Early vs. Late Extubation After Bilateral Lung Transplantation: Predictors and Outcomes
Nicolò Sella, Sabrina Congedi, Francesco Monteleone, Angela Bianco, Giordana Coniglio, Alice Perazzolo, Irene Paiusco, Anna Michielin, Giulia Fichera, Gabriella Roca, Silvia Piovesan, Luisa Muraro, Arianna Peralta, Gaia Furlan, Giorgia Pacchiarini, Francesco Zarantonello, Tommaso Pettenuzzo, Fausto Braccioni, Chiara Giraudo, Eleonora Faccioli, Roberto Stramare, Andrea Vianello, Andrea Dell’Amore, Annalisa BoscoloBackground: Early extubation after bilateral lung transplantation (LT) may reduce intensive care unit (ICU) complications, but evidence from heterogeneous real-world cohorts and of its impact on mid-term functional recovery remains limited. Methods: We conducted a single-centre observational study of 149 consecutive adult bilateral LT recipients (February 2016–February 2023). Patients extubated within 24 h were assigned to the early extubation (EE) group (n = 63, 42%) (extubated within 24 h of the end of surgery), while those extubated later comprised the late extubation (LE) group (n = 86, 58%) (extubated beyond 24 h). Multivariable logistic regression identified predictors of late extubation. Outcomes included postoperative extracorporeal membrane oxygenation (ECMO), pneumonia, ICU length of stay, and spirometric parameters at 9–12 months after LT. Results: Higher Lung Allocation Score (LAS; adjusted OR 1.19, 95% CI 1.02–1.38) and intraoperative red blood cell (RBC) transfusions (adjusted OR 1.47, 95% CI 1.04–2.06) independently predicted late extubation. Compared with the LE group, EE recipients required less postoperative ECMO (2% vs. 23%; p = 0.008), had shorter inhaled nitric oxide treatment (7 vs. 17 h; p = 0.006), lower pneumonia rates (8% vs. 23%; p = 0.043), and shorter ICU stays (6 vs. 9 days; p = 0.005). In-hospital and 1-year mortality were similar between groups. At 9 ± 1 months, EE recipients showed better volumetric lung recovery, with higher FVC as a percentage of pre-transplant baseline (78.0% vs. 69.5%; p = 0.048) and higher TLC percentage predicted (77% vs. 68%; p = 0.015). Airflow indices and respiratory muscle strength did not differ. Conclusions: In a broadly inclusive LT cohort, higher LAS and intraoperative RBC transfusion independently predicted late extubation. Early extubation was associated with lower postoperative support requirements and was associated with higher FVC relative to pretransplant baseline, an association that should be interpreted in light of the unadjusted comparison and baseline heterogeneity rather than as evidence of a causal benefit.