Lung transplant complications
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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