Lung Transplant
21/10/10
PY Mindmaps
INDICATIONS
- can have one or both lungs transplanted depending on disease process
-
emphysema/COPD
idiopathic pulmonary fibrosis
alpha-1-antitrypsin deficiency
re-transplant
CF
primary pulmonary hypertension
bronchiectasis
CONTRAINDICATIONS
-
evidence of severe extra-pulmonary disease
poor nutritional or rehabilitation status
recent or current malignancy
poor psychosocial profile
DONOR CRITERIA
-
< 55 years
ABO compatible
clear CXR
PaO2 >300mmHg on FiO2 1.0 and PEEP 5
< 20 pack year smoking history
absence of chest trauma
no aspiration or sepsis
sputum: no bacteria, fungus, WCC (gram stain)
POST-OPERATIVE MANAGEMENT
Early complications
(1) Hypotension
-
often cause by volume depletion
gentle volume resuscitation (avoid APO)
albumin + RBC
if related to positive pressure -> remove from mechanical ventilation
(2) Mucous plugging
- suction
Jeremy Fernando (2011)
- bronchoscopy
(3) Allograft problems
- this often causes inadequate ventilation and oxygenation -> supportive care
- in single lung transplant -> isolate transplanted lung and ventilate native lung, native lung
down
(4) Bleeding
- haemostatic resuscitation
- early return to OT
(5) Bronchial anastamosis problems
- dehiscence or stricture usually occur later
(6) Pulmonary artery anastamosis problems
- PA stricture is very common -> oxygenation problems in absence of radiographic
abnormalities
- diagnosis requires a pulmonary angiogram
(7) Pulmonary venous anastamosis problems
- susceptible to kinking and clot formation -> immediate and profound pulmonary oedema
- requires immediate Doppler measurement of venous anastomosis using TOE
Haemodynamic Management
- transplanted lung very susceptible to pulmonary oedema (lymphatic disruption, SIRS
response to allograft -> reimplantation response, overzealous crystalloid use)
- cautious use of volume in first 72 hours
- use colloids, blood and albumin
Ventilator Management
- double lung recipient: PEEP 5-15 (helps with oxygenation and also tamponade of small
blood vessels in chest)
- single lung recipient: PEEP will be directed to native lung (more compliant) -> acute native
lung hyperinflation -> can cause cardiac tamponade (don’t use high level of PEEP)
Chest Physio
- very important
- transplanted lung is denervated so cough reflex impaired
Jeremy Fernando (2011)
Patient Position
- should be nursed with native lung down for 6 hours -> diminish blood flow to transplant
and decrease risk of pulmonary oedema
Immunosuppression
- local protocols exist
- some involve early antibody administration -> lymphocyte depletion or IL receptor
antagonism
- usually on 3 agents:
(1) corticosteroids
(2) calcineurin inhibitors (tacrolimus, cyclosporine)
(3) azathioprine or mycophenolate
Infectious disease prophylaxis
-
nosocomial infections common – HAP, lines, chest tubes
prophylaxis using late generation cephalosporins and vancomycin
CMV prophylaxis sometime used as well
use of anti-fungal agent is controversial
PROGNOSIS
- develop broncholitis obliterans (called chronic rejection)
- variable time
Jeremy Fernando (2011)