at 30 days, 1 year, and 5 years. Similar survival findings persisted regardless of pretransplant lung allocation score. Although the rates of posttransplant stroke (1.0% versus 3.1%, P = 0.04) and the length of hospital stay (19 versus 22 d, P = 0.004) were elevated in the unmatched DA MOD recipients, these differences were mitigated after propensity matching. CONCLUSIONS This study evaluated the impact of DA MOD donors in pediatric lung transplant recipients and found similar rates of complications and survival in a propensity-matched cohort. These data collectively support the consideration of DA MOD donors for use in pediatric lung transplantation.
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Affiliation(s)
- Laura Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Harma K Turbendian
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, Wolfson Children's Hospital, Jacksonville, FL
| | - Pablo G Sanchez
- Division of Lung Transplantation, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Carlos E Diaz-Castrillon
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Victor O Morell
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, Wolfson Children's Hospital, Jacksonville, FL
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Kayawake H, Chen-Yoshikawa TF, Saito M, Yamagishi H, Yoshizawa A, Hirano SI, Kurokawa R, Date H. Protective Effects of a Hydrogen-Rich Preservation Solution in a Canine Lung Transplantation Model. Ann Thorac Surg 2020; 111:246-252. [PMID: 32649946 DOI: 10.1016/j.athoracsur.2020.05.076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/17/2020] [Accepted: 05/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Molecular hydrogen (H2) has protective effects against ischemia-reperfusion injury in various organs. Because they are easier to transport and safer to use than inhaled H2, H2-rich solutions are suitable for organ preservation. In this study, we examined the protective effects of an H2-rich solution for lung preservation in a canine left lung transplantation (LTx) model. METHODS Ten beagles underwent orthotopic left LTx after 23 hours of cold ischemia followed by reperfusion for 4 hours. Forty-five minutes after reperfusion, the right main pulmonary artery was clamped to evaluate the function of the implanted graft. The beagles were divided into two groups: control group (n = 5), and H2 group (n = 5). In the control group, the donor lungs were flushed and immersed during cold preservation at 4°C using ET-Kyoto solution, and in the H2 group, these were flushed and immersed using H2-rich ET-Kyoto solution. Physiologic assessments were performed during reperfusion. After reperfusion, the wet-to-dry ratios were determined, and histology examinations were performed. RESULTS Significantly higher partial pressure of arterial oxygen and significantly lower partial pressure of carbon dioxide were observed in the H2 group than in the control group (P = .045 and P < .001, respectively). The wet-to-dry ratio was significantly lower in the H2 group than in the control group (P = .032). Moreover, in histology examination, less lung injury and fewer apoptotic cells were observed in the H2 group (P < .001 and P < .001, respectively). CONCLUSIONS Our results demonstrated that the H2-rich preservation solution attenuated ischemia-reperfusion injury in a canine left LTx model.
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Affiliation(s)
- Hidenao Kayawake
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Masao Saito
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Thoracic Surgery, Shimada Municipal Hospital, Shimada, Japan
| | - Hiroya Yamagishi
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiko Yoshizawa
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | | | | | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Spratt JR, Mattison LM, Kerns NK, Huddleston SJ, Meyer L, Iles TL, Loor G, Iaizzo PA. Prolonged extracorporeal preservation and evaluation of human lungs with portable normothermic ex vivo perfusion. Clin Transplant 2020; 34:e13801. [DOI: 10.1111/ctr.13801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/24/2020] [Indexed: 01/16/2023]
Affiliation(s)
- John R. Spratt
- Department of Surgery University of Minnesota Minneapolis Minnesota
| | - Lars M. Mattison
- Department of Surgery University of Minnesota Minneapolis Minnesota
- Department of Biomedical Engineering University of Minnesota Minneapolis Minnesota
| | - Natalie K. Kerns
- Division of Cardiothoracic Surgery Department of Surgery University of Minnesota Minneapolis Minnesota
| | - Stephen J. Huddleston
- Division of Cardiothoracic Surgery Department of Surgery University of Minnesota Minneapolis Minnesota
| | | | - Tinen L. Iles
- Department of Surgery University of Minnesota Minneapolis Minnesota
| | - Gabriel Loor
- Division of Cardiothoracic Surgery Department of Surgery University of Minnesota Minneapolis Minnesota
- Division of Cardiothoracic Transplantation and Circulatory Support Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston Texas
| | - Paul A. Iaizzo
- Department of Surgery University of Minnesota Minneapolis Minnesota
- Department of Biomedical Engineering University of Minnesota Minneapolis Minnesota
- Institute for Engineering in Medicine University of Minnesota Minneapolis Minnesota
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Spratt JR, Mattison LM, Iaizzo PA, Meyer C, Brown RZ, Iles T, Panoskaltsis-Mortari A, Loor G. Lung transplant after prolonged ex vivo
lung perfusion: predictors of allograft function in swine. Transpl Int 2018; 31:1405-1417. [DOI: 10.1111/tri.13315] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/06/2018] [Accepted: 07/04/2018] [Indexed: 12/11/2022]
Affiliation(s)
- John R. Spratt
- Department of Surgery; University of Minnesota; Minneapolis MN USA
| | - Lars M. Mattison
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
| | - Paul A. Iaizzo
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
- Department of Integrative Biology and Physiology; University of Minnesota; Minneapolis MN USA
- Institute for Engineering in Medicine; University of Minnesota; Minneapolis MN USA
| | - Carolyn Meyer
- Department of Pediatrics; University of Minnesota; Minneapolis MN USA
- Department of Medicine; University of Minnesota; Minneapolis MN USA
- Masonic Cancer Center; University of Minnesota; Minneapolis MN USA
| | - Roland Z. Brown
- Division of Biostatistics; University of Minnesota; Minneapolis MN USA
| | - Tinen Iles
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
| | - Angela Panoskaltsis-Mortari
- Department of Pediatrics; University of Minnesota; Minneapolis MN USA
- Department of Medicine; University of Minnesota; Minneapolis MN USA
- Masonic Cancer Center; University of Minnesota; Minneapolis MN USA
| | - Gabriel Loor
- Division of Cardiothoracic Surgery; Department of Surgery; University of Minnesota; Minneapolis MN USA
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Spratt JR, Mattison LM, Iaizzo PA, Brown RZ, Helms H, Iles TL, Howard B, Panoskaltsis-Mortari A, Loor G. An experimental study of the recovery of injured porcine lungs with prolonged normothermic cellularex vivolung perfusion following donation after circulatory death. Transpl Int 2017; 30:932-944. [DOI: 10.1111/tri.12981] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 03/31/2017] [Accepted: 05/05/2017] [Indexed: 12/14/2022]
Affiliation(s)
- John R. Spratt
- Department of Surgery; University of Minnesota; Minneapolis MN USA
| | - Lars M. Mattison
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
| | - Paul A. Iaizzo
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
- Department of Integrative Biology and Physiology; University of Minnesota; Minneapolis MN USA
- Institute for Engineering in Medicine; University of Minnesota; Minneapolis MN USA
| | - Roland Z. Brown
- Division of Biostatistics; University of Minnesota; Minneapolis MN USA
| | - Haylie Helms
- Department of Pediatrics; University of Minnesota; Minneapolis MN USA
- Department of Medicine; University of Minnesota; Minneapolis MN USA
- Masonic Cancer Center; University of Minnesota; Minneapolis MN USA
| | - Tinen L. Iles
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
| | - Brian Howard
- Department of Surgery; University of Minnesota; Minneapolis MN USA
- Department of Biomedical Engineering; University of Minnesota; Minneapolis MN USA
| | - Angela Panoskaltsis-Mortari
- Department of Pediatrics; University of Minnesota; Minneapolis MN USA
- Department of Medicine; University of Minnesota; Minneapolis MN USA
- Masonic Cancer Center; University of Minnesota; Minneapolis MN USA
| | - Gabriel Loor
- Division of Cardiothoracic Surgery; Department of Surgery; University of Minnesota; Minneapolis MN USA
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Hijiya K, Chen-Yoshikawa TF, Kondo T, Motoyama H, Ohsumi A, Nakajima D, Sakamoto J, Ohata K, Takahashi M, Tanaka S, Miyamoto E, Aoyama A, Date H. Bronchodilator Inhalation During Ex Vivo Lung Perfusion Improves Posttransplant Graft Function After Warm Ischemia. Ann Thorac Surg 2017; 103:447-453. [DOI: 10.1016/j.athoracsur.2016.07.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/03/2016] [Accepted: 07/25/2016] [Indexed: 11/25/2022]
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Levin K, Kotecha S, Westall G, Snell G. How can we improve the quality of transplantable lungs? Expert Rev Respir Med 2016; 10:1155-1161. [PMID: 27656957 DOI: 10.1080/17476348.2016.1240035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Optimization of lungs for organ donation is becoming increasingly important as donation rates stagnate despite growing waiting lists. Improving procurement and utilization of donated lungs has the ability to reduce mortality and time on the lung transplantation (LTx) waiting list. Additionally, assessment and optimization of donor lungs can reduce both early and late post-LTx morbidity and mortality, as well as reduce overall costs and resource utility. Areas covered: Strategies that we will discuss in detail include intensive care management practices, such as targeted ventilation protocols and therapeutic bronchoscopy, as well as the ever expanding possibilities within the arena of ex vivo lung perfusion (EVLP). Expert commentary: Donor lung quality is currently optimized both in vivo prior to organ procurement, and also via EVLP circuits. Despite good evidence demonstrating the utility of both approaches, data remain elusive as to whether EVLP is beneficial for all donor lungs prior to implantation, or instead as a tool by which we can evaluate and recondition sub-optimal donor lungs.
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Affiliation(s)
- Kovi Levin
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Sakhee Kotecha
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Glen Westall
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Gregory Snell
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
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Yamada T, Chen F, Sakamoto J, Nakajima D, Ohsumi A, Bando T, Date H. Impact of the cardiac arrest mode on cardiac death donor lungs. J Surg Res 2015; 195:596-603. [DOI: 10.1016/j.jss.2015.02.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/26/2015] [Accepted: 02/13/2015] [Indexed: 10/24/2022]
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Whitson BA, Hertz MI, Kelly RF, Higgins RS, Kilic A, Shumway SJ, D’Cunha J. Use of the Donor Lung After Asphyxiation or Drowning: Effect on Lung Transplant Recipients. Ann Thorac Surg 2014; 98:1145-51. [DOI: 10.1016/j.athoracsur.2014.05.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/04/2014] [Accepted: 05/07/2014] [Indexed: 10/24/2022]
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Lindstedt S, Pierre L, Hlebowicz J, Ingemansson R. Heparin does not seem to improve the function of pulmonary grafts for lung transplantation. SCAND CARDIOVASC J 2013; 47:307-13. [DOI: 10.3109/14017431.2013.825734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Protective effect of surfactant inhalation against warm ischemic injury in an isolated rat lung ventilation model. PLoS One 2013; 8:e72574. [PMID: 24009692 PMCID: PMC3757025 DOI: 10.1371/journal.pone.0072574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 07/09/2013] [Indexed: 12/29/2022] Open
Abstract
Warm ischemia-reperfusion injury remains a crucial issue in transplantation following the cardiac death of donors. Previously, we showed that surfactant inhalation during warm ischemia mitigated ischemia-reperfusion injury. This study investigated the mechanisms of surfactant inhalation protection of the warm ischemic lung after reoxygenation with ventilation alone. In an isolated rat lung ventilation model, cardiac arrest was induced in the CTRL (control) and SURF (surfactant treatment) groups by ventricular fibrillation. Ventilation was restarted 110 min later; the lungs were flushed, and a heart and lung block was procured. In the SURF group, a natural bovine surfactant (Surfacten®) was inhaled for 3 min at the end of warm ischemia. In the Sham (no ischemia) group, lungs were flushed, procured, and ventilated in the same way. Afterwards, the lungs were ventilated with room air without reperfusion for 60 min. Surfactant inhalation significantly improved dynamic compliance and airway resistance. Moreover, surfactant inhalation significantly decreased inducible nitric oxide synthase and caspase-3 transcript levels, and increased those of Bcl-2 and surfactant protein-C. Immunohistochemically, lungs in the SURF group showed weaker staining for 8-hydroxy-2′-deoxyguanosine, inducible nitric oxide synthase, and apoptosis, and stronger staining for Bcl-2 and surfactant protein-C. Our results indicate that surfactant inhalation in the last phase of warm ischemia mitigated the injury resulting from reoxygenation after warm ischemia. The reduction in oxidative damage and the inhibition of apoptosis might contribute to the protection of the warm ischemic lungs.
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