Lung transplant complications: Difference between revisions
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==Background== | ==Background== | ||
[[File:Lung and diaphragm.jpg|thumb|Lobes of the lung with related anatomy.]] | |||
*Can transplant single lung, bilateral lungs, or heart-lungs | *Can transplant single lung, bilateral lungs, or heart-lungs | ||
*Indications: [[cystic fibrosis]], [[COPD]], idiopathic [[pulmonary fibrosis]] > alpha-1 antitrypsin deficiency, primary [[pulmonary hypertension]], bronchiectasis, [[sarcoidosis]] | *Indications: [[cystic fibrosis]], [[COPD]], idiopathic [[pulmonary fibrosis]] > alpha-1 antitrypsin deficiency, primary [[pulmonary hypertension]], bronchiectasis, [[sarcoidosis]], [[COVID-19]] | ||
*Lung is denervated | *Lung is denervated | ||
**regulation of breathing is not lost, as it is through chest wall efferents | **regulation of breathing is not lost, as it is through chest wall efferents | ||
| Line 14: | Line 15: | ||
**usually bacterial early in course | **usually bacterial early in course | ||
**[[MRSA]] and [[pseudomonas]] common | **[[MRSA]] and [[pseudomonas]] common | ||
**[[Fungi]], [[ | **[[Fungi]], [[protozoa]], [[CMV]] more common >6 weeks post-op | ||
*Extra-pulmonary infections (may be severe or opportunistic due to immunosuppression) | *Extra-pulmonary infections (may be severe or opportunistic due to immunosuppression) | ||
===Medication adverse effects=== | ===Medication adverse effects=== | ||
*Prednisone | *Prednisone | ||
| Line 25: | Line 27: | ||
*Azathioprine | *Azathioprine | ||
**Cytopenias, pancreatitis, hepatitis | **Cytopenias, pancreatitis, hepatitis | ||
===Airway complications=== | ===Airway complications=== | ||
*Anastomotic bronchial necrosis, dehiscence, or stenosis | *Anastomotic bronchial necrosis, dehiscence, or stenosis | ||
| Line 65: | Line 68: | ||
==See Also== | ==See Also== | ||
*[[Transplant complications]] | *[[Transplant complications]] | ||
*[[Neutropenic fever]] | |||
*[[Immunocompromised antibiotics]] | *[[Immunocompromised antibiotics]] | ||
*[[Pneumonia]], [[pneumothorax]], [[mediastinitis]], [[pneumomediastinum]] | *[[Pneumonia]], [[pneumothorax]], [[mediastinitis]], [[pneumomediastinum]] | ||
Latest revision as of 22:07, 13 December 2023
Background
- Can transplant single lung, bilateral lungs, or heart-lungs
- Indications: cystic fibrosis, COPD, idiopathic pulmonary fibrosis > alpha-1 antitrypsin deficiency, primary pulmonary hypertension, bronchiectasis, sarcoidosis, COVID-19
- Lung is denervated
- regulation of breathing is not lost, as it is through chest wall efferents
- cough response lost below anastomosis
- should have normal ABG (unless patient reliant on hypoxic respiratory drive), exercise response, and bronchomotor tone
Immunosuppressant Medications
- Balance between immune suppression, rejection and susceptibility to infection
- Typical regimen includes: calcineurin inhibitor + antimetabolite + steroid
- Calcineurin inhibitor
- Steroids
- +/- Antimetabolite
Clinical Features/Differential Diagnosis
Infection
- Bronchitis, Pneumonia (common)
- usually bacterial early in course
- MRSA and pseudomonas common
- Fungi, protozoa, CMV more common >6 weeks post-op
- Extra-pulmonary infections (may be severe or opportunistic due to immunosuppression)
Medication adverse effects
- Prednisone
- Hyperglycemia, psychiatric symptoms, poor wound healing, edema, hypertension
- Tacrolimus, cyclosporine
- Neurotoxicity, tremor, hyperkalemia, nephrotoxicity, hypertension, hyperglycemia, gout
- Mycophenolate
- Cytopenias, GI distress
- Azathioprine
- Cytopenias, pancreatitis, hepatitis
Airway complications
- Anastomotic bronchial necrosis, dehiscence, or stenosis
- bronchial vasculature is disrupted during procedure, ergo:
- donor bronchus reliant on retrograde pulmonary circulation for perfusion
- anastomoses vulnerable to ischemia
- mild cases may be asymptomatic
- may lead to worsening respiratory symptoms, pneumothorax, pneumomediastinum, focal infections/abscess
- bronchial vasculature is disrupted during procedure, ergo:
- Occlusive granulation tissue
- bronchial/tracheal stenosis, tracheobronchomalacia
- bronchopleural, bronchomediastinal, or bronchovascular fisulae
- Pulmonary vasculature problems
- Pulmonary artery stricture→ hypoxia
- Pulmonary venous anastomoses: vulnerable to kinking, pulmonary embolism, and thromboses→ pulmonary edema
- Rejection
- Acute/cellular rejection: clinically silent or nonspecific respiratory symptoms
- Chronic rejection (bronchiolitis obliterans): leads to airflow limitation
Evaluation
- CBC, BMP, tacrolimus/cyclosporine levels
- Infectious workup (including sputum and testing for opportunistic/atypical infections if indicated)
- CXR, CT Chest
- Advanced/inpatient workup may include:
- Bronchoscopy
- Biopsy
- Angiography or dopplers of pulmonary vasculature
Management
- See Immunocompromised antibiotics, pneumonia, sepsis
- See Pneumothorax, mediastinitis, pneumomediastinum
- Bronchoscopic debridement of necrotic, infected, or overly granulated anastomotic tissue may be needed
- Severe/symptomatic tracheobronchial stenosis may require stenting or resection
Disposition
- Depends on complication, usually admit.
See Also
- Transplant complications
- Neutropenic fever
- Immunocompromised antibiotics
- Pneumonia, pneumothorax, mediastinitis, pneumomediastinum