1) The document discusses ways for OPOs to improve lung offers to transplant centers, including providing more complete information in offers and ensuring offers accurately reflect the donor's condition. 2) It emphasizes the importance of thorough donor testing and clear communication between OPOs and transplant centers. 3) The document provides tips for OPOs, such as listing key elements in offers, using donor highlights to direct centers to relevant information, and knowing when to stop pursuing offers for donors with non-treatable issues.

1. Breathe Easy:
Making Lung Offers That Can Be Accepted
Adam Bell, BS, CCEMT-P, CPTC
Donor Network of Arizona
NATCO Annual Meeting Aug 11, 2014

2. Disclosures
There are no financial conflicts of interest from the presenters for this
approved course.
All individuals in positions to control content of the educational activity have
disclosed all financial relationships and there are no conflicts of interest.
There is no commercial support of this educational activity.
There is no off-label usage/no product related to this activity.

3. Objectives
 Identify 3 reasons transplant center
physicians may not be familiar with offers
when they become primary
 List 5 things an OPO can do to speed
allocation and acceptance of lungs
 List 8 elements of a “complete” lung offer
 Describe 3 factors transplant centers can
consider to help identify which recipients
might be appropriate for a given set of lungs

4. The Need
As of today 1,653 people in the US are waiting
for a lung transplant

5. Indications for Lung Transplant
Congenital
Idiopathic
Pulmonary
Fibrosis
Cystic
Fibrosis
Pulmonary
HTN
A1AT , COPD
CLAD
…and recipients have myriad comorbidities

6. Ethical Concepts in Organ
Allocation
Beneficence
Non-Malfeasance
Justice (equitable distribution)
We don’t work in sales. Our goal must
be to help recipients rather than to
place organs.
If it’s bad: write it in neon!

7. Why isn’t the Transplant Center
familiar with my offer?
They gave a “Prov Yes.”
Incomplete offers
Call centers and non-physician staff
taking offers
Decision makers are busy
Offer may change before becoming
“primary”

8. What do Transplant Centers want?
To transplant organs with good
long-term outcomes
That’s really it, but, they have to
protect recipients from bad offers, and
that’s our fault.

9. UNOS Requirements

10. Elements of a “Complete” lung offer

11. Using Donor Highlights
FBO and ground time info
Allocation plan and laterality issues
DCD tool
Direct Centers to what their organ
needs (LU team see Echo, and CT-
chest)
If “backing up” Who will be recovering
what and when, Will you delay XC?

12. Attachments in UNET
Are NOT available in mobile view
Searchable documents are best
Legibility is an issue
Small, discrete, well labeled
attachments are better
If it matters: Type it into UNET!

13. Med-Soc Follow up
Old Op-notes re chest surgeries
High Risk
H&P vs. Med-Soc
Travel
Place of birth? (Immunization Hx)

14. Highlights MUST Reflect Reality
SameDonor

15. TB
Where is your donor
from?
Travel?
Immunization? → + PPD
Maps by CDC

16. TB 2
 Never tested +, but…
Ever tested at all?
 Hx and follow up
 Latent TB QuantiFeron
test (24 hrs)
CDC QuantiFeron info
 CT is more sensitive
than CXR

17. Bronchoscopy findings
Did secretions clear
easily?
Did they re-
accumulate?
Aspiration? (Of
What? Where?)
Legibility of report
Clarify findings
before Dr. leaves

18. A good bronch form
asks the tough questions

19. Pulmonary Contusions
Hard to eval pre-OR
(progressive process)
CT
Fx sternum or scapula? (Force)
Have a plan for R and L separately PRN
Pulm venous gas in OR?
Ex-Vivo perfusion may provide eval
tool in non-inflammatory setting

20. When to CT
30+ pack years (maybe 20)
Suspicion for TB or consolidated
pneumonia
Significant chest trauma
Most donors over 60
Pulm Embolism
Need to R/O malignancy

21. Worth 1,000 words…

22. Quiz Show
Vent: PIP, rate, mode, PEEP, Tidal Vol,
FiO2, I:E ratio (in APRV high and low
times and P high and low also)
Recruitment: When relative to ABGs?
How? Ongoing (how & when?)
Why is your PcO2 high or low?
Fluid management plan?
Why is your PA pressure high?
Why are other centers saying “No?”

23. If you’re going to cath anyway
Get R side
pressures
Leave a SWAN in
Combine this with
the CT road trip
If not traveling on
a vent, use a PEEP
valve

24. Transplant Center Challenges
Front line staff may lack autonomy
Lack of R/O criteria
Listed pts who aren’t local
(recipient transport times)
Surgeon availability
Time to set up flights
Willingness to spend $$ on flights
(DCD, others recovering far away?)

25. Transplant Center Responsibilities
Search for any global R/O
Decline based on antigens to avoid
Decline based on size
Decline based on available organs
and laterality
Create a list of ??s that need to be
answered by OPO and testing
requests

26. What does the list tell us?

27. Bypass impossible placements
Save time &
let transplant center staff sleep.

28. Exhausting the list:
Heroic or Wasteful?
830 isn’t a reason; it’s a vague code
STOP and ASK WHY !!
Innate vs. treatable issues
 “Fix” your donor before making
more offers
Consider stopping when efforts are
clearly futile

29. Know when to fold ‘em
COPD
Pulm HTN refractory to diuresis
HCV
Aspiration of things you can’t
remove
Severe aspiration of gastric
contents, food, gravel, glass etc.
Bullets in LU parenchyma

30. Reaching Transplant Center Staff:
Using the OPO Console
OPO staff contact info can be found in the Match Run

31. Real offer

32. Setting OR times
Do not set OR times prior to placing
all organs, period
If you’ve ignored the above, stop
making offers when OR timing will
R/O those offers

33. In Summary
Thorough donor testing is essential to
recipient safety
Both OPO and Transplant Center staff
need to seek clear and open
communication at all times
Offers need to be complete, and
Transplant Center responses timely

34. Special Thanks To:
Cleveland Clinic
Lung Transplant Program
Staff
…and
Thank YOU, for your daily dedication!!

35. Questions?

36. References & Sources
CDC.gov
optn.transplant.hrsa.gov
OPTN Policies
Unet
seemyradiolgy.com