Lung transplantation.ppt

1. LUNG TRANSPLANTATION Dr. Pratik Kumar 1

2. Overview : Introduction Purpose of lung transplantation History Indications Disease specific selection criteria Contraindications 2

3. Overview : Description Laboratory studies Donor-related issues Preoperative care Post operative care Complications Normal results 3

4. Introduction : Lung transplantation involves removal of one or both diseased lungs from a patient and the replacement of the lungs with healthy organs from a donor Lung transplantation may refer to single, double, or even heart-lung transplantation . Lung transplantation is an accepted modality of treatment for end stage lung disease that is unresponsive to medical therapy 4

5. Purpose : To replace a lung that no longer functions with a healthy lung . To perform a lung transplantation, there should be potential for rehabilitated breathing function. Other medical treatments should be attempted before transplantation. Many candidates for this procedure are dependent on oxygen therapy 5

6. History of procedure : Animal experimentation by various pioneers, including Demikhov and Metras , in 1940s and 1950s demonstrated that the procedure is feasible technically. First human lung transplantation was done in 1963. The donation was essentially after cardiac death, and the recipient of the left lung transplant survived only 18 days . 6

7. Cont……….d: From 1963-1978, multiple attempts at lung transplantation failed because of rejection and problems with anastomotic bronchial and tracheal healing. The first successful single lung transplant was reported by Dr. Joel Cooper at the University of Toronto in 1986 .   7

8. Cont……….d : In 1988, Dr. Alexander Patterson described the technique of double-lung transplantation. Dr . Denton Cooley and associates were the first to attempt heart-lung transplantation in 1968. First heart-lung transplant in India- 3 May 1999 at Madras Medical Mission. 8

9. AGE DISTRIBUTION OF LUNG TRANSPLANT RECIPIENTS J Heart Lung Transplant 2008;27: 937-983 9

10. Indication of lung transplantation : Obstructive lung disease : A. Chronic obstructive pulmonary disease Restrictive lung diseases : A. Idiopathic pulmonary fibrosis ( IPF) B. Interstitial lung disease 10

11. Indication of lung transplantation : Septic lung disease : A. Cystic fibrosis (CF) B. Bilateral bronchiectasis Pulmonary vascular disease : A. Primary pulmonary hypertension (PPH) B. Eisenmenger’s syndrome 11

12. Diagnosis of Lung Transplant Recipients in US (1986-2007) 40% 13% 13% 8% 14% 2% 4% 1% 4% 1% COPD Alpha I Anti Def IPF Other Cystic Fibrosis IPAH Talcosis BO Eisenmenger's Bronchiectasis J Heart Lung Transplant 2008;27: 937-983 12

13. Disease specific selection criteria COPD- Pt. with BODE index 7 to 10 of at least 1 of the following: FEV1 < 25% predicted ( without reversibility) PaCO2 >55 mm of Hg Elevated pulmonary artery pressure (PAP) Cor pulmonale 13

14. Cont……….d: Other indices shown to correlate mortality- 1)subjective breathlessness 2)weight loss 3)exercise tolerance 4)hospitalization 5) lung morphology all patients requiring hospitalization for exacerberation should be considered for surgery 1 year mortality after hospitalization -23% 14

15. The BODE Index For COPD Can Fam Physician 2008;54:706-11

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17. Cont……….d: IPF- Highest attrition rate with waiting list mortality 30% Initially, owing to unpredictable nature of course, view was to refer all patients for transplantation at diagnosis Patients with exercise induced desaturation are ideal candidates 17

18. Cont……….d: Current consensus- 1) Symptomatic progressive disease despite 3 months of medical therapy 2) Rest or exercise induced desaturation 3) Symptomatic with- VC< 60-70%predicted DLCO < 50-60% pred. 18

19. Cont……….d: Cystic fibrosis Prognostic criteria- 1)age per year 2)sex 3)FEV1 4)weight for age 5)Pancreatic insufficiency 6)D.M. 7) S.aureus 8) B.cepacia 9)No. of acute exacerberations 19

20. Cont……….d: Patients divided into 5 prognostic groups Only group 1&2 with 5 year survival rate <30% benefited Resistant B. cepacia infection is absolute contraindication 20

21. Cont……….d: PPH Advancement in medical management-reduced need for transplantation 1990- 10.5% of all cases 2001- 3.6% of all cases 21

22. Cont……….d: Criterias for PPH Symptomatic progressive disease despite optimal medical treatment for 3 months Cardiac index < 2 lit/min/m2 Right atrial pessure >15 mm Hg PAP mean > 55 mm Hg 22

23. Cont……….d: Eisenmengers syndrome Better prognosis than patients with PPH with similar PAP levels Epoprostenol therapy improved survival & reduced need for transplantation Heart -lung transplantation is preferred 23

24. Cont……….d: Sarcoidosis Most patients benign course 10-20% permanent sequel 2.5% of all transplants Only stage 4 disease is considered FVC < 50% & FEV1 < 40% 24

25. Cont……….d: Lymphangioleiomyomatosis FEV1/FVC < 45% Average from diagnosis to transplant -11yr 25

26. Contra-indication (Absolute ): Malignancy in the last 2 years Non-curable chronic  extra pulmonary infection including chronic active hepatitis B , C , and HIV Untreatable advanced dysfunction of another major organ system Current cigarette smoking 26

27. Poor nutritional status Poor rehabilitation potential Significant psychosocial problems S ubstance abuse history of medical noncompliance 27

28. Relative Contraindications : Age : advanced age is associated with higher mortality rates . Most centers have an age cut-off 50 years for - H eart-lung transplantation, 60 years for- B ilateral lung transplantation , 65 years for - S ingle-lung transplantation. 28

29. Ventilator dependence : patients who are dependent on a ventilator prior to the transplant have higher mortality rates . A prolonged wait while the patient is on a mechanical ventilator may lead to various complications such as infections, cardiovascular de-conditioning . 29

30. Psychosocial issues : Individuals who currently smoke, abuse drugs, or drink alcohol heavily are not candidates for transplantation . Patients with other psychosocial issues, such as poor compliance and psychiatric disorders that may complicate post transplant therapy, are not considered good candidates . 30

31. I nfection : patients who have active tuberculosis infection are not candidates for transplantation. Body weight : Patients who have poor nutritional status and would have a poor outcome following transplantation. 31

32. Obesity (BMI >30 ) :  also may be a concern because of postoperative atelectasis and pneumonia Extra pulmonary organ dysfunction : Patients with a significant heart, liver, or kidney disease are not transplant candidates . 32

33. Description : Single lung transplantation is performed via a standard thoracotomy (incision in the chest wall) with the patient under general anesthesia . Cardiopulmonary bypass (diversion of blood flow from the heart) is not always necessary for a single lung transplant . 33

34. Cont ………..d: If bypass is necessary, it involves re-routing of the blood through tubes to a heart-lung bypass machine. Double lung transplantation involves implanting the lungs as two separate lungs, and cardiopulmonary bypass is usually required The patient's lung or lungs are removed and the donor lungs are stitched into place. Drainage tubes are inserted into the chest area to help drain fluid, blood, and air out of the chest . 34

35. Figure Patient positioned for bilateral lung transplant, through a clamshell incision with the arms abducted. The skin incision is depicted in the mammary fold heading laterally toward the mid- axillary line. The dotted line shows the level of the 4th intercostal space. The position of the femoral artery, on both sides, is also marked. The groin is prepped and draped, since during the transplant procedure, an arterial femoral line may become necessary for monitoring or even for cannulation for cardiopulmonary bypass. 35

36. ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2007) *Other includes: Sarcoidosis : 2.1% Bronchiectasis : 0.4% Congenital Heart Disease: 0.2% LAM: 0.7% OB (non- ReTx ): 0.5% Miscellaneous: 5.8% J Heart Lung Transplant 2008;27: 937-983

37. ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2007) *Other includes: Sarcoidosis : 3.0% Bronchiectasis : 4.8% Congenital Heart Disease: 1.3% LAM: 1.2% OB (non- ReTx ): 1.1% Miscellaneous: 6.6% J Heart Lung Transplant 2008;27: 937-983

38. Laboratory studies : The following diagnostic tests are usually performed to evaluate a patient for lung transplantation: Arterial blood gases (ABG ) test: which measures the amount of oxygen that the blood is able to carry to body tissues. 38

39. Pulmonary function tests (PFTs): which measure lung volume and the rate of air flow through the lungs; the results measure the progress of the lung disease. Computerized tomography (CT) scan. A chest CT scan is taken of horizontal slices of the chest to provide detailed images of the structure of the chest. 39

40. Ventilation perfusion scan (lung scan, V/Q scan) is a test that compares right and left lung function Electrocardiogram (ECG): is performed by placing electrodes on the chest. A recording of the electrical activity of the heart is obtained to provide information about the rate and rhythm of the heartbeat 40

41. Echocardiogram (ECHO) is performed to evaluate the impact of lung disease on the heart. It examines the chambers, valves, aorta, and the wall motion of the heart. ECHO also provides information concerning the blood pressure in the pulmonary arteries. This information is required to plan the transplantation surgery . 41

42. Blood test : Complete blood count , Coagulation profile. HIV , hepatitis B, hepatitis C 42

43. Donor-related issues: Younger than 65 years for lung transplantation and younger than 45 years for heart-lung transplantation Absence of severe chest trauma or infection Absence of prolonged cardiac arrest (heart-lung only) Minimal pulmonary secretions Negative screens for HIV, hepatitis C, and hepatitis B 43

44. Blood type (ABO) compatibility Close match of lung size between donor and recipient PaO2 > 300 mm Hg on 100% fraction of inspired oxygen Clear chest radiograph No history of malignant neoplasms 44

45. Preoperative care: Preoperative assessment consist of both medical & psychosocial evaluation. Assessment of patient‘s physical health is assessed to determine candidacy for transplantation. In preoperative phase the patient is assessed for cardiac output & renal functions . Psychosocial evaluation focuses on assessing the patient‘s history of compliance with medical therapy & ability to cope with stress. 45

46. Post operative care : The patient is observed for excessive bleeding. Monitor vital signs ,ECG ,ABG values ,urine output, O 2 level analysis & chest tube drainage. The patient may be started on mechanical ventilation for 24 to 48 hours. 46

47. Serum electrolytes ,complete blood count, chest radiographs are obtained daily. Fluids are restricted. Lung sounds are auscultated . Severity of peripheral edema is monitored. Pain control is important to allow deep breathing & coughing with chest physiotherapy . 47

48. The patient with lung transplantation is at high risk to develop infection. So isolation is used to decrease exposure to pathogens. Monitor the patient for clinical manifestation of infection such as: Change in vital signs especially fever Local infection at i /v site & incision line Changes in respiratory status like excessive secretions, tachypnea,dyspnea 48

49. Immunosuppression Induction phase- A) ATG B) Selective IL2 receptor antagonists Maintenance phase- A) Steroid + calceneurin inhibitor B) Steroids ( low dose ) life long C) Tacrolimus for 1-5 years 49

50. Newer drugs Sirolimus ( Rapamycine )- An analog of Tacrolimus 2) Everolimus - used in combination with cyclosporin & prednisolone shown to have freedom from biopsy proven acute rejection in 88% cases 50

51. Complications Causes of respiratory failure after LTx Early ischemia reperfusion injury infection technical problems acute rejection >3months Infections BOS Curr.opin.Crit.care 2006 Feb;12, 19-24 51

52. Ischemia reperfusion injury Most frequent cause of early mortality presents as ALI / ARDS Reduced incidence since 1990- 1) low K- dextran solution 2) nitric oxide added to flush solution 3) prevention of hyperinflation during harvesting 4)controlled reperfusion with leucocyte depletion 52

53. Ischaemia reperfusion injury contd. Treatment- A) diuretics B) maximal ventilatory support Newer modalities A) inhaled nitric oxide B) inhaled prostacyclin Course- resolves in 48-72 hrs 53

54. Infections Bacterial- A) psuedomonas predominate in early post op(75%) B) nocardia-2.1% C) legionella , mycobacteria rare routine antibiotic prophylaxis reduced the incidence sputum cultures & antibiotic sensitivity done every 3 months 54

55. Viral infections CMV predominates within 30-100 days after transplant occurs as reactivation or prim. infection (donor) incidence varies between 13-75% in various studies routine prophylaxis replaced by close monitoring Treatment- gancyclovir 5mg/kg for 2-3 weeks 55

56. HSV&VZV can cause pnuemonia Acyclovir prophylaxis effective in patients not on gancyclovir EBV related post-transplant lymphoproliferative disease 4-10% cases usually fatal outcome recently Rituximab ( anti CD20 Ab ) found effective 56

57. Fungal infections Aspergillus most common 1) ulcerative trachitis 2) bronchitis 3) pnuemonitis 4) disseminated diesase 5) ABPA- reported I.V. or aerolised ampho -B used for prophylaxis 57

58. Other rarer organisms Histoplasma Sedosporium Pnuemocystis jirovecii 58

59. Rejection Acute rejection- < 7 days onset low grade fever, dyspnoea CXR- 1) Clear 2) illdefined infiltrates 3) pleural effusion reduced FEV1 59

60. Acute rejection TBLB - gold standard in diagnosis Noninvasive means-area of active research 1) Cytokine milieu in BAL fluid 2) gene upregulation as a biomarker Treatment- bolus I.V. steroids + increase in maintenance immunosuppression role of surveillance bronchoscopy to detect rejection early is controversial 60

61. Chronic rejection Bronchiolitis Oblitrance Symdrome (BOA) : 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 HRCT- mottled appearance with peripheral lucency 61

62. TBLB- gold standard Role of induced sputum & BAL- 1) Induced sputum – RANTES levels and eosinophils correlate with BOS development 2) BAL- IL8 & neutrophil levels have negative correlation 62

63. Treatment - variable course even without treatment various immunosuppressive regimens tried macrolides under evaluation 63

64. Factors associated- 1) CMV pnuemonitis -no. of episodes 2) HLA mismatch 3) GERD- laproscopic fundoplication reduces incidence 64

65. Self care : Before discharge the patient should be teach about the medication regimen. The patient should report for fever, dyspnea , cough ,increased sputum production ,chest pain, excessive weight gain, fatigue to physician. During follow up the client is monitored for manifestation of rejection & progress in functional status . 65

66. Exercise capacity has been the most interesting functional outcome observes in lung transplant recipient . Typically transplant recipient can walk 100 to 120m/min within 6 months of transplantation . 66

67. Normal results: Demonstration of normal results for lung transplantation patients include a) adequate lung function, b) improved quality of life, c) lack of infection and rejection . 67

68. http://articles.timesofindia.indiatimes.com/2012-07-31/mumbai/32960286_1_lung-transplants-transplant-team-surgery Cost of Lung Transplantation in India Surgery alone cost Rs 10 lakh . The ICU and medications will work up to an equal amount 68

69. THANK YOU 69