LUNG TRANSPLANT 1Dr.yekehfallah- phd of nursing /18/2015

Introduction First attempt of lung transplantation in 1963 by Hardy & coworkers First successful transplantation by Toronto group in transplantations are done worldwide per year International society of heart-lung transplantation has registered > lung transplant recipients 2Dr.yekehfallah- phd of nursing /18/2015

Introduction Advances in operative technique & immunosuppression led to reduction in mortality rates to <10% 1 year survival of > 80% Improvement in post-transplant quality of life is noted Greatest risk factor for mortality is found to be ventilator dependency These patients not considered for transplantation. 3Dr.yekehfallah- phd of nursing /18/2015

Introduction Recently various other issues have been raised - 1) Effect of obesity- high BMI : adverse effect on short term as well as long term survival 2) Effect of gender combination : significant risk of primary graft failure is associated with Female to Male but beneficial results with Female to Female 4Dr.yekehfallah- phd of nursing /18/2015

Pathophysiology  Early allograft failure (1) Early lung graft dysfunction manifests as persistently marginal gas exchange (i.e., hypoxia, hypercarbia) and pulmonary hypertension in the absence of infection or rejection. 5Dr.yekehfallah- phd of nursing /18/2015

Pathophysiology  Early allograft failure (2) Occurring in less than 15%, primary graft failure is usually caused by ischemia-reperfusion injury and results in pulmonary capillary leak causing alveolar edema, impaired lung compliance, and elevated pulmonary vascular resistance shortly after ICU admission. (a) Particularly severe cases of pulmonary hypertension can lead to right ventricular failure. (b) This syndrome resembles ARDS with a severe arterial- alveolar gradient (PaO2:FiO2 ratio <150 mm Hg), diffuse interstitial infiltrates on early postoperative chest radiographs, and diffuse alveolar damage on histology. (c) The degree of pulmonary edema has been observed to be inversely related to the quality of preservation, although the development of severe ischemia-reperfusion injury is still largely unpredictable 6Dr.yekehfallah- phd of nursing /18/2015

Pathophysiology  (3) Early lung graft dysfunction is managed by increased FiO2, PEEP, sedation, neuromuscular blockade, and careful diuresis to maintain fluid balance and reduce pulmonary edema. 7Dr.yekehfallah- phd of nursing /18/2015

Management issues 1/Inotropic and fluid management 2/Respiratory management a/After ICU admission: anteroposterior chest radiograph; initial ventilator settings: FiO2 of 50%, tidal volume of 10 to 15 mL/Kg, assist-control rate of 10 to 14 breaths per minute, and PEEP of 3 to 5 cm H2O. Initial tidal volumes and flow rates are adjusted to limit peak airway pressures to less than 40 cm H2O, to minimize barotrauma and high airway pressures, which may compromise bronchial mucosal blood flow. b/Arterial blood gases 30 minutes after each ventilator setting change to achieve a paO2 greater than 75 mmHg on an FiO2 of 0.4, a paCO2 between 30 and 40 mmHg, and a pH between 7.35 and c/Weaning to extubation is initiated after the patient is stable, awake, and alert. Generally, weaning is conducted through successive decrements in the intermittent mandatory ventilation (IMV) rate, followed by a sustained trail of continuous positive airway pressure (CPAP). Extubation is often possible within the first 24 hours posttransplant. 8Dr.yekehfallah- phd of nursing /18/2015

Typical Evaluation Criteria  Less than 60 years old for a single lung transplant  Less than 50 years old for a double lung transplant  Less than 50 years old for a heart and lung transplant 9Dr.yekehfallah- phd of nursing /18/2015

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Types of transplantations Unilateral / Single lung transplant : good results in patients with 1)pulmonary fibrosis 2)emphysema ( small size & older patients) 3) acceptable option in pulmonary hypertension Experience over past two decades shows that bilateral lung transplants shows better results 11Dr.yekehfallah- phd of nursing /18/2015

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Donor Criteria Standard Age<55 years ABO compatibility Clear CXR PaO2>300 on FIO2=1.0, PEEP- 5 cm H2O Tobacco history<20 pack years Absence of chest trauma No evidence of aspiration HIV / HepB S Ag/ Hep C negative Sputum gram stain-absence of organisms Absence of purulent secretions at bronch 19Dr.yekehfallah- phd of nursing /18/2015

Selection criteria Criterias to define end stage lung disease in various diagnosis are still under way Age limits- Relative 55 years - heart-lung 60 years- bilateral lung 65 years- single lung 20Dr.yekehfallah- phd of nursing /18/2015

Contraindications Absolute- 1) Significant nonpulmonary vital organ dysfunction 2) active malignancy within last 2 years 3) HBsAg +ve 4) HCV with abnormal liver biopsy 5) Substance abuse in last 6 months 21Dr.yekehfallah- phd of nursing /18/2015

Disease specific selection criteria COPD- FEV1 < 25% predicted ( without reversibility) PaCO2 >55 mm of Hg elevated pulmonary artery pressure (PAP) cor pulmonale Other indices shown to correlate mortality- 1)subjective breathlessness 2)weight loss 3)exercise tolerance 4)hospitalization 5) lung morphology 22Dr.yekehfallah- phd of nursing /18/2015

Disease specific selection criteria all patients requiring hospitalization for exacerberation should be considered for surgery 1 year mortality after hospitalization - 23% 23Dr.yekehfallah- phd of nursing /18/2015

Factors Predisposing to Infection Mechanical mucociliary clearance cough reflex lymphatic drainage bronchial stenosis bronchiolitis Obliterans Presence of Source “inherited” ischemic airways native lung 24Dr.yekehfallah- phd of nursing /18/2015

Rejection Acute rejection- < 7 days onset low grade fever, dyspnoea CXR- 1) Clear 2) illdefined infiltrates 3) pleural effusion reduced FEV1 25Dr.yekehfallah- phd of nursing /18/2015

Acute rejection Treatment- bolus I.V. steroids + increase in maintenance immunosuppression role of surveillance bronchoscopy to detect rejection early is controversial 26Dr.yekehfallah- phd of nursing /18/2015

Bronchiolitis Obliterans Syndrome BOS ( chronic rejection) Predominantly a small airway disease occurs in 50% patients surviving for 5 years onset > 6months major cause of mortality CXR- can be normal late cases- bronchiectesis 27Dr.yekehfallah- phd of nursing /18/2015

BOS Treatment- variable course even without treatment various immunosuppressive regimens tried 28Dr.yekehfallah- phd of nursing /18/2015

BOS Factors associated- 1) CMV pnuemonitis -no. of episodes 2) HLA mismatch 29Dr.yekehfallah- phd of nursing /18/2015

Survival statistics TORONTO GROUP 1 year survival – 76% 3 year survival – 57% 5 year survival - 44% 6 year survival - 34% 7 year survival – 29% Pulmonary fibrosis has worst outcome 30Dr.yekehfallah- phd of nursing /18/2015

Current Status of Lung Transplantation  Long term survival—50% die by 5 years  Bronchiolitis obliterans (chronic rejection)—primary cause of poor survival  Future of lung transplantation— prevent bronchiolitis obliterans 31Dr.yekehfallah- phd of nursing /18/2015

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