LUNG TRANSPLANT 1Dr.yekehfallah- phd of nursing- 20159/18/2015

LUNG TRANSPLANT

1Dr yekehfallah- phd of nursing- 2015041923

Introduction1048708 First attempt of lung transplantation in 1963 by Hardy amp coworkers1048708 First successful transplantation by Toronto group in 19831048708 1400 transplantations are done worldwide per year1048708 International society of heart-lung transplantation has registered gt 14500 lung transplant recipients


Introduction1048708 Advances in operative technique amp

immunosuppression led to reduction in mortality rates to lt10

1048708 1 year survival of gt 801048708 Improvement in post-transplant quality of

life is noted1048708 Greatest risk factor for mortality is found

to be ventilator dependency1048708 These patients not considered for

transplantation


Introduction1048708 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


Pathophysiology Early allograft failure

(1) Early lung graft dysfunction manifests as persistently marginal gas exchange (ie hypoxia hypercarbia) and pulmonary hypertension in the absence of infection or rejection


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 (PaO2FiO2 ratio lt150 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


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


Management issues 1Inotropic and fluid management2Respiratory management aAfter ICU admission anteroposterior chest radiograph initial

ventilator settings FiO2 of 50 tidal volume of 10 to 15 mLKg 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

bArterial blood gases 30 minutes after each ventilator setting change to achieve a paO2 greater than 75 mmHg on an FiO2 of 04 a paCO2 between 30 and 40 mmHg and a pH between 735 and 745

cWeaning 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


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



Types of transplantations1048708 Unilateral Single lung transplant good results in patients with 1)pulmonary fibrosis 2)emphysema ( small size amp older patients) 3) acceptable option in pulmonary hypertension

Experience over past two decades shows that bilateral lung transplants shows better results









Donor CriteriaStandard 1048708 Agelt55 years1048708 ABO compatibility1048708 Clear CXR1048708 PaO2gt300 on FIO2=10 PEEP- 5 cm H2O1048708 Tobacco historylt20 pack years1048708 Absence of chest trauma1048708 No evidence of aspiration1048708 HIV HepB S Ag Hep C negative1048708 Sputum gram stain-absence of organisms1048708 Absence of purulent secretions at bronch


Selection criteriaCriterias to define end stage lung disease in

various diagnosis are still under way1048708Age limits- Relative1048708 55 years - heart-lung1048708 60 years- bilateral lung1048708 65 years- single lung


ContraindicationsAbsolute-1) Significant nonpulmonary vital organ dysfunction2) active malignancy within last 2 years3) HBsAg +ve4) HCV with abnormal liver biopsy5) Substance abuse in last 6 months


Disease specific selection criteriaCOPD-1048708 FEV1 lt 25 predicted ( without reversibility)1048708 PaCO2 gt55 mm of Hg1048708 elevated pulmonary artery pressure (PAP)1048708 cor pulmonale1048708 Other indices shown to correlate mortality- 1)subjective breathlessness 2)weight loss 3)exercise tolerance 4)hospitalization 5) lung morphology


Disease specific selection criteria1048708 all patients requiring hospitalization for exacerberation should be considered for

surgery

1048708 1 year mortality after hospitalization -23


Factors Predisposing to InfectionMechanical 1048708 mucociliary clearance 1048708 cough reflex 1048708 lymphatic drainage 1048708 bronchial stenosis 1048708 bronchiolitis Obliterans1048708 Presence of Source 1048708ldquoinheritedrdquo 1048708ischemic airways 1048708native lung


Rejection1048708 Acute rejection-1048708 lt 7 days onset1048708 low grade fever dyspnoea1048708 CXR- 1) Clear 2) illdefined infiltrates 3) pleural effusion1048708 reduced FEV1


Acute rejection

1048708 Treatment- bolus IV steroids + increase in maintenance immunosuppression

1048708 role of surveillance bronchoscopy to detect rejection early is controversial


Bronchiolitis Obliterans Syndrome BOS ( chronic rejection)

1048708 Predominantly a small airway disease1048708 occurs in 50 patients surviving for 5

years1048708 onset gt 6months1048708 major cause of mortality1048708 CXR- can be normal late cases-

bronchiectesis


BOS

1048708 Treatment- variable course even without treatment

1048708 various immunosuppressive regimens tried


BOS

1048708 Factors associated-1) CMV pnuemonitis -no of episodes2) HLA mismatch


Survival statistics1048708 TORONTO GROUP1 year survival ndash 763 year survival ndash 575 year survival - 446 year survival - 347 year survival ndash 29

1048708 Pulmonary fibrosis has worst outcome


Current Status of Lung Transplantation Long term survivalmdash50 die by 5 years

Bronchiolitis obliterans (chronic rejection)mdashprimary cause of poor survival

Future of lung transplantationmdashprevent bronchiolitis obliterans



Introduction1048708 First attempt of lung transplantation in 1963 by Hardy amp coworkers1048708 First successful transplantation by Toronto group in 19831048708 1400 transplantations are done worldwide per year1048708 International society of heart-lung transplantation has registered gt 14500 lung transplant recipients







transplantation
















Pathophysiology











transplant
























surgery







Acute rejection







bronchiectesis


BOS




BOS
















transplantation
















Pathophysiology











transplant
























surgery







Acute rejection







bronchiectesis


BOS




BOS

























Pathophysiology











transplant
























surgery







Acute rejection







bronchiectesis


BOS




BOS




















Pathophysiology











transplant
























surgery







Acute rejection







bronchiectesis


BOS




BOS

















Pathophysiology











transplant
























surgery







Acute rejection







bronchiectesis


BOS




BOS











Pathophysiology











transplant
























surgery







Acute rejection







bronchiectesis


BOS




BOS



















transplant
























surgery







Acute rejection







bronchiectesis


BOS




BOS














transplant
























surgery







Acute rejection







bronchiectesis


BOS




BOS
































surgery







Acute rejection







bronchiectesis


BOS




BOS































surgery







Acute rejection







bronchiectesis


BOS




BOS




























surgery







Acute rejection







bronchiectesis


BOS




BOS



























surgery







Acute rejection







bronchiectesis


BOS




BOS


























surgery







Acute rejection







bronchiectesis


BOS




BOS

























surgery







Acute rejection







bronchiectesis


BOS




BOS
























surgery







Acute rejection







bronchiectesis


BOS




BOS























surgery







Acute rejection







bronchiectesis


BOS




BOS






















surgery







Acute rejection







bronchiectesis


BOS




BOS





















surgery







Acute rejection







bronchiectesis


BOS




BOS



















surgery







Acute rejection







bronchiectesis


BOS




BOS
















surgery







Acute rejection







bronchiectesis


BOS




BOS














surgery







Acute rejection







bronchiectesis


BOS




BOS












surgery







Acute rejection







bronchiectesis


BOS




BOS















Acute rejection







bronchiectesis


BOS




BOS













Acute rejection







bronchiectesis


BOS




BOS











Acute rejection







bronchiectesis


BOS




BOS














bronchiectesis


BOS




BOS











BOS




BOS











BOS

























Documents

LUNG TRANSPLANT 1Dr.yekehfallah- phd of nursing- 20159/18/2015