Lung Transplant

WHAT IS A LUNG TRANSPLANT?

A lung transplant is surgery done to remove a diseased lung and replace it with a healthy lung from another person. The surgery may be done for one lung or for both. Lung transplants can be done on people of almost all ages from newborns to adults up to age 65.

Types of lung transplant procedures include:

• Single lung. This is the transplant of one lung.
• Double lung. This is the transplant of both lungs.
• Bilateral sequential. This is the transplant of both lungs, done one at a time. It’s also called bilateral single.
• Heart-lung transplant. This is the transplant of both lungs and the heart taken from a single donor.

Most lungs that are transplanted come from deceased organ donors. This type of transplant is called a cadaveric transplant. Healthy, non-smoking adults who are a good match may be able to donate part of one of their lungs. The part of the lung is called a lobe. This type of transplant is called a living transplant. People who donate a lung lobe can live healthy lives with the remaining lungs.

WHY MIGHT I NEED A LUNG TRANSPLANT?

A lung transplant may be advised for someone who:

• Has serious lung problems that can’t be improved with any other treatment, and
• Has a life expectancy of 12 to 24 months without a transplant

A lung transplant may be needed for the following conditions:

• Severe cystic fibrosis (CF). This is an inherited disease that causes problems in the glands that make sweat and mucus. It is ongoing, gets worse over time, and is usually fatal.
• Bronchopulmonary dysplasia or chronic obstructive pulmonary disease (COPD).These are lung diseases that can interfere with normal breathing.
• Pulmonary hypertension. This is increased blood pressure in the arteries of the lungs.
• Heart disease. Heart disease or heart defects that affect the lungs may need a heart-lung transplant.
• Pulmonary fibrosis. This is scarring of the lungs.
• Other diseases. Other conditions that can cause severe lung damage include sarcoidosis, histiocytosis, and lymphangioleiomyomatosis. Also, certain hereditary conditions can affect the lungs.

Not all people with these conditions need a lung transplant. A lung transplant is not advised as a treatment for lung cancer. Your healthcare provider may have other reasons to advise a lung transplant.

WHAT ARE THE RISKS OF A LUNG TRANSPLANT?

All procedures have some risks. The risks of this procedure may include:

• Bleeding
• Infection
• Blockage of the blood vessels to the new lung(s)
• Blockage of the airways
• Severe pulmonary edema (fluid in the lung)
• Blood clots
• Rejection of the new lung(s)

Rejection is major risk of transplant. This is a normal body reaction to a foreign object or tissue. When an organ is transplanted into a person’s body, their immune system sees it as a threat and attacks the organ. To allow the transplanted organ to survive in a new body, medicines are used to trick the immune system into not attacking the transplant. The medicines used to prevent or treat rejection have a lot of side effects. The exact side effects will depend on the specific medicines that are taken.

In some cases, a person shouldn’t have a lung transplant. Reasons for this can include:

• Current or recurring infection that can’t be treated
• Cancer that has spread to other parts of the body(metastatic cancer)
• Severe heart problems
• Health problems that make the person unable to tolerate surgery
• Serious health conditions other than lung disease that won’t get better after transplant
• Not being willing or able to stick to all treatment requirements for getting a lung transplant

Your risks may vary depending on your general health and other factors. Ask your healthcare provider which risks apply most to you. Talk with him or her about any concerns you have.

HOW DO I GET READY FOR A LUNG TRANSPLANT?

To get a lung from an organ donor who has died, you will first be evaluated by a transplant team. The team may include:

• A transplant surgeon
• A doctor specializing in the treatment of the lungs (transplant pulmonologist),
• One or more transplant nurses
• A social worker
• A psychiatrist or psychologist
• A dietitian
• A chaplain
• An anesthesiologist

The transplant evaluation process includes:

• Psychological and social evaluation. This includes assessing your stress, financial issues, and support by family and other loved ones. These issues can have a major affect the outcome of a transplant.
• Blood tests. Blood tests are needed to help find a good donor match. This helps improve the chances that the donor organ will not be rejected.
• Diagnostic tests. Tests may be done to check your lungs and your overall health. These tests may include X-rays, ultrasound, CT scans, pulmonary function tests, lung biopsy, and dental exams. Women may also get a Pap test, gynecology evaluation, and a mammogram.
• Stopping smoking. Lung transplant recipients who smoke must quit. They must be nicotine-free for several months before being put on the transplant list.
• Other preparations. Several immunizations will be given. These are to lessen the chance of infections that can affect the transplanted lung.

The transplant team will consider all information from interviews, your medical history, physical exam, and diagnostic tests in deciding your eligibility for a lung transplant.

Once you have been accepted as a transplant candidate, you will be placed on a waiting list of the United Network for Organ Sharing (UNOS.) Waiting times vary greatly. They depend on which organ(s) you need, your age, your blood type, and the reason for your transplant. People who are unable to wait may be considered for lung transplant from a living donor.

When a donor organ is available from a deceased person, you will be notified and told to come to the hospital right away so you can be prepared for the transplant. If you are getting a lung from a living donor, the transplant can be done at a planned time. The potential donor(s) must have a compatible blood type and be in good health. Psychological tests will be done to be sure the donor is fine with the decision.

Before the transplant:

• Your transplant team will explain the procedure to you and give you a chance to ask any questions about the procedure.
• You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if anything is not clear.
• For a cadaver organ transplant, don’t eat or drink as soon as you are told that a lung has become available.
• For a planned living transplant, you should not eat or drink for 8 hours before the surgery, most often after midnight.
• You may be given a sedative prior to the procedure to help you relax.

Your healthcare providers may give you other specific instructions to get ready.

WHAT HAPPENS DURING A LUNG TRANSPLANT?

Lung transplant requires a stay in a hospital. The way the procedure is done may vary. It depends on your condition and your health care provider’s methods. In most cases, the procedure will follow this process:

1. You will be asked to remove your clothes and given a hospital gown to wear. You will also be asked to remove jewelry or other objects.
2. A plastic bracelet with your name and an identification number will be put on your wrist. You may get a second bracelet if you have allergies.
3. An intravenous (IV) line will be put in your arm or hand.
4. Thin, flexible tubes (catheters) will be put in your neck, wrist, under the collarbone (subclavian), or the groin. These are used to monitor your heart and blood pressure, and to take blood samples.
5. You will lie down on an operating table. For a single lung transplant, you will lie on your side. For a bilateral sequential lung transplant, you will lie on your back with your arms above your head.
6. You will be given general anesthesia. This is medicine that prevents pain and lets you sleep through the procedure.
7. A breathing tube will be put into your throat and hooked up to a breathing machine (ventilator). Your heart rate, blood pressure, and breathing will be watched during the procedure.
8. A catheter will be put into your bladder to drain urine during the surgery.
9. Hair at the surgical site may be trimmed. The skin will be cleaned with an antiseptic solution.
10. The surgeon will make a cut (incision) in your chest. For a single lung transplant, the incision will be made on the side of chest where the lung will be replaced. For a bilateral sequential transplant, the incision will be made horizontally across the chest below the breasts.
11. Depending on your lung condition and the type of transplant being done, you may be put on a cardiopulmonary bypass machine (heart-lung machine). This machine sends blood and oxygen to your body during the procedure.
12. The diseased lung(s) will be removed and replaced with the donor lung(s). The new lung’s blood vessels and airways will be attached. For a bilateral sequential transplant, the lungs will be attached one at a time.
13. The incision will be closed with stitches (sutures) or surgical staples.
14. A bandage or dressing will be put on the incision site.
15. One or more tubes will be put in your chest. These are to remove air, fluid, and blood from the chest and to allow the new lung(s) to expand fully.
16. A thin tube (epidural catheter) may be put in. This is done to send pain medicine into your back. It may be done in the operating room or in the recovery room.

WHAT HAPPENS AFTER A LUNG TRANSPLANT?

After the surgery you may be taken to a recovery room. You will then be taken to the intensive care unit (ICU). This is a ward in a hospital where you will be watched closely. You will be in the ICU for several days. You will be in the hospital 7 to 14 days or longer.

IN THE ICU

• You will be connected to monitors that will constantly show your heart rhythms, blood pressure, breathing rate, and oxygen level.
• The catheter will stay in your bladder until you can pass urine on your own.
• You will have a breathing tube in your throat hooked up to a ventilator. The tube will stay in place until you are able to breathe on your own. This may be for a few hours up to several days.
• You may have a thin, plastic tube put through your nose and into your stomach. This is to remove air that you swallow. The tube will be taken out when your bowels resume normal function. You will not be able to eat or drink until the tube is removed.
• Blood samples will be taken several times a day. These are done to check the health of the new lung(s), and your kidneys, liver, and blood system.
• You may be on special IV medicine to help your blood pressure and your heart, and to control any problems with bleeding.
• You will be given pain medicine as needed, either by a nurse, through an epidural catheter, or by giving it yourself through a device connected to your IV.
• Once the breathing and stomach tubes have been removed and your condition has stabilized, you may start drinking liquids. Your diet may slowly include more solid foods as you are able to eat them.
• Your anti-rejection (immunosuppression) medicines will be closely watched to make sure you are getting the right dose and the best combination of medicines.
• Nurses, respiratory therapists, and physical therapists will work with you as you begin physical therapy and breathing exercises.

When your healthcare provider feels you are ready, you will be moved from the ICU to a private room on a regular nursing unit or transplant unit. Your recovery will continue there. You will increase your activity by getting out of bed and walking around for longer periods of time. Catheters and tubes will be removed. Your diet will be progress to solid foods.

Nurses, pharmacists, dietitians, physical therapists, and other members of the transplant team will teach you how to take care of yourself once you are discharged from the hospital.

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AT HOME

• Keep the incision clean and dry. Your healthcare provider will give you instructions for careful bathing. The sutures or staples will be removed during a follow-up office visit.
• You should not drive until your healthcare provider says it’s okay. You may need to avoid other types of activity for a while.

You will have follow-up visits frequently after leaving the hospital. These visits may include:

• Blood tests
• Pulmonary function tests
• Chest X-ray
• An exam of the main airways of the lungs using a long, thin tube (bronchoscopy)
• Removal of tissue from the lung for examination (biopsy)

The transplant team will explain the schedule for these tests. Your rehabilitation program will continue for many months.

Call your healthcare provider if you have any of the below:

• Fever of 100.4°F (38°C) or higher
• Redness or swelling of the incision
• Blood or other fluid leaking from the incision
• Pain around the incision that gets worse
• Feeling short of breath
• Trouble breathing

Your healthcare provider may give you other instructions after the procedure.

To allow the transplanted lung(s) to survive in your body, you will take medicines for the rest of your life to fight rejection. Each person may react differently to the medicines. Each transplant team has preferences for different medicines. Healthcare providers tailor medicine plans to meet the needs of each person. In most cases, 3 types of anti-rejection medicines are given. Anti-rejection medicines affect the way the immune system works, so people on these medicines have a higher risk for infections. The doses of these medicines may change often, depending on your response. While taking these medicines, you will be more likely to have certain infections. These include oral yeast infection (thrush), herpes, and respiratory viruses. For the first few months after surgery, make sure to avoid crowds and anyone who has an infection.

Call your transplant team if you have signs of rejection, such as:

• Fever of 100.4°F (38°C) or higher
• Flu-like symptoms such as body aches
• Fluid in the lung
• Tiredness
• Feeling short of breath
• Cough
• New chest pain

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When is Lung Transplant Done?

Unhealthy or damaged lungs can make it difficult for your body to get the oxygen it needs to survive. A variety of diseases and conditions can damage your lungs and hinder their ability to function effectively, including:

• Chronic obstructive pulmonary disease (COPD), including emphysema
• Scarring of the lungs (pulmonary fibrosis)
• Cystic fibrosis
• Sarcoidosis with advanced fibrosis
• Pulmonary hypertension

Lung damage can often be treated with medication or with special breathing devices. But when these measures no longer help or your lung function becomes life-threatening, your doctor might suggest a lung transplant.

What happens During Lung Transplant?

The procedure will be done with general anesthesia, so you will be unaware and won’t feel any pain. Doctors will insert a tube through your mouth and into your windpipe to help you breathe. You will also have a tube in your nose down to your stomach to drain your stomach contents. A catheter will keep your bladder empty.

Your surgeon will make a cut in your chest to remove your diseased lung. The main airway to that lung and the blood vessels between that lung and your heart will then be connected to the donor lung. For some lung transplants, you may be connected to a heart-lung machine, which circulates your blood during the operation.

A single-lung transplant takes about four to eight hours to complete, while a double-lung transplant usually takes six to 12 hours.

What happens after your Lung Transplant?

Immediately after the surgery, you’ll spend several days in the hospital’s intensive care unit. A mechanical ventilator will help you breathe for a few days, and tubes in your chest will drain fluids from around your lungs and heart.

A tube in a vein will deliver strong medications to control pain and to prevent rejection of your new lung. As your condition improves, you’ll no longer need the mechanical ventilator and you’ll be moved out of the intensive care unit. Recovery often involves a one- to three-week hospital stay.

After you’re discharged from the hospital, you’ll require about three months of frequent monitoring by the lung transplant team to prevent, detect and treat complications and to assess your lung function. During this time, you’ll need to stay close to the transplant center. Your follow-up visits may involve laboratory tests, chest X-rays, an electrocardiogram (ECG) and checkups with a specialist.

Living a healthy lifestyle is key to sustaining your new lung. Smoking isn’t allowed, and the use of alcohol is strictly limited. Following a nutritious diet also can help you stay healthy.

Exercise is an extremely important part of rehabilitation after your lung transplant and will begin within days of your surgery. Your health care team will work with you to design an exercise program that’s right for you.

How to Prepare for Lung Transplant?

The number of people needing lung transplants far exceeds the number of donated lungs available. When a donor organ becomes available, the donor-recipient matching system administered by the United Network for Organ Sharing (UNOS) finds an appropriate match based on specific criteria, including:

• Blood type
• Size of organ compared with chest cavity
• Geographic distance between donor organ and transplant recipient
• Severity of the recipient’s lung disease
• Recipient’s overall health
• Likelihood that the transplant will be successful

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