Lung transplant complications: Difference between revisions
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==Background== | ==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]] | |||
*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 medication complications}} | |||
==Differential Diagnosis== | ==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 | |||
*Occlusive granulation tissue | |||
**Asymptomatic, or worsening [[cough]], [[wheezing]], post-obstructive pneumonia | |||
*bronchial/tracheal stenosis, tracheobronchomalacia | |||
**cough, [[dyspnea]], difficulty clearing respiratory secretions, recurrent infections, wheezing, [[stridor]] | |||
*bronchopleural, bronchomediastinal, or bronchovascular fisulae | |||
**can cause [[pneumothorax]], [[hypotension]], [[mediastinitis]], [[pneumomediastinum]], [[respiratory distress]] | |||
*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== | ==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== | ==Disposition== | ||
*Depends on complication, usually admit. | |||
==See Also== | ==See Also== | ||
*[[Transplant complications]] | *[[Transplant complications]] | ||
*[[Immunocompromised antibiotics]] | |||
*[[Pneumonia]], [[pneumothorax]], [[mediastinitis]], [[pneumomediastinum]] | |||
==External Links== | ==External Links== | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Pulmonary]] |
Revision as of 12:48, 19 September 2017
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
- 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
- Immunocompromised antibiotics
- Pneumonia, pneumothorax, mediastinitis, pneumomediastinum