Management of postoperative hypoxemia in pediatric patients with hepatopulmonary syndrome through ventilatory support strategies: a report of three cases

Objective: To describe the ventilatory management strategies used for the treatment of refractory hypoxemia in the postoperative period of liver transplantation in pediatric patients with hepatopulmonary syndrome, also considering postoperative complications, duration of ventilatory support, and length of stay in the intensive care unit Materials and methods: An observational, descriptive, retrospective, and longitudinal study was conducted. All pediatric patients with HPS who underwent liver transplantation at Garrahan Hospital (Argentina) during 2023 were included. Diagnosis was established according to the criteria of the International Liver Transplantation Society. Ventilatory strategies, use of inhaled nitric oxide, individualized titration of PEEP and FiO₂, assessment of respiratory effort, and use of non-invasive ventilatory support after extubation were analyzed. Results: The cohort included three patients aged 20 to 168 months. All required invasive mechanical ventilation for 4 to 15 days and iNO for 8 to 19 days. Post-extubation non-invasive ventilation was implemented in all cases, lasting 2 to 17 days, allowing safe transition to low-flow oxygen therapy without associated respiratory complications such as atelectasis or secretion retention. ICU stay ranged from 16 to 34 days. Different recovery patterns were identified, highlighting the importance of dynamic adjustment of PEEP and FiO₂ and close monitoring of respiratory muscle function. Conclusion: The implementation of stepwise strategies, including prolonged and adjusted use of inhaled nitric oxide, higher levels of PEEP and FiO₂, quantification of respiratory effort, and systematic use of post-extubation non-invasive ventilation, allowed optimization of oxygenation, prevention of severe respiratory complications, and guidance of ventilator weaning.