Lung transplant complications

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

Clinical Features/Differential Diagnosis

Infection

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
  • Pulmonary vasculature problems
  • 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

Disposition

  • Depends on complication, usually admit.

See Also

External Links

References