Lung Transplant

Preparation

Lung disease is characterized by the inability to breathe -- that most basic of all human biological functions. People with lung disease are likely to experience shortness of breath, chronic cough and exhaustion. If the condition is severe and untreated, the patient eventually will die.

Lung transplantation for patients with severe diseases of the lung -- such as emphysema, cystic fibrosis, pulmonary fibrosis, sarcoidosis and pulmonary hypertension -- is considered only after all other treatments have failed. In some cases, congenital heart disease may cause advanced lung disease, requiring repair of these heart defects at the time of lung transplantation.

For a lung transplant to happen, two things must occur. First, the patient must be eligible for the transplant. Second, a suitable donor organ must be available.

Evaluation

Patients must meet a broad range of physical and psychosocial criteria to become eligible for transplantation. A social evaluation determines if transplant candidates have the psychological stability, motivation and personal support to meet the challenges of transplantation. Then the patient and family meet with the team of experts who will be with them throughout the transplant process.

Each patient's team includes a transplant lung specialist called a pulmonologist, transplant surgeon, transplant nurse coordinator, transplant social worker, psychologist and physical therapist.

• The transplant pulmonologist completes a physical examination and determines the cause of disease during the selection process. The pulmonologist reviews the patient's current medications, assesses the risks and benefits of transplant surgery, and makes recommendations to the team. In conjunction with the team, the pulmonologist remains involved throughout the transplant process.

• The transplant surgeon completes a general surgical evaluation, reviewing any previous operations and assessing the risks and benefits of surgery. In consultation with the other team members, the surgeon makes recommendations for transplantation. The surgeon follows the patient before transplant, performs the transplant, and continues following the patient post-operatively and after discharge.

• The thoracic surgeons who perform the lung transplantation will meet with you for a surgical consultation. They will discuss any previous abdominal or chest surgery that you may have had and describe the surgical plan for your transplantation. The thoracic surgeon reviews your medical plan-of-care daily with the surgical resident and nursing staff. Additionally, he or she will see you in clinic after discharge.

• The transplant nurse coordinator organizes all aspects of care before and after the transplant. The coordinator oversees the selection process and facilitates communication among all members of the team. In addition, the coordinator provides patient education, coordinates testing and follow-up care and maintains records.

• The insurance coordinator reviews the patient's available insurance to ensure that the patient will not experience financial hardship related to the transplant or postoperative and discharge care and coordinates insurance coverage with outside case managers.

• The social worker completes a psychosocial evaluation and provides support to the transplant patients and their families throughout the process. The social worker also makes recommendations to the team regarding the patient's psychosocial status, commitment to transplantation, and relevant financial issues.The social worker for our Lung Transplant Program will meet with you to review the program in detail and to provide any patient educational assistance you will require preoperatively.

• Long-standing lung disease can strain your heart so you will need to be evaluated by the transplantation cardiologist. He or she will examine you and will also review your medical history, electrocardiogram and echocardiogram. The cardiologist may recommend that you have a further study of your heart with a procedure called a cardiac catheterization. This procedure will be scheduled by the Division of Cardiology and may require an overnight stay in the hospital.

Persons with cystic fibrosis are required to consult with an ear, nose and throat specialist. If minor sinus surgery is required, a short hospital stay is arranged. Several other team members conduct appropriate specialty evaluations when indicated and make recommendations to the team. These include but are not limited to the anesthesiologist, cardiologist, psychologist, intervention counselor, infectious disease specialist, hematologist and physical therapist.

Transplant candidates undergo a battery of tests that may include routine blood work, electrocardiogram (ECG) and other radiological and diagnostic procedures. UCSF Medical Center uses state-of-the-art imaging technology to obtain the most accurate diagnoses. After the medical work-up, our team designs care plans for each patient, drawing on resources from a variety of disciplines, including social work, nursing and nutrition. Patients are never out of touch with the team: an expert who knows about each case is on call 24 hours a day, seven days a week.

Eligibility

To be eligible for a lung transplant, you must meet the following requirements:

• In general, you must be physiologically 60 years of age or less for bilateral lung transplantation and 65 years of age or less for single lung transplantation. This means that your physical condition must at least meet the typical condition of someone 60 years old or younger, or someone 65 years old or younger. Your chronological age is not a factor.
• You must have a poor prognosis, with an anticipated 18 to 24-month survival.
• You must have no other life-threatening systemic disease.
• You must have demonstrated absolute compliance with medications and medical recommendations, and have good rehabilitation potential.
• You must demonstrate emotional stability and must have a realistic understanding of the implications of organ transplantation.
• You must have a supportive social support system.

Once all the interviews and tests are completed, the members of the transplant team review the information and make a recommendation about treating your lung disease. They may suggest further testing or other therapies prior to considering a lung transplant. It is important to remember that lung transplantation is not appropriate therapy for all patients with lung disease.

Waiting for a Lung

If accepted as a lung transplant patient, you will join many other patients who are awaiting a transplant. You will be seen on a regular basis to monitor your progress. If you are not accepted initially as a lung transplant candidate, the reasons for the decision and any further testing and therapeutic options will be discussed with you and your referring physician.

As a result of your lung condition, you may have several associated problems that must be addressed. These include:

• Shortness of breath and increased oxygen need
• Decreased activity level
• Wasting of your muscle groups including respiratory muscles, postural or trunk muscles, and your arm and leg muscles
• Cardiovascular deconditioning
• Fear or anxiety due to breathlessness

Evaluation in a pulmonary rehabilitation program is essential if you are considering transplantation. It is important that you be in the best physical shape as possible at the time of your surgery. Lung transplantation will improve your shortness of breath and oxygen need. Therefore, you will be introduced to the importance of exercise and activity before your transplant. This will include training your respiratory muscles as well as a biking or walking program for general conditioning. You will need to continue this program even after your transplant occurs.

We also require all patients to have an annual flu shot, a pneumonia vaccine, up-to-date tetanus shots (within the last 10 years) and H.influenzae B. vaccine.

After being approved for transplantation, patients are immediately put on the United Network for Organ Sharing (UNOS) lists. Your placement on the waiting list is determined by the severity of your condition and the likelihood that your transplant would be successful, known as your lung allocation score. Those with higher scores get higher priority when a compatible lung becomes available. During the waiting period, UCSF Medical Center provides a network of support for patients and family members, including a long-running, popular support group.

A new lung or lungs will come from a person who is an organ donor. This person has suffered an injury to the blood supply to the brain, which results in "brain death."

Organ procurement organizations work to match donors with people who are awaiting transplants. This matching is based primarily on the size of the donor and the blood type and is started through a computerized listing created by UNOS. A transplant team removes the lungs from the donor and brings them to UCSF Medical Center. While this is happening, you will be notified to come to the medical center. You will then be transferred to the operating room where an anesthesiologist will prepare you for surgery.

Procedure

You can be called into the hospital for the transplant at any time. When the call comes, you will proceed to the Intensive Critical Care Unit (ICC) to prepare for surgery. Then you will be transferred to the operating room.

The surgery takes from six to 10 hours, depending on medical conditions. After surgery, you will go back to the ICC. From there, your are transferred to the cardiothoracic nursing unit, depending on your condition. The expected length of stay for an uncomplicated lung transplant is eight to 21 days.

If you are having a single lung transplant, the incision will be made on your side, either right or left, about six inches below your armpit. Your old lung will be removed through this opening and the new lung will be implanted. In the case of a double lung transplant, the incision will run across the lower part of your chest. The lung, whether single or double, is connected to the pulmonary artery, pulmonary veins and the main stem bronchus or airway. The incisions will be uncomfortable and will take several weeks to heal.

Recovery

Once your surgery has been completed and the lung transplant is a technical success, the issue of successfully living with a transplant becomes quite involved. The two major issues are rejection and infection.

Lung transplant recipients undergo specialized rehabilitation programs. The transplant team follows patients throughout this process -- and for the rest of their lives. Patients are seen as needed in the outpatient clinic. A transplant expert is available 24 hours a day, seven days a week for questions or consultation.

Rejection and Infection

Rejection is the natural process of your body that recognizes your new lung as being foreign to the body and attempts to destroy it. This reaction originates within your immune system. This is similar to the way your body identifies a splinter in your finger as a foreign object. The redness and inflammation in the area of the splinter is an immune response. To prevent rejection, you must be treated with immunosuppressants, medications that interfere with the body's normal immune response.

We expect that you will have episodes of rejection in the first several months after transplant. The treatment requires that you receive doses of the anti-rejection medications intravenously. You will require frequent blood sampling to determine the levels of immunosuppressant drugs, as each individual is unique and requires an individualized approach. The goal is to find the lowest immunosuppressant dose that will prevent rejection and therefore minimize the risk of infection and side effects from the medications. Failure to take these medications will result in the rejection of your new lung.

Because your immune system is suppressed to prevent you from rejecting your new lung, you will be more prone to infection. We will monitor your temperature for sign of infection and your count for white blood cells, which help fight infections. Infections are generally treated with antibiotics and you will be asked to take certain medications on a regular basis to prevent certain types of infection. You may have to undergo intermittent short courses of intravenous antibiotics. The signs of infection are redness, swelling and tenderness at a surgical site. A new lung infection may begin with a mild fever, new cough and change in lung secretions.