Lung Transplant

What is a Lung Transplantation?

Lung transplant, or pulmonary transplantation is a surgical procedure in which a Patient’s diseased lungs are partially or totally replaced by lungs which come from a donor. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for end-stage pulmonary Patients.

A doctor may recommend a lung transplant if you have disease that cannot be controlled any other way. These diseases include

  • COPD(chronic obstructive pulmonary disease)
  • Cystic fibrosis(CF)
  • Idiopathic pulmonary fibrosis
  • Interstitial lung diseases
  • Primary pulmonary hypertension

  • What does the respiratory system do?
  • What happens during Lung- transplantation?
  • What happens in Intensive Care?
  • Immunosuppression
  • Complications
  • How long will my loved one stay in Intensive Care?
  • Links

 
What does the Respiratory System do ?

The respiratory system consists of the lungs, airways and blood vessels. The respiratory system inhales oxygen into the body and exchanges oxygen by removing carbon dioxide from the body. A normal breath requires a complex coordination between the nervous system (brain & spinal cord) and the muscles of breathing (including the diaphragm and muscles between the ribs).

Abnormal and or inadequate breathing can occur as a result of:

  • An interruption to the nervous system (head injuries or spinal injuries for example)
  • Barriers to the absorption of oxygen (eg fluid or secretions in the alveoli);
  • Obstruction to the flow of gases through the lungs, both breathing in or out (eg asthma);
  • Damage to the rib cage such as rib fractures or flail chest(in motor vehicle trauma for example);
  • Pneumothorax(deflation of one part of the lung)
  • Haemothorax(infiltration with blood to parts of the lung)
  • Pain, which makes taking a normal breath difficult.

What happens during lung transplantation?

While the surgical details will depend on the type of transplant, many steps are common to all these procedures. Prior to operating on the recipient, the transplant surgeon inspects the donor lung(s) for signs of damage or disease. If the lung or lungs are approved, then the recipient is connected to an IV line and various monitoring equipment, including pulse oximetry. The Patient will be given general anesthesia, and a machine(Ventilators (Breathing Machines) will breathe for him or her.

It takes about one hour for the pre-operative preparation of the Patient. A single lung transplant takes about four to eight hours, while a double lung transplant takes about six to twelve hours to complete. A history of prior chest surgery may complicate the procedure and require additional time.

File:DoubleLungTransplantScar.jpg

Incision scarring from a double lung transplant

Single-lung transplantation

In single-lung transplants, the lung with the worse pulmonary function is chosen for replacement. If both lungs function equally, then the right lung is usually favored for removal because it avoids having to maneuver around the heart, as would be required for excision of the left lung.

In a single-lung transplant the process starts out after the donor lung has been inspected and the decision to accept the donor lung for the Patient has been made. An incision is generally made from under the shoulder blade around the chest, ending near the sternum. An alternate method involves an incision under the breastbone.In the case of a singular lung transplant the lung is collapsed, the blood vessels in the lung tied off, and the lung removed at the bronchial tube. The donor lung is placed, the blood vessels reattached, and the lung re-inflated. To make sure the lung is satisfactory and to clear any remaining blood and mucus in the new lung a Bronchoscopy will be performed. When the surgeons are satisfied with the performance of the lung the chest incision will be closed.

Double-lung transplantation

A double-lung transplant, also known as a bilateral transplant, can be executed either sequentially, en bloc, or simultaneously. Sequential is more common than en bloc.This is effectively like having two separate single-lung transplants done.

The transplantation process starts after the donor lungs are inspected and the decision to transplant has been made. An incision is then made from under the Patient’s armpit, around to the sternum, and then back towards the other armpit; this is known as a clamshell incision. In the case of a sequential transplant the recipients lung with the poorest lung functions is collapsed, the blood vessels tied off, and cut at the corresponding bronchi. The new lung is then placed and the blood vessels reattached. To make sure the lung is satisfactory before transplanting the other a Bronchoscopy is performed. When the surgeons are satisfied with the performance of the new lung, surgery on the second lung will proceed. In 10% to 20% of double-lung transplants the Patient is hooked up to a heart-lung machine which pumps blood for the body and supplies fresh oxygen.

What happens in Intensive Care?

  • After Lung Transplantation your loved one is admitted to the Intensive Care Unit.
  • Full ventilation using a Ventilators(Breathing Machine) and a Breathing Tube (endotracheal tube) will usually be required for up to 24 hours after surgery to improve and maintain the oxygen delivery, as your loved one is usually unable to breath for themselves immediately after surgery. The ventilator is usually “weaned off” over the next 12-24 hours, sometimes even quicker, after ensuring haemodynamic stability of your loved one is achieved. The process of weaning somebody off the ventilator my take longer in a Patient after lung-transplant, but can be quick as well. This depends on a number of factors, but Patients after lung-transplantation are at risk to be slowly weaned off the ventilator and they might require a Tracheostomy. If your loved one requires long-term ventilation with Tracheostomy please don’t be discouraged. It might take time. If you are looking for home care alternatives for long-term ventilated Adults& Children with Tracheostomy check out this link www.intensivecareathome.com.au
  • Sedation may be used for ventilator tolerance and if your loved one is in a medically induced coma. Common sedation used is Propofol and Morphine or Fentanyl. If your loved one is unstable and/o is showing signs of bleeding, sedation may be increased, in order to minimise further risk of bleeding and also to focus on haemodynamic stability first
  • Your loved one will require frequent Bronchoscopy‘s in the first few days
  • For pain control an Epidural Catheter might be used, as well as Morphine and/or Fentanyl
  • Your loved one will require monitoring using a Bedside Monitors and an Arterial Catheter(Arterial Line)
  • You can expect your loved one to have frequent Chest X-rays and blood tests(Blood& Pathology tests in Intensive Care) especially arterial blood gases (ABGs), testing the effectiveness of the ventilation
  • Infusion pumps are administering drugs to support your loved ones blood pressure and haemodynamic system, as well as intravenous fluids may be administered via a central venous catheter/ CVC(Central Venous Lines)
  • Use of a Pulmonary Artery Catheters or a PICCO catheter to closely monitor cardiac function is not uncommon.
  • An NG Tube (Nasogastric Tubes) is usually inserted into your loved ones stomach, in order to commence nutrition or to remove fluids
  • Urine Output is usually measured hourly, after insertion of a Urinary Catheter
  • An oxygen saturation probe attached to the your loved ones finger monitors the oxygen level in the blood continuously
  • Monitoring of the chest drains(Under Water Seal Drain & Chest Tube) coming out of your loved ones chest, to drain any excess fluids of the surgery site and also to monitor any bleeding
  • Abnormalities in heart rhythm usually require treatment
  • In some cases V-V(veno- venous) ECMO(Extracorporeal Membrane Oxygenation) may be commenced in order to give the new lungs a rest and let the body slowly adapt to the new lungs
  • Strict blood pressure control is achieved by medications infused via rate-controlled pumps. Fluid is also given intravenously at first to treat low blood pressure
  • Body temperature is monitored. A blanket filled with warm air may be used to bring the body temperature back to normal

If you are visiting your loved one in the Intensive Care Unit at this stage you should expect to see many lines, tubes, and drains attached to your loved one.

Immunosuppression

Immunosuppression remains the mainstay of therapy for successful outcomes after lung transplantation. The need for optimal immunosuppression became evident to maintain long-term survival and to navigate the delicate balance between infection and rejection.

Main drugs used for immunosuppression in lung transplants are

  • Cyclosporine is an immunosuppressant drug widely used in organ transplantation to prevent rejection
  • Tacrolimus is an immunosuppressive drug that is mainly used after allogeneic organ transplant to reduce the activity of the Patient’s immune system and so lower the risk of organ rejection
  • Azathioprine (AZA) and Mycophenolate mofetil (MMF) are the antiproliferative agents used commonly after heart transplantation. Azathioprine is used alone or in combination with other immunosuppressive therapy to prevent rejection following organ transplantation. Mycophenolate is a less toxic alternative to azathioprine
  • Corticosteroids (Steroids) such as Hydrocortisone and Methylprednisolone. Steroid therapy is a standard component of induction, maintenance, and antirejection therapy in lung transplant recipients. High-dose steroids are generally administered intraoperatively and postoperatively with gradual weaning of doses over months
  • Everolimus is currently used as an immunosuppressant to prevent rejection of organ transplants and treatment of renal cell cancer and other tumours

Complications

  • Rejection is the most common complication following transplant surgery. It happens when the immune system, which defends the body against foreign agents such as viruses or bacteria, treats a transplanted organ as foreign and tries to attack it. To prevent your body from rejecting your new lung, you will take medications called immunosuppressants which lower your immunity or defense against foreign agents
  • Infection. A lung transplant recipient will be more susceptible to infection because he or she will take immunosuppressant medications to help prevent rejection. The risk of infection from bacteria, viruses, and fungi are greatest in the early period after transplant when dosages of medicines are at their highest
  • Chronic lung rejection(bronchiolitis obliterans syndrome or BOS). It is the most common late complication of lung transplant. Chronic lung rejection is an inflammatory disorder of the small airways, leading to obstruction and destruction of pulmonary bronchioles. Chronic lung rejection affects up to 50 percent of lung transplant Patients within five years of the transplant and is perhaps the main impediment to prolonged survival. Patients who suffer from chronic lung rejection often require readmission to hospital and most often end up in Intensive Care for mechanical ventilation(Ventilators (Breathing Machines) with Tracheostomy. If your loved one ends up with long-term Tracheostomy ventilation in Intensive Care and has no or little Quality of Life, check out www.intensivecareathome.com.au for alternative options and Quality of Life for you and your Family at home
  • Hypertension(High blood pressure). Many transplant recipients take blood pressure medications, since prednisone and cyclosporine, two of the medications used to limit rejection, can raise blood pressure
  • Some of the immunosuppressant medications that you take may increase your chance of developing diabetes. Diabetes is an increased level of sugar in your blood. Signs of diabetes include excessive thirst, frequent urination, blurred vision, drowsiness, or confusion
  • Cytomegalovirus (CMV) is a very common virus. About 70 percent of adults have been exposed to CMV at some time. It usually causes a flu-like illness with fever, body aches, and decreased appetite for two or three days. After exposure to the CMV virus, antibodies form in your blood to protect you from future exposures to CMV. This is similar to what happens after you have chickenpox. Because of the immunosuppressant medications, your loved one will be at risk for CMV infection after transplant. During the first few months, while the immunosuppressant doses are highest and your immune system is especially weak, the CMV virus can reactivate or “wake up”. Blood tests are performed to check both the transplant recipient and donor for the presence of CMV antibodies.

 
How long will my loved one stay in Intensive Care?

The length of stay in Intensive Care after Lung-Transplantation ranges from 1 or two days after an uncomplicated and straight forward procedure and recovery, up to many weeks and sometimes many months in Intensive Care, especially if your loved one requires mechanical ventilation with Ventilators (Breathing Machines) and with Tracheostomy.

Long-term ventilation with Tracheostomy leaves you loved one with little Quality of Life and/or Quality of-end-of-Life in Intensive Care and you might think about other options for your lovedone and your Family. Having your loved one at home whilst ventilated with Tracheostomy is possible, check out www.intensivecareathome.com.au

Links
http://www.transplant.org.au/Why-people-need-transplants.html  Transplant Australia

http://www.ahlta.com.au/site/index.cfm  Australian Heart/Lung Transplants association

http://www.organdonor.gov  U.S. Government Information on Organ and Tissue Donation and Transplantation

http://www.organdonation.nhs.uk/    Organ donation in the United Kingdom

Any Questions?
Of course, if you have any questions or concerns, please discuss them with the ICU nurses and doctors.

All Intensive Care interventions and procedures carry a degree of potential risk even when performed by skilled and experienced staff. Please discuss these issues with the medical and nursing staff who are caring for your loved one.

The information contained on this page is general in nature and therefore cannot reflect individual Patient variation. It is meant as a back up to specific information which will be discussed with you by the Doctors and Nurses caring for your loved one. INTENSIVE CARE HOTLINE attests to the accuracy of the information contained here BUT takes no responsibility for how it may apply to an individual Patient. Please refer to the full disclaimer.

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