Lung transplantation involves removing diseased lungs and replacing them with healthy donor lungs. It is used to treat end-stage lung diseases like COPD, pulmonary fibrosis, and cystic fibrosis. Candidates undergo evaluation including lung function tests and imaging. Donor lungs must be disease-free and match the recipient's size. The surgery connects the donor lungs to blood vessels and airways. Patients are monitored closely after for bleeding, infection, and organ rejection. Long term immunosuppression is required to prevent rejection and complications include infections and chronic lung allograft dysfunction.

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
0
5
10
15
20
25
18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-65 66+
Recipient Age
%oftransplants
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:
1. FEV1 < 25% predicted ( without
reversibility)
2. PaCO2 >55 mm of Hg
3. Elevated pulmonary artery pressure
(PAP)
4. 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

16. 16

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
• Substance 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 -Heart-lung transplantation,
60 years for- Bilateral lung transplantation,
65 years for -Single-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. • Infection : 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)
50%
28%
2%
1%
2%
7%
10%
Alpha-1 COPD CF IPF PPH Re-TX Other*
*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)
24%
14%
18%
8%
28%
6% 2%
Alpha-1 COPD CF IPF PPH Re-Tx Other*
*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, O2 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
1) 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 weeks55

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