Slides for a talk by Professor David Pilcher about Lung Transplantation. The talk is aimed at the general intensivist and intensive care trainees and focuses on general and post-operative management. It is available as an episode of The INTENSIVE Podcast here:

1. The Alfred Intensive Care Unit, Melbourne, Australia
General & post-operative management
for the general Intensivist
Lung Transplantation
David Pilcher
Intensive Care Specialist, The Alfred

2. The Alfred Intensive Care Unit, Melbourne, Australia
Summary
Background – donors & recipients
Post-operative management
Complications:
Primary Graft Failure
Dynamic Hyper-inflation
Outcomes
The Future

3. The Alfred Intensive Care Unit, Melbourne, Australia
11
6
14 14
9
2
7
11
11
22
10
9
7
9
9
5
8
2
0
2
1
0
10
20
30
40
50
60
1-4 5-9 10-19 20-29 30-39 40-49 50+
NumberofCenters
Average number of lung transplants per year
Other
North America
Europe
Adult and Pediatric Lung Transplants
Average Center Volume by Location
(January 2009 – June 2015)

4. The Alfred Intensive Care Unit, Melbourne, Australia
Adult Lung Transplants - major Indications
0
500
1,000
1,500
2,000
2,500
3,000
3,500
NumberofTransplants
Year
COPD A1ATD CF IIP ILD-not IIP Retransplant

5. The Alfred Intensive Care Unit, Melbourne, Australia
0
12
24
36
48
60
72
0%
20%
40%
60%
80%
100%
Medianrecipientage(years)(blueline)
%ofTransplants
Year
0-10 11-17 18-34 35-49 50-59 60-65 66+ Median age
Adult and Pediatric Lung Transplants
Recipient Age by Year (Transplants: 1987 – 2015)

6. The Alfred Intensive Care Unit, Melbourne, Australia
DONOR SELECTION

7. The Alfred Intensive Care Unit, Melbourne, Australia
Call

8. The Alfred Intensive Care Unit, Melbourne, Australia
RECIPIENT SELECTION

9. The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung disease
Emphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension

10. The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung disease
Emphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
SINGLE LUNG?

11. The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung disease
Emphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
DOUBLE LUNG

12. The Alfred Intensive Care Unit, Melbourne, Australia
SURGERY &
POST-OPERATIVE CARE

13. The Alfred Intensive Care Unit, Melbourne, Australia

14. The Alfred Intensive Care Unit, Melbourne, Australia
Thoracotomy Clamshell
Bronchial anastomosis
Bypass only rarely
(Pulm hypertension)

15. The Alfred Intensive Care Unit, Melbourne, Australia
Bilateral Sequential Lung Transplant

16. The Alfred Intensive Care Unit, Melbourne, Australia
Transplant - physiology
Infection
Denervation
No bronchial blood supply
No lymphatics
“Leaky” lungs
Lungs

17. The Alfred Intensive Care Unit, Melbourne, Australia
Respiratory
ICC drainage
Chest X-ray
Bronchoscopy(when practical)
Poor gas exchange
Primary Graft Dysfunction – “leaky” lungs
ABG at 6 – 12 hours predicts outcome
Post-op management

18. The Alfred Intensive Care Unit, Melbourne, Australia
Cardiovascular
Hypotension - epidural
ECG changes
Low filling pressures
CVP less than 7 mmHg = better outcomes
Manage by CVS-Resp guideline
Post-op management

19. The Alfred Intensive Care Unit, Melbourne, Australia
Neurological
Pain
Anxiety
Psychosis & confusion
Management
Paracetamol
Epidural
No NSAIDS or Tramadol
Post-op management

20. The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline

21. The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline

22. The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Haemodynamic Guideline
Target blood pressure
Target cardiac index
Vasoconstrictor
CVP 7 mmHg
iv fluids / diuretics

23. The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Respiratory Guideline
Manage as per PaO2/FiO2 ratio
Wean mechanical ventilation
Check list

24. The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Analgesia &
Immunosuppression
Epidural & pain team
Immunosuppression “sticker”

25. The Alfred Intensive Care Unit, Melbourne, Australia
Post-operative Complications
S**t happens

26. The Alfred Intensive Care Unit, Melbourne, Australia
Causes of death
Early Mortality
Primary Graft Failure
Dynamic Hyperinflation
Rejection
Late Mortality
Bronchiolitis obliterans
Chronic Rejection
Malignancy
Infection
Lungs

27. The Alfred Intensive Care Unit, Melbourne, Australia
Causes of death
Early Mortality
Primary Graft Failure
Dynamic Hyperinflation
Rejection
Late Mortality
Bronchiolitis obliterans
Chronic Rejection
Malignancy
Infection
Lungs

28. The Alfred Intensive Care Unit, Melbourne, Australia
Primary Graft Dysfunction
Risk Factors:
Poor gas exchange in donor
Pulmonary thrombo-embolism
Intra-operative colloid
Very long ischaemic time
Causes:
Lymphatics disruption
Inadequate preservation
Surgical trauma
Inflammatory mediators
Treatment
Supportive
Diuretic
Avoid excess iv fluid
Pulmonary vasodilator
Consider alternative diagnosis
Pulmonary Venous Anastomosis
Rejection

29. The Alfred Intensive Care Unit, Melbourne, Australia
Dynamic Hyperinflation
Causes:
Hyperinflated Native Lung
Transplant Graft Dysfunction
Proportion needing ILV
TLC % Predicted < 150% 7%
TLC % Predicted > 150% 26%
TLC % Predicted > 175% 44%
Treatment
Independent lung ventilation
Native Lung
Low RR
Normal tidal volume
No PEEP
Transplanted lung
High RR
Small tidal volume
High PEEP

30. The Alfred Intensive Care Unit, Melbourne, Australia
Other Post-op Management
Immunosuppression
Steroids
Mycophenolate
Tacrolimus or Cyclosporin
(Basiliximab – IL2R antagonist)
Infection Prophylaxis
CMV prophylaxis (for all except Neg. donor /Neg. recipient)
PCP prophylaxis (starts at 3 weeks post op)

31. The Alfred Intensive Care Unit, Melbourne, Australia
Are things getting better?
New organ preservation techniques
Perfadex
New surgical techniques
Retrograde flush
Bilateral thoracotomy
No more aprotonin
New anaesthetic techniques
Crystalloids & epidurals
New ICU management
Protocolised care
Recognition of potential complications

32. The Alfred Intensive Care Unit, Melbourne, Australia
OUTCOMES

33. The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality
ICU length of stay
Duration of ventilation
Hospital length of stay

34. The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality 4%
ICU length of stay
Duration of ventilation
Hospital length of stay

35. The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality 4%
ICU length of stay 4.1 days (3.3 – 7.6)
Duration of ventilation 24 hours (13 – 73)
Hospital length of stay 23 days (17 – 35)

36. The Alfred Intensive Care Unit, Melbourne, Australia
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Survival(%)
Years
1990-1998 (N=9,794) 1999-2008 (N=21,666) 2009-6/2014 (N=20,067)
Adult Lung Transplants
Survival by Era
(1990 – 2014)
The Alfred

37. The Alfred Intensive Care Unit, Melbourne, Australia
THE FUTURE

38. The Alfred Intensive Care Unit, Melbourne, Australia
The Future
DCD lungs
Elderly donors
Ex-vivo perfusion/preservation
ECMO - bridge to transplant
Xenotransplantation

39. The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation

40. The Alfred Intensive Care Unit, Melbourne, Australia
Australian DCD vs BD v the World
0
25
50
75
100
0 1 2 3 4
Survival(%)
Years
Aus DCD
Aus Brain
Dead Donors
World
The Future……….is now

41. The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation

42. The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation

43. The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….will always be the future
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation

44. The Alfred Intensive Care Unit, Melbourne, Australia
Thank you
Any more questions?