I. INTRODUCTION
It has been over 50 years since the first human lung transplant was performed by Hardy and colleagues at the University of Mississippi in 1963.1
The donor died from a myocardial infarction and the donation after cardiac death (DCD) lungs were transplanted into the recipient who succumbed 18 days later of renal failure. Similar to the experiences of other solid organ transplant pioneers, dismal outcomes resulted in slow progress.2,3
It took another 20 years before the Stanford group performed the first successful heart-lung transplant in 1981.4
Subsequently in 1983, the Toronto Lung Transplant Group reported the first successful single-lung transplant.5
In 1993, the University of Wisconsin team reported the first successful lung transplant using a DCD lung.6
These noteworthy events led to a series of clinical advances in the area of lung transplantation, including improved selection criteria, implementation of the lung allocation score (LAS), refined surgical techniques, advancements in immunosuppression, and avoidance of steroids immediately postoperatively.7,8,9,10,11
Three decades later, lung transplantation has become an established treatment of choice for selected patients with a variety of end-stage lung diseases, leading to increased survival and improvement in quality of life.
Remarkable progress continues to evolve with improved understanding of transplant immunology, microbiology, and pathology. Surgeons continue to explore opportunities to improve techniques such as the omentopexy, bronchial wrap, or telescoping or end-to-end anastomosis, which result in fewer airway-related complications.12
FIGURE 11-1 Adult lung transplant survival (Transplants: January 1990-June 2012). These survivals are estimates as some patients were lost to follow-up. (Data retrieved from ISHLT registry. Yusen RD, Edwards LB, Kucheryavaya AY, et al. The registry of the international society for heart and lung transplantation: thirty-first adult lung and heart-lung transplant report—2014; focus theme: retransplantation. J Heart Lung Transplant. 2014;33(10):1009-1024.)
For adults, recent unadjusted survival rates are 80% and 53% at 1 and 5 years, respectively. Median survival is 5.6 years (Figure 11-1).13
Despite these improvements in short- and intermediate-term survival, long-term survival of lung transplant recipients is less than that of other solid organ transplant recipients. Survival is limited by the prevalence of chronic allograft rejection, known as bronchiolitis obliterans syndrome (BOS), and by the worldwide shortage of donor organs, which leads to mortality rates on the waiting list of approximately 8% to 10%.13,14
II. INDICATIONS AND CONTRAINDICATIONS FOR LUNG TRANSPLANT
Patients with chronic, end-stage lung disease and who meet all of the following criteria should be considered for lung transplantation per 2014 International Society for Heart and Lung Transplant (ISHLT) consensus guidelines.15
High (>50%) risk of death from lung disease within 2 years if lung transplant is not performed.
High (>80%) likelihood of surviving at least 90 days after lung transplantation.
High (>80%) likelihood of 5-year posttransplant survival from a general medical perspective, provided that there is adequate graft function.
Diseases currently accepted as indications for lung transplantation (single or bilateral) or a combined heart and lung transplant (HLT) are listed in Table 11-1.13,15
TABLE 11-1 Diseases Treated by Lung Transplantation
Diagnosis
SLT (N = 15,321)
BLT (N = 26,579)
HLT (N = 3,255)
COPD/emphysema
6,594 (43.0%)
7,078 (26.6%)
141 (4.3%)
Idiopathic pulmonary fibrosis
5,354 (34.9%)
4,825 (18.2%)
121 (3.7%)
Cystic fibrosis
234 (1.5%)
6,628 (24.9%)
459 (13.9%)
Alpha-1
771 (5.0%)
1,572 (5.9%)
62 (1.9%)
Idiopathic pulmonary arterial hypertension
92 (0.6%)
1,158 (4.4%)
907 (27.4%)
Pulmonary fibrosis, others
677 (4.4%)
970 (3.6%)
121 (3.7%)
Bronchiectasis
62 (0.4%)
1,069 (4.0%)
30 (0.9%)
Sarcoidosis
280 (1.8%)
776 (2.9%)
54 (1.6%)
Retransplant: obliterative bronchiolitis
312 (2.0%)
379 (1.4%)
24 (0.7%)
Connective tissue disease
177 (1.2%)
409 (1.5%)
n/a
Obliterative bronchiolitis (not retransplant)
105 (0.7%)
351 (1.3%)
25 (0.8%)
LAM disease
138 (0.9%)
302 (1.1%)
n/a
Retransplant: not obliterative bronchiolitis
205 (1.3%)
227 (0.9%)
32 (1%)
Congenital heart disease
58 (0.4%)
291 (1.1%)
1,178 (35.5%)
Cancer
7 (0.0%)
29 (0.1%)
n/a
Others
255 (1.7%)
515 (1.9%)
101 (3%)
Data collected from ISHLT registry: 1995-2013.
Adapted from Yusen RD, Edwards LB, Kucheryavaya AY, et al. The registry of the international society for heart and lung transplantation: thirty-first adult lung and heart-lung transplant report—2014; focus theme: retransplantation. J Heart Lung Transplant. 2014;33(10):1009-1024.
Chronic obstructive pulmonary disease (COPD); approximately 33% of patients
Idiopathic pulmonary fibrosis (IPF); approximately 24% of patients
Cystic fibrosis (CF); approximately 16% of patients13
The number of combined HLTs continues to decline.13
The highest number of HLTs was approximately 170 cases in 1994 and 1995, out of a total of approximately 1,200 lung and heart-lung transplant procedures worldwide.
Since 1999, the number of HLTs has declined overall; however, since 2003, the number appears to have stabilized between 62 and 94 procedures per year.
As of 2012, only 75 HLTs out of a total of approximately 3,000 lung and heart-lung transplant procedures were performed worldwide.
Congenital heart disease (CHD), pulmonary arterial hypertension (PAH), and CF remain the most common indications (see Table 11-1).
Contraindications to lung transplantation:
In 2014, selection criteria were updated by the ISHLT to standardize the selection process and to provide evidence-based guidelines.15
See Tables 11-2 and 11-315,16 for detailed criteria concerning medical conditions that may have an impact on transplant selection eligibility for and contraindications to lung transplantation.
TABLE 11-2 Medical Conditions Impacting Lung Transplantation Eligibility
Colonization of respiratory tract with fungi or atypical mycobacterium
Requirement of mechanical ventilation
Previous thoracotomy, sternotomy, pneumonectomy, or extensive pleural scarring
Active infection/sepsis
Active or recent malignancy/cancer
Substance abuse or addiction
Cigarette smoking within 4-6 mo of activation on the waiting list
Irreversible left heart failure
Severe osteoporosis (e.g., symptomatic compression fractures)
Severe musculoskeletal disease
Malnutrition: <70% or >130% of ideal body weight
Psychosocial problems that place patient at high risk of poor outcome
Severe, untreated psychiatric disease
Data from Weill D, Benden C, Corris P, et al. A consensus document for the selection of lung transplant candidates: 2014 an update from the pulmonary transplantation council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34(1):1-15; Kreider M, Hadjiliadis D, Kotloff RM. Candidate selection, timing of listing, and choice of procedure for lung transplantation. Clin Chest Med. 2011;32(2):199-211.
Upper age limits for lung or heart-lung transplantation
Selection of patients colonized or infected with antibiotic-resistant organisms
Selection of patients with a history of nonadherence or with limitations due to physical conditions
Lack of reliable social support
TABLE 11-3 Absolute Contraindications to Lung Transplantation | ||||
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III. PATIENT REFERRAL AND EVALUATION OF POTENTIAL CANDIDATES
Medical information is sent to the transplant center for review.
The patient is then scheduled for a clinic visit to determine
Whether the patient does indeed have end-stage disease
If the patient has any conditions that may preclude lung transplantation
Timing of the referral is one of the most important aspects in lung transplantation.
Referrals that are late in the disease process may result in the patient being too sick for transplantation.
Careful consideration of the natural history and prognosis of the underlying primary disease is crucial in this decision process.16,19
Attention should be given to
The patient’s age at time of referral
Associated consequences of the lung disease on other organ systems
Current physical condition
Waiting time on the list for donor lungs or combined heart-lungs must be factored into the decision regarding the timing of referral.
Per 2012 Organ Procurement and Transplantation Network (OPTN) data, 12.7% of patients waiting had an LAS of 50% to 100%, and 65% of patients were transplanted within 1 year of listing.22 Data accessed on October 1, 15 from www.optn.transplant.hrsa.gov/.
Per Scientific Registry of Transplant Recipients (SRTR) data, 2014 waitlist mortality was 13.3%.23
Referring a patient late in the disease process state or at an older age may prevent the patient from being listed for transplantation. Older adults have difficulty enduring prolonged wait times, and this may lead to an increased waitlist mortality or removal from the list due to a deterioration in health if they become “too sick to transplant.” Blood type and HLA reactivity may also lead to prolonged wait times and higher waitlist mortalities.16
Patient referrals can also come from another transplant center when dual listing is advantageous to the patient. The United Network for Organ Sharing (UNOS) mandates that patients are informed of the right to be dual listed, as this may provide more opportunities for organ offers and expedite transplantation. Potential dual listing may be recommended for patients with
Elevated HLA antibodies
Worsening disease progression
Uncommon size
Adequate health care insurance
Prior approval from insurance company is typically required.
IV. TRANSPLANT EVALUATION
Tests are tailored to the patient’s specific lung disease.
The purpose of this evaluation is to
Ensure that the individual meets medical and psychosocial eligibility criteria for transplantation
Minimize the risk associated with the transplant surgery
The evaluation is typically done as an outpatient and takes 3 to 5 days to complete. It consists of
Objective measures of end-stage organ failure
Psychosocial assessment, including, but not limited to
Cognitive functioning
Psychiatric disorders
Substance abuse
Informed consent is obtained from the patient to proceed with the evaluation after comprehensive patient education is provided regarding the nature and rationale for all tests, procedures, and consults. Refer to the Patient Education chapter for additional information.
TABLE 11-4 Evaluation Protocol for Lung Transplantation
General
Vital signs
Height, weight, body mass index
Functional level
Lab tests/blood chemistries
Liver function tests (bilirubin, aspartate aminotransferase; alanine transaminase, and alkaline phosphatase)
Blood urea nitrogen, creatinine, and estimated glomerular filtration rate
Calcium
Phosphorus
Magnesium
Serum electrolytes
Fasting lipid profile
Stool for heme (×3), or recent colonoscopy
Prostate-specific antigen (males)*
Beta-hCG (females)
Hematology and coagulation profile
Complete blood cell count with differential and platelet count
Prothrombin time (or international normalized ratio) and partial thromboplastin time
Urine tests
Urinalysis
24-Hour urine for creatinine clearance
24-Hour urine for protein if diabetic or if urinalysis positive for protein*
Scans
Ventilation-perfusion scan (V-Q scan)*
Computed tomography scan with high resolution to chest
Radiology and ultrasound
Consultations and evaluations
Pulmonary
Pulmonary function testing with arterial blood gases
Six-minute walk (at most centers)
Cardiopulmonary exercise test (CPET)* optional test
– Measure as oxygen uptake and abbreviated as VO2
– VO2 ≤ 8.3 mL/kg/min is associated with increased mortality risk
Cardiovascular
Electrocardiogram
Two-dimensional echocardiogram with Doppler study
Right heart catheterization with detailed hemodynamic evaluation
Left heart catheterization with coronary angiography*
Immunology
ABO blood type and antibody screen
Panel-reactive antibody screen
Human leukocyte antigen typing (if listed for transplantation)
Digestion and gastrointestinal
Barium swallow or esophagram
pH probe testing and manometry
Gastric emptying study
Infectious disease screening Serologies for:
Hepatitis virus A, B, and C
Herpes simplex virus
Human immunodeficiency virus
Cytomegalovirus (CMV)
Toxoplasmosis
Varicella virus
Rubella
Epstein-Barr virus
Venereal disease research laboratory
Lyme titers*
Histoplasmosis
Cultures
Skin test
Purified protein derivative skin test with controls (i.e., mumps, dermatophytin, histoplasmosis, and coccidioidomycosis) or QuantiFERON Gold, a blood test to screen for exposure to tuberculosis
Vaccinations
Hepatitis A and B series
Pneumovax every 5 y
Influenza vaccine each fall
Consider shingles vaccine and measles, mumps, and rubella for age-appropriate, nonimmunocompromised candidates.
* Only performed if appropriate or indicated.
From Weill D, Benden C, Corris P, et al. A consensus document for the selection of lung transplant candidates: 2014 an update from the pulmonary transplantation council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34(1):1-15; Kreider M, Hadjiliadis D, Kotloff RM. Candidate selection, timing of listing, and choice of procedure for lung transplantation. Clin Chest Med. 2011;32(2):199-211; Dudley KA, El-Chemaly S. Cardiopulmonary exercise testing in lung transplantation: a review. Pulm Med. 2012;2012:237852.
TABLE 11-5 Objective Measures of Deteriorating Medical Condition, Guidelines for Selection
Primary Disease
Clinical Criteria
COPD/emphysema
BODE index of 7-10 or at least 1 of the following:
History of hospitalization for lung exacerbation associated with hypercapnia (pCO2 > 50 mm Hg)
pO2 < 50 mm Hg (rest)
Pulmonary hypertension or cor pulmonale or both despite O2 therapy
FEV1 <25% and either DLCO <20% or homogeneous distribution of emphysema without reversibility
Cystic fibrosis
FEV1 < 30 % predicted
pCO2 > 50 mm Hg
pO2 < 50 mm Hg (rest)
Rapid decline in FEV1, particularly if female (*list urgently)
Increased antibiotic resistance and/or incomplete recovery from exacerbations.
Frequent hospitalization, use of noninvasive ventilation
Recurring hemoptysis
Pneumothoraces, loss of body weight
Pulmonary hypertension
Pulmonary fibrosis
Histologic or radiologic evidence of usual interstitial pneumonia
FVC < 60%-80% predicted or ≥ 10% decrease in FVC during 6-month follow-up
DLCO < 40% predicted
PAPm > 25 mm Hg
ANY O2 requirement.
Honeycombing on high-resolution CT scan (fibrosis score > 2)
Symptomatic, progressive disease with failure to maintain lung function despite steroids and good medical therapy
Pulmonary hypertension
NYHA class III or IV despite combination medical therapy including prostanoids.
Low or declining 6 MWT (350 m)
Right arterial pressure > 15 mm Hg
Pulmonary arterial pressure > 50 mm Hg
Cardiac index < 2 L/min/m2
Uncontrolled syncope, hemoptysis, pericardial effusions, or progressive right heart failure
Right arterial pressure >15 mm Hg
Sarcoidosis
NYHA functional class III or IV and any of the following:
Hypoxemia at rest
Pulmonary hypertension
Elevated right atrial pressure > 15 mm Hg
Lymphangioleiomyomatosis (LAM)
VO2 max < 50% predicted (severe impairment in exercise and lung function)
Hypoxemia at rest
* Special circumstances.
BODE index, body mass index, airflow obstruction, dyspnea, exercise. Scores range from 0 to 10 and provide mortality risks based on data entered. CT, computed tomography; FEV1, forced expiratory volume in 1 second; MWT, minute walk test; pCO2, carbon dioxide tension; PAPm, pulmonary arterial pressure by mean; VC, vital capacity; DLCO, diffusing capacity of carbon monoxide; oxygen, O2; NYHA, New York Heart Association.
Adapted from Hook J, Lederer D. Selecting lung transplant candidates: where do current guideline fall short? Expert Rev Respir Med. 2012;6(1):51-61; Weill D, Benden C, Corris P, et al. A consensus document for the selection of lung transplant candidates: 2014 an update from the pulmonary transplantation council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34(1):1-15; Kreider M, Hadjiliadis D, Kotloff RM. Candidate selection, timing of listing, and choice of procedure for lung transplantation. Clin Chest Med. 2011;32(2):199-211.
If the patient is acutely ill, an expedited inpatient evaluation can be done. This type of evaluation has limitations as it does not
Provide the most accurate assessment of the patient’s functional status, compliance, and social support
Allow for a demonstration of commitment by the patient and his/her support system
The evaluation process can be a very stressful time for the patient and family.
Many patients experience feelings of anxiety, ambivalence, and hopelessness during this process.
The needs of the patient should be addressed by providing educational and emotional support to the patient and family.24,25,26
Members of the patient’s support system are evaluated for their willingness and ability to provide care for the patient long term, as caregiver burden can become problematic with prolonged illness.25,26,27
Please see chapters on the Evaluation of Transplant Patients and Psychosocial Issues in Transplantation for additional information.
V. LISTING PATIENTS FOR LUNG TRANSPLANTATION
Pulmonologists
Cardiothoracic surgeons
Cardiologists, for patients who may require combined HLT
Respiratory, speech, and physical therapists
Dietitians
Nurse coordinators
Social workers
Psychiatrists or psychologists
Pharmacists
Ethicists
Research staff
Financial counselor/coordinator
Determine that the patient meets disease-specific criteria for lung transplantation (see Table 11-5).11,14,15,16
If candidate meets medical criteria to be placed on the transplant waiting list, the timing of listing must be determined.
Is the patient ready to list?
Is the patient above the functional threshold for listing, in which case the patient is monitored for disease progression and functional decline (Figure 11-2) as indicated by
Decline in FVC ≥10% during 6 months of follow-up
Decline in DLCO ≥ 15% during 6 months of follow-up
Desaturation to <88% or walking <250 m on 6-minute walk test over a 6-month follow-up period
FIGURE 11-2 The order of tests to determine the cardiopulmonary status of the patient and the extent of lung resection that would be tolerated. A. The whole-lung function test is a basic screening test. B. The split-lung function tests are regional tests to determine the involvement of the diseased lung to be removed. ABG, arterial blood gas; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second; VC, vital capacity; MVV, maximum voluntary ventilation; RV/TLC, residual volume/total lung capacity; DLT, double-lumen tube. DLCO, diffusing capacity for carbon monoxide. (Adapted from Neustein SM, Cohen E. Preoperative evaluation of thoracic surgical patients. In: Cohen E, ed. The Practice of Thoracic Anesthesia. Philadelphia, PA: JB Lippincott; 1995:187, with permission.)
Pulmonary hypertension on right heart catheterization
Decide that the patient does not meet medical or psychosocial transplant eligibility criteria at this time and determine whether or not
The issue can be corrected or resolved over time, with recognition of current medical status and if feasible and realistic
The patient should consider alternative centers for listing if the contraindications are center specific and not universal
The patient should be reassessed after current medical and/or psychosocial concerns are resolved and reconsidered for listing
If all viable treatment options are exhausted and a decision is made to offer transplant listing to the patient, the patient must then decide if he/she wants to be placed on the waiting list for a donor organ.
Listing information is outlined in Table 11-6 per UNOS guidelines.
TABLE 11-6 UNOS Listing Information
Listing information consists of
Social security number
Organ—heart-lung or lung
Age group—adult or pediatric
Patient name
Locality
Date of birth
Race
Diagnosis and blood group
Height and weight
Forced expiratory volume in 1 sec (FEV1) and forced vital capacity (FVC)
Right heart catheterization pressures
6-Minute walk test distance
Acceptable smoking history for a donor >20 pack years
Acceptable donor serologies (human immunodeficiency virus, hepatitis B virus, and hepatitis C virus)
Acceptable donor height range and age range
A maximum distance the organ recovery team is willing to travel
Whether a donor-specific crossmatch will be needed at the time of transplant
Adapted in part from United Network of Organ Sharing (UNOS). Available at https://www.unos.org/wp-content/uploads/unos/Lung_Professional.pdf?b2d5de. Accessed October 12, 2015 and personal experience.
The patient’s LAS is calculated using a series of data factors that determine the probability of a patient surviving the next year without a transplant (urgent need) and the projected survival with a transplant (long-term benefit).15,28,29,30
Data for clinical variables are entered into the LAS calculator and the LAS score is calculated (see Table 11-7).15,28,29,30
The LAS ranges from 0 to 100 with a higher score suggestive of a higher severity of illness/increased urgency for transplantation and a higher probability of success following transplant.
The LAS is used to prioritize patients on the lung transplant waiting list.
The score is typically provided to the patient at the time of official listing notification.
Candidates are typically required to reside or establish temporary residency within a 2-hour distance to the transplant center (by ground or air transportation).
When distance precludes arrival at the transplant center via ground transportation within the 2-hour time limit, some transplant centers assist patients and families with alternate air transportation arrangements when a donor organ becomes available. Such arrangements
Afford patients the opportunity to wait for their transplant in their own home, which is an important consideration in areas of the country where there are few lung transplant programs (e.g., rural communities). This allows patients to remain close to family and friends for support.
Attempt to maintain equity of organ allocation and distribution
Other centers will allow for long-distance travel by notifying patients of organ offers earlier in the process and thus for car travel at the time of donor organ offers.
Patients are notified that there is a risk that the organ offer may not be accepted as additional clinical information regarding the donor is obtained while the patient is en route.
TABLE 11-7 Lung Allocation Score (LAS) | ||
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VI. MANAGEMENT OF PATIENTS AWAITING LUNG TRANSPLANTATION
Stable patients are typically followed in an outpatient clinic every 8 to 12 weeks.
Other variables including pulmonary function tests, 6-minute walk, and serum creatinine are updated at least every 6 months.15,28,29,30
It is important to impress upon the patient and family that the transplant team must be notified of any hospitalizations, deterioration in pulmonary or general health status, and change in insurance or contact information and must keep all scheduled appointments.
Many transplant centers require patients to participate in cardiopulmonary rehabilitation two to three times a week while they are on the waiting list.
VII. INDICATORS OF DETERIORATION
Symptoms of increased anxiety and depression.
Fear of dying.
Increased shortness of breath.
Decreased exercise tolerance.
Increased dependence on others.
Complaints of weight loss despite increase caloric intake.
Early satiety or decreased appetite.
These factors are multidimensional influences and may be interrelated.
Weight loss.
Decline in pulmonary function measurements (↓ forced vital capacity [FVC] or ↓ diffusing capacity of the lung for carbon monoxide [DLCO]).
Pulmonary hypertension (elevated right heart pressures).
Decline of walk distance on a 6-minute walk test (6 MWT).
Increasing supplemental O2 requirements at rest and/or with exertion:
6 MWT O2 requirements may be increased.
Respiratory support requirements (continuous positive airway pressure [CPAP], bilevel positive airway pressure [BIPAP], mechanical ventilation).
Increased work of breathing.
Hospitalization for respiratory distress indicates higher urgency for transplant.
VIII. EDUCATION FOR THE LUNG TRANSPLANT PATIENT ACROSS THE TRANSPLANT CONTINUUM
Education begins at the time the patient is referred for transplant evaluation and continues throughout the transplant continuum.
Given poor oxygenation and high levels of anxiety and overstimulation, patients may have less ability to concentrate and learn.
Small amounts of information shared at each interaction with repetition and gradual expansion of concepts optimizes retention.
The evaluation process:
Expected time line from beginning of evaluation to completion (scheduling testing and consultations, follow-up appointments, review of results, and recommendations from the selection team)
These vary from transplant program to transplant program.
Consultation with interdisciplinary team members
Note: the Centers for Medicare and Medicaid (CMS) requires the following:
All patients must be evaluated using an interdisciplinary team approach.
Notes from each discipline must be documented in the patient record for CMS review.
If the patient does not have a need for a specific interdisciplinary team assessment, this must be documented in lieu of the consult note.
Interdisciplinary team assessments from a social worker, dietician, and pharmacist must occur prior to listing, immediately after transplantation, and prior to discharge.
In addition to patient education, discipline-specific consults may include the following assessments:
Social worker:
Emotional status and coping skill
Support system and resources
Existing stressors and prior mental health support
History of adherence to medical regimen
See chapter on Psychosocial Issues in Transplantation for additional information
Dietician:
Body habitus
Nutritional status
Bone health indicators and osteoporosis status
Pharmacist:
Current medications and tolerance
Medication allergies
Potential problems with posttransplant immunosuppression regimen
Financial coordinator:
Current health care insurance, including medication benefits
Disability status
Transplant coordinator:
Overall patient and family awareness of health status and disease state
Current status of routine health screening (e.g., mammography, prostate-specific antigen tests, dental examinations)
Waiting for a transplant
Self-care
Follow-up care with the transplant center; periodic labs and other tests
Exercise program
Nutrition and weight management:
Cachectic patients may require nutritional supplements to achieve a body mass index (BMI) > 18.
Obese patients may be required to lose weight to achieve a BMI < 30.
Support groups
Communication with the transplant center reporting:
Admission to other hospitals during the waiting period
Deterioration of condition and change in O2 requirement
Signs and symptoms of infection
Change of insurance, address, or phone number
Optimal donor:
Donor evaluation, matching, and selection31
Immediate preoperative period:
Offer reviewed by surgeon and accepted if
The donor/recipient are ABO compatible
The size of the donor is appropriate for the size of the patient
The donor organ is deemed suitable for transplant
Patient notification of donor offer and admission to hospital:
Appropriate hospital entry to use
Estimated time line of events; potential for delays
Testing on admission:
Lab work
Chest radiograph (CXR)
Electrocardiogram (ECG)
Preoperative shower/scrub preparation
Placement of lines and catheters
Holding area
Family waiting area
Consent
Completion of central lines and arterial line placement
Initiation of anesthesia
Type of incision
Duration of surgical procedure
Updating family during surgical procedure
Transfer from the operating room directly to the intensive care unit (ICU). Postanesthesia management and recovery occur in the critical care unit, rather than in a postanesthesia care unit (PACU). Anesthesia is nearby if needed.
Immediate postoperative course:
Length of stay in the ICU and intermediate care unit
Lines, tubes, and devices insertion, maintenance, and removal
Ventilator and ventilator weaning protocol
Bronchoscopy for airway inspection and culture collection
Supplemental O2
Pain management
Medications:
Tolerance and safety for oral administration of medications
Weaning of intravenous (IV) inotropic and vasopressor support
Weaning of inhaled medications
Immune suppression:
In addition, antifungal medications interact with immunosuppression and complicate management.
Precautions vary from center to center and even provider to provider.
Postoperative routines:
Frequent vital sign/hemodynamic assessments
Diet progression
Ambulation (progressive increase in activity and physical therapy)
Use of incentive spirometer
Wound care and dressing changes
Visitation by family and significant others
Long-term follow-up care posttransplantation:
Adherence with the medical regimen.
Posttransplant clinic appointments.
Strategies to prevent infections, for example:
Wearing a mask for a specified time after surgery (per transplant program protocol). May include use when the patient is
Exposed to crowds during the first 3 months following transplant
Around sick people during the cold/flu season
Returning to the hospital or physician’s office where exposure to sick people is possible
Good hand hygiene.
Patients should not accompany others to physician office appointments.
Patients should not visit other patients in the hospital within 3 months posttransplant.
Patients should avoid crowded times at restaurants, movie theaters, banks, grocery stores, shopping malls, and indoor sporting events.
Limit hand contact with contaminated surfaces such as handrails, doorknobs, and countertops.
Proper food preparation and food handling and preparation surface maintenance and cleaning.
Pet care:
Patients should not have contact with domestic birds (risk for psittacosis, histoplasmosis, and other diseases).
Patients should not have contact with cat litter boxes due to risk of toxoplasmosis exposure.
Obtaining a new pet is typically discouraged during the first year posttransplant.
Home construction or gardening can be hazardous due to risk of dust/spore inhalation.
Dust inhaled related to these activities may often contain mold spores and can lead to fungal infections, which are difficult to treat.
Some are more conservative and instruct patients to avoid all of the above activities at all costs, while others allow patients to participate, but instruct patients to use protective masks of varying quality.
Wearing masks will reduce, but not completely eliminate, the risk.
In general, programs typically advise recipients to avoid the following activities:
Pulling up carpets
Repairing or replacing walls/ceilings
Gardening and yard work involving digging, fertilizing, and leaf raking
Daily use of a home spirometry device to monitor the lung function.
Immunosuppressants and other medications:
Purpose
Adherence regarding timing, exact dosing, and intervals
Potential side effects
Potential drug interactions:
Prescription drugs
Over-the-counter medications
Food/drug interactions such as those with grapefruit and/or grapefruit juice
Supplements and herbal remedies (avoid Echinacea, probiotics, and other remedies that are contraindicated posttransplant)
Monitoring medication supply, availability, and trough levels
Management of symptom distress:
When to call the transplant center or coordinator on call
Quality of life and realistic expectations
Posttransplant health care costs:
Coverage of health care costs for the posttransplant treatment and potentially expensive immunosuppressant medications can be one of the greatest concerns for patients and health care professionals.
Without prescription drug, transplant recipients face a significant financial challenge.
Patients should be referred to a social worker, pharmacist, and/or transplant financial coordinator who can
Identify potential financial resources.
Help the patient apply for pharmacy assistance programs or grants or engage in fundraising to defray future costs.
Patients should not share medications with one another as this is illegal.
Returning to work after lung transplantation should be encouraged.
The social worker may assist patients and families with return to work issues, including, but not limited to
Insurance coverage concerns
Potential loss of Medicare or other public insurance benefits
IX. DONOR SELECTION
Usually younger than 55 years of age.
Chest radiograph: clear:
Ventilator recruitment maneuvers may clear areas of atelectasis.
Arterial blood gas (ABG) with normal gas exchange and PaO2 > 300 mm Hg on 100% FiO2, 5 cm positive end-expiratory pressure (PEEP) for 5 minutes (Figure 11-3).
No previous thoracic surgery, pulmonary contusions, or chest trauma.
No evidence of aspiration.
FIGURE 11-3 Acid-base nomogram NB. If ABG not available, can use VBG, but note that pH ˜0.04 ↓, PaCO2 ˜8 mm Hg ↑, and HCO3 ˜2 mEq ↑. (Adapted from Brenner BM, ed. Brenner & Rector’s The Kidney. 8th ed. Philadelphia, PA: Elsevier; 2007; Ferri F, ed. Practical Guide to The Care of the Medical Patient. 7th ed. Philadelphia, PA: Elsevier; 2007.)
Bronchoscopy should demonstrate clear airways:
Free of purulent or aspirated material.
Cultures should be negative, no lung infection.
Tobacco history < 20 pack/years.
Absence of any transmittable diseases.
If considering DCD lungs, follow above criteria and use direct visualization of lungs in the operating room.
Some programs will consider extended criteria lung donors (ECLD). These donors may be above age 55 and have an abnormal CXR or infiltrate, smoking history >20 pack/years, positive sputum cultures, and heavy secretions upon bronchoscopy.
X. SURGICAL PROCEDURE
Single-lung transplantation (SLT), either left or right
Bilateral sequential lung transplant
Double-lung en bloc
Heart-lung transplantation
Living donor lobar transplant
Underlying disease
Recipient age
Recipient anatomy
Surgeon’s preference (to some degree)
Procedure requires two living donors.
Each donates a lower lobe of a lung to the recipient.
This procedure is usually reserved for pediatric patients.
Clamshell approach (standard and modified) (see Figure 11-4)
Standard median sternotomy incision
Standard thoracotomy incision
Minimally invasive thoracotomy incisions
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