lung transplantation by david pilcher

The Alfred Intensive Care Unit, Melbourne, Australia

General & post-operative managementfor the general Intensivist

Lung Transplantation

David PilcherIntensive Care Specialist, The Alfred


Summary

Background – donors & recipients

Post-operative management

Complications:

Primary Graft Failure

Dynamic Hyper-inflation

Outcomes

The Future


116

14 149

27

11

11

22

10

9

7

9

9

5

8

2

0

2

1

0

10

20

30

40

50

60

1-4 5-9 10-19 20-29 30-39 40-49 50+

Nu

mb

er

of

Ce

nte

rs

Average number of lung transplants per year

Other

North America

Europe

Adult and Pediatric Lung TransplantsAverage Center Volume by Location

(January 2009 – June 2015)


Adult Lung Transplants - major Indications

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Nu

mb

er

of

Tra

ns

pla

nts

Year

COPD A1ATD CF IIP ILD-not IIP Retransplant


0

12

24

36

48

60

72

0%

20%

40%

60%

80%

100%

Me

dia

n r

ecip

ien

t a

ge

(ye

ars

) (b

lue

lin

e)

% o

f T

ran

sp

lan

ts

Year

0-10 11-17 18-34 35-49 50-59 60-65 66+ Median age

Adult and Pediatric Lung Transplants Recipient Age by Year (Transplants: 1987 – 2015)


DONOR SELECTION


Call


RECIPIENT SELECTION


Who gets what?

Depends on the disease processes:

Restrictive lung disease: pulmonary fibrosis

Obstructive lung diseaseEmphysema / COAD

Alpha 1 antitrypsin deficiency

Cystic fibrosis

Bronchiectasis

Pulmonary hypertension


Who gets what?





Cystic fibrosis

Bronchiectasis


SINGLE LUNG?


Who gets what?





Cystic fibrosis

Bronchiectasis


DOUBLE LUNG


SURGERY &

POST-OPERATIVE CARE


Thoracotomy Clamshell

Bronchial anastomosis

Bypass only rarely (Pulm hypertension)


Bilateral Sequential Lung Transplant


Transplant - physiology

Infection

Denervation

No bronchial blood supply

No lymphatics

“Leaky” lungs

Lungs


RespiratoryICC drainage

Chest X-ray

Bronchoscopy(when practical)

Poor gas exchange

Primary Graft Dysfunction – “leaky” lungs

ABG at 6 – 12 hours predicts outcome

Post-op management


Cardiovascular

Hypotension - epidural

ECG changes

Low filling pressures

CVP less than 7 mmHg = better outcomes

Manage by CVS-Resp guideline

Post-op management


Neurological

Pain

Anxiety

Psychosis & confusion

Management

Paracetamol

Epidural

No NSAIDS or Tramadol

Post-op management


Post-op management guideline



Haemodynamic Guideline

Target blood pressure

Target cardiac index

Vasoconstrictor

CVP 7 mmHg

iv fluids / diuretics



Respiratory Guideline

Manage as per PaO2/FiO2 ratio

Wean mechanical ventilation

Check list



Analgesia &

ImmunosuppressionEpidural & pain team

Immunosuppression “sticker”


Post-operative Complications

S**t happens


Causes of death

Early Mortality

Primary Graft FailureDynamic HyperinflationRejection

Late Mortality

Bronchiolitis obliterans

Chronic Rejection

Malignancy

Infection

Lungs


Primary Graft Dysfunction

Risk Factors:

Poor gas exchange in donor

Pulmonary thrombo-embolism

Intra-operative colloid

Very long ischaemic time

Causes:

Lymphatics disruption

Inadequate preservation

Surgical trauma

Inflammatory mediators

TreatmentSupportiveDiureticAvoid excess iv fluidPulmonary vasodilator

Consider alternative diagnosis

Pulmonary Venous AnastomosisRejection


Dynamic Hyperinflation

Causes:

Hyperinflated Native Lung

Transplant Graft Dysfunction

Proportion needing ILV

TLC % Predicted < 150% 7%

TLC % Predicted > 150% 26%

TLC % Predicted > 175% 44%

TreatmentIndependent lung ventilation

Native LungLow RRNormal tidal volume No PEEP

Transplanted lungHigh RRSmall tidal volumeHigh PEEP


Other Post-op Management

ImmunosuppressionSteroids

Mycophenolate

Tacrolimus or Cyclosporin

(Basiliximab – IL2R antagonist)

Infection ProphylaxisCMV prophylaxis (for all except Neg. donor /Neg. recipient)

PCP prophylaxis (starts at 3 weeks post op)


Are things getting better?

New organ preservation techniquesPerfadex

New surgical techniquesRetrograde flush

Bilateral thoracotomy

No more aprotonin

New anaesthetic techniquesCrystalloids & epidurals

New ICU managementProtocolised care

Recognition of potential complications


OUTCOMES


So how do they do?

Overall mortality

ICU length of stay

Duration of ventilation

Hospital length of stay


So how do they do?

Overall mortality 4%

ICU length of stay

Duration of ventilation

Hospital length of stay


So how do they do?

Overall mortality 4%

ICU length of stay 4.1 days (3.3 – 7.6)

Duration of ventilation 24 hours (13 – 73)

Hospital length of stay 23 days (17 – 35)


0

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Su

rviv

al

(%)

Years

1990-1998 (N=9,794) 1999-2008 (N=21,666) 2009-6/2014 (N=20,067)

Adult Lung TransplantsSurvival by Era

(1990 – 2014)

The Alfred


THE FUTURE


The Future

DCD lungs

Elderly donors

Ex-vivo perfusion/preservation

ECMO - bridge to transplant

Xenotransplantation


The Future……….is now

DCD lungs

Elderly donors



Xenotransplantation


Australian DCD vs BD v the World0

25

50

75

100

0 1 2 3 4

Su

rviv

al

(%)

Years

Aus DCD

Aus Brain

Dead Donors

World




DCD lungs

Elderly donors



Xenotransplantation


The Future……….will always be the future

DCD lungs

Elderly donors



Xenotransplantation


Thank you

Any more questions?

lung transplantation by david pilcher

Health & Medicine