Can Better Donor Management Increase Lung Utilization? What a New Donor Care Unit Study Found

By Brooke Wallace, BSN, RN, CCRN ΓÇö founder of CPTCexam.com. ICU RN; previously worked as an Organ Procurement Coordinator and authored CPTC handbooks. CPTCexam.com is independent exam-prep and is not affiliated with or endorsed by ABTC.

The lungs you start with arenΓÇÖt always the lungs you recover

Anyone who has managed a lung donor knows this: the first ABG and the first chest X-ray are not destiny. Atelectasis, secretions, volume status, ventilator settings, and time all move the pictureΓÇösometimes a lot.

A new Journal of Heart and Lung Transplantation analysis from Stewart and colleagues looked at that reality in a structured way. Using OPTN data on donors recovered from March 2021 through December 2024, they compared propensity-weighted outcomes for donors managed at an in-hospital donor care unit (DCU) (n=334) versus those managed at the donor hospital (n=399). After adjustment, lung utilization was 88% higher with DCU management (adjusted risk ratio [aRR] 1.88; 95% CI 1.40ΓÇô2.53). Median PaO2/FiO2 (P/F) in the DCU group rose from 275 to 348 mmHg (p<0.0001), and that P/F change explained roughly 38% of the utilization improvement.

Important caveat: this is an observational association. It does not prove that transferring every donor to a DCU caused the improvement. Selection, logistics, staffing, and local culture all matter. Still, for OPCs in the field, the signal is practical: better, sustained donor lung management is linked to more transplantable lungsΓÇöwithout a clear trade-off in graft survival or pulmonary function in this study, and with non-lung organ utilization that was improved or non-inferior.

The authors also offered a national projection: if an 88% relative improvement were realized among donors who are not currently transferred to a DCU, that could theoretically mean ≥300 more lung transplants per year. Treat that as a ceiling estimate from modeling—not a guarantee for your DSA.

Full paper: https://doi.org/10.1016/j.healun.2026.08.026

What is a donor care unit (DCU)?

A donor care unit (sometimes called a specialized donor care facility or organ recovery center) is a dedicated settingΓÇöhospital-based or freestanding/independentΓÇöwhere authorized deceased donors can be transferred for focused ICU-level management and recovery. The idea is simple: remove competing hospital priorities, put experienced donor teams on the bedside, and run protocolized evaluation and optimization with easier access to imaging, bronchoscopy, labs, and OR time.

Not every OPO has one. Some have hospital-embedded DCUs; some have independent facilities; many still manage most or all donors in the referring hospital. Transfer decisions depend on donor stability, family logistics, geography, timing, and OPO capacity. A DCU is a tool, not a magic roomΓÇöwhat happens at the bedside still matters.

What the Stewart study found (at a glance)

Item Finding
Comparison In-hospital DCU management vs donor hospital (propensity-weighted)
Cohort OPTN donors recovered Mar 2021ΓÇôDec 2024; DCU n=334 vs hospital n=399
Adjusted lung utilization 88% higher with DCU (aRR 1.88; 95% CI 1.40ΓÇô2.53)
Median P/F in DCU 275 → 348 mmHg (p<0.0001)
Role of P/F change Explained ~38% of utilization improvement
Other organs Non-lung utilization improved or non-inferior
Recipient outcomes Lung graft survival and pulmonary function similar
National projection Theoretical ≥300 additional lung transplants/year if similar relative gain among non-DCU donors
Limit Observational ΓÇö association Γëá proven causation

Why lungs change during donor management

Brain death and ICU care are hard on lungs. Catecholamine surge and inflammation can drive neurogenic edema and capillary leak. Immobility, absent cough, and time on the ventilator invite atelectasis, mucus plugging, aspiration, and infection. Fluid shifts, DI, and vasoactive drugs change hemodynamics and extravascular lung water. None of that is ΓÇ£one ABG and done.ΓÇ¥

That is why lung-focused resuscitation literatureΓÇöseparate from the Stewart utilization analysisΓÇöemphasizes lung-protective ventilation, recruitment, secretion clearance/bronchoscopy, and thoughtful hormone/hemodynamic support as part of many specialized donor care models. Those associations come from clinical donor-management work (for example, Bery, Marklin, and colleaguesΓÇÖ review of the specialized donor care facility model), not as results claimed by Stewart. Your OPO protocol and accepting centers still call the shots.

Where the OPC actually moves the needle

You do not need a freestanding DCU to practice disciplined lung management. You do need a system and a habit. Frameworks that commonly appear in lung-focused donor resuscitation teaching (again: general OPC practice aligned with published specialized-facility experienceΓÇönot a Stewart protocol) include:

  • Ventilation: lung-protective tidal volumes often in the 6ΓÇô8 mL/kg (ideal body weight) range, appropriate PEEP, and avoidance of unnecessary high tidal volume stretchΓÇöguided by OPO protocol and ABG/CXR trends.
  • Airway hygiene: scheduled suctioning, chest PT as indicated, and bronchoscopy for assessment and clearance when secretions, plugs, or anatomic questions matter.
  • Fluid and hemodynamics: support perfusion without drowning the lungs; goal-directed thinking beats ΓÇ£keep dry at all costsΓÇ¥ or ΓÇ£bolus forever.ΓÇ¥ Follow your OPOΓÇÖs hemodynamic targets and transplant-center preferences.
  • Positioning and recruitment: turns, head-of-bed, and recruitment maneuvers per protocol when atelectasis is the storyΓÇönot as a one-size ritual.
  • Serial assessment: timed ABGs (including standardized P/F checks), CXR/CT when indicated, bronch findings, and honest charting of trends for offers. Lungs that improve over hours get a different conversation than lungs showing little response to optimization.

OPO protocols and transplant-center requirements vary. This is teaching context, not a rigid national protocol.

P/F ratio is usefulΓÇöand not the whole story

P/F (PaO2 ÷ FiO2) is the number everyone quotes on lung offers. Example: PaO2 100 mmHg on FiO2 0.40 → P/F = 250. Same PaO2 on FiO2 1.0 would be a P/F of 100—very different story. Always pair the number with vent settings, PEEP, timing after recruitment, secretions, and imaging.

StewartΓÇÖs analysis suggests oxygenation improvement tracked with a meaningful share (~38%) of the utilization differenceΓÇöbut utilization also reflects offer behavior, center appetite, anatomy, infection workup, and logistics. A rising P/F helps. It is not the entire case.

Hypothetical progression (illustrative only)

Illustrative example ΓÇö not study data: A DBD donor arrives with basilar atelectasis and a P/F around 180. Over the next many hours, the team optimizes lung-protective settings, clears secretions with bronch, recruits and rechecks ABGs after standardization, and steadies hemodynamics. Later ABGs show a P/F near 320 with a cleaner CXR. That trajectory is the kind of bedside story OPCs liveΓÇöand the kind of oxygenation change that, in aggregate observational data, tracks with higher utilization. Individual donors still get accepted or declined case by case.

A second lens: DCU availability at the OPO level (Yang et al.)

Stewart asks: what happens when this donor is managed in an in-hospital DCU versus the donor hospital? Yang and colleagues ask a different question in the American Journal of Transplantation (2026): is OPO-level DCU availability (none vs hospital-based vs independent) associated with lung utilization and graft survival?

Among DBD donors, unadjusted lung utilization rose stepwise:

  • DCU-negative: 24.4% (10,615/43,562)
  • Hospital-based DCU available: 27.8% (3,924/14,118)
  • Independent DCU available: 30.5% (4,608/15,111)

After adjustment, DBD odds remained higher versus no DCU: hospital-based OR 1.11 (95% CI 1.01ΓÇô1.22); independent OR 1.21 (95% CI 1.08ΓÇô1.36). Among DCD donors, after mixed-effects adjustment there was no significant DCU associationΓÇöa critical nuance if your DSA is growing DCD volume. Recipient graft survival was similar for DCU-positive versus DCU-negative OPOs (HR 1.03; 95% CI 0.96ΓÇô1.11)ΓÇöthat HR is a survival finding, not the DCD utilization result.

Do not mash these papers together. Yang is structural availability at the OPO level; Stewart is individual donor management setting. Both are observational. Together they suggest DCU capacity and lung-focused management culture often travel with higher DBD lung useΓÇöwithout a clear graft-survival penalty in these analyses.

Yang et al.: DOI 10.1016/j.ajt.2026.08.013 ┬╖ PMC13525923

The bigger question: more donors and better utilization

National lung transplant volume depends on authorization, donor identification, DCD growth, allocation policy, EVLP, and center behaviorΓÇönot DCU status alone. But utilization of the lungs you already have is still a stewardship problem. An observational signal of substantially higher adjusted utilization with in-hospital DCU management (aRR 1.88 in Stewart), plus stepwise DBD utilization where DCUs are available, pushes the field conversation toward: Can we deliver DCU-quality lung management more oftenΓÇöinside a DCU when transfer makes sense, and inside the donor hospital when it does not?

For new OPCs, that means learning the physiology, owning the serial assessment, and knowing when to escalate to medical director/transplant inputΓÇönot waiting for a building to teach you how to recruit a base.

Takeaways for new OPCs

  • Treat early lung numbers as a baseline, not a verdictΓÇötrack standardized P/F, imaging, and bronch findings over time.
  • Know your OPOΓÇÖs lung pathway: protective vent targets, recruitment rules, fluid/hemo goals, and when transfer to a DCU is on the table.
  • Read utilization papers with the design in mind: individual DCU management (Stewart) Γëá OPO DCU availability (Yang); DBD signals Γëá DCD signals.
  • Respect the limits: association is not causation; center acceptance still decides transplant.
  • Non-lung organs matter tooΓÇöStewartΓÇÖs non-lung findings were improved or non-inferior, which is the bar you want when advocating for aggressive lung work.

Donor management is still one of the most teachable, high-leverage skills in procurement. The new DCU data will not replace bedside judgmentΓÇöbut they reinforce why that judgment, practiced well and repeated, can change how many lungs leave the OR for a recipient instead of a pathology report.

If you are a new OPC building confidence in donor managementΓÇöor studying for the CPTC examΓÇöCPTCexam.com has free and structured prep materials, including CPTC exam study resources and the OPC Starter Pack ($200). Use what helps you manage the next donor better.

Field-honest donor management education from someone who has done the workΓÇöCPTCexam.com.

Sources

  1. Stewart DE, et al. Lung Utilization and Transplant Outcomes after Donor Management at an In-Hospital Donor Care Unit versus the Donor Hospital. J Heart Lung Transplant. 2026. doi:10.1016/j.healun.2026.08.026
  2. Yang Z, Liu CR, Wang X, et al. Donor Care Unit Availability and Organ Procurement Organization Performance in Lung Transplantation. Am J Transplant. 2026. doi:10.1016/j.ajt.2026.08.013. PMC: PMC13525923
  3. Bery A, Marklin G, Itoh A, et al. The Specialized Donor Care Facility Model and Advances in Management of Thoracic Organ Donors. Ann Thorac Surg. 2022;113(6):1778-1786. PMC: PMC8257761
  4. Chang SH, Kreisel D, Marklin GF, et al. Lung Focused Resuscitation at a Specialized Donor Care Facility Improves Lung Procurement Rates. Ann Thorac Surg. 2018;105(5):1531-1536.
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