Patient Corner

When do you need a Lung Transplant

Your lungs have an important job of providing the oxygen and extracting carbon dioxide from the body. When lungs are healthy, you are rarely aware of the automatic process of breathing. You feel "short of breath" only when your lungs have to work harder than usual. This makes your breathing muscles expend extra energy on breathing, causing constant fatigue. This struggle to breathe diminishes your quality & life expectancy. Further testing and medications may help restore and in some cases reverse this process. However; if your lungs have physical damage that is progressive and resistant to therapy, you may become bed bound and oxygen dependent. It is in such cases that you may have to consider detailed investigation and candidacy for Lung transplantation.

Diseases that affect the lung and require transplantation, and types of transplants-

A number of disease conditions can cause irreversible organ damage requiring the replacement of the diseased lung (Double/Bilateral Lung Transplant). Children & certain adult with congenital heart defect that have been treated late or are inoperable do end up at our centre with irreversible pulmonary hypertension. These individuals will be candidates for a Heart and Bilateral lung transplant as corrective therapy.

The commonly encountered diseases include

  • Chronic Obstructive Pulmonary Disease (COPD): due to smoking tobacco usage), alpha-1-antitrypsin deficiency or other causes
  • Interstitial Lung Diseases (ILD) including Pulmonary fibrosis
  • Sarcoidosis
  • Cystic Fibrosis
  • Bronchiectasis
  • Primary Pulmonary Hypertension
  • Lymphangioleiomyomatosis (LAM)
  • Langerhans cell histiocytosis (PLCH)
  • Pulmonary alveolar microlithiasis
  • Pulmonary alveolar proteinosis
  • Congenital heart disease with Eisenmenger syndrome
  • Other diseases causing end stage

Why do you need a lung transplant

You are being referred for a transplant surgery, because your quality of life has been severely affected by a disease. You have developed lung disease, that neither medicine nor surgery will be able to help. Transplant is considered a final treatment option, when failure of the lungs and heart results in a poor quality of life and severely limits life expectancy. Lung and heart-lung transplantation is a surgical and medical therapy that can lead to

  • a better quality of life
  • improved lung function
  • a chance for you to experience a normal lifestyle with precaution under lifelong medical supervision

Pertinent investigations

Standard Pre-Transplant Testing:

Lungs

  • Chest CT to get a 3D X-ray picture of your lungs
  • PFT to measure lung function
  • Ventilation-perfusion scan to determine the degree of irreversible damage to the blood and air supply of each lung
  • Cardiopulmonary exercise testing
  • DLCO to measure oxygen extracting capacity of lungs

Heart

  • ECG - This test records the rhythm of the heart
  • ECHO Doppler -This test uses sound waves to look at heart size and how the heart muscle and valves are working
  • Cardiac catheterization - It is an inpatient procedure, done to measure the blood pressures in the lung and the heart. It is done with the patient under sedation {administered by an anesthesiologist) and requires a catheter to be placed through a large vein into the heart and dye injected through the catheter while X-ray is taken

Others

  • Lab tests to determine functions of various organs, Immune status and other parameters
  • Bone densitometry scan
  • Exercise capacity tests
  • Any other tests that we believe are needed to complete a thorough evaluation

Preparing for the transplant

Transplant Education - Your family will meet one of our transplant doctors and transplant nurses who will educate you about lung transplant, and answer any questions. We encourage you to ask the transplant team questions any time during the course of your stay.

Social Health / Family Support Assessment - Your family will meet our transplant social worker to review psychosocial issues and concerns, especially those that affect normal functioning and family Issues.

Social Health / Family Support Assessment - Your family will meet our transplant social worker to review psychosocial issues and concerns, especially those that affect normal functioning and family Issues.

Nutrition Consultation - The dietician will perform an assessment of the weight, height, body muscle and fat stores, and will review your dietary history in detail. Your nutritional status is very important in maintaining health during the waiting period, lowering the risk of the surgery, and aiding in the recovery after transplantation.

Mental Health Assessment - Your family will meet one of our psychologists to review cognitive (thinking skills) and emotional functioning of you and your family as a whole. The stresses of lung transplantation make this an important and mandatory part of the evaluation.

Financial Screening / Insurance Coverage - Lung transplantation is not covered by most insurance companies. An advisor will assist you in determining how the surgery and long-term medications will be paid for. This is done before you are evaluated.

Once you are accepted into the lung transplant program, you will be placed on the waiting list for organ allocation. During the waiting period you will

  • Be given regular assessment – Including clinical evaluation and lab work / imaging
  • Undergo regular pulmonary rehabilitation guided by our team of physical therapy experts that will get you in best possible physical condition for surgery, with exercise and good nutrition
  • Be required to quit smoking/ alcohol / other drug use
  • Be put in touch with social and financial coordinators for help with logistical issues
  • Be counselled along with your family members at regular intervals about what to expect before, during, and after lung transplantation
  • Be told what to do when it is your time to receive a donor organ

Benefits of Lung Transplant

Lung transplantation has the potential to both lengthen life expectancy and substantially improve quality of life. It is impossible to predict how long you may survive after transplantation. The most critical period for survival is the first year after transplant. This is the period when the surgical complications, rejection and infections are the greatest threat to survival. Patients who survive the first year can easily survive 5 years or longer after transplantation. There are patients alive today who had lung transplantation 10 or more years ago. The real challenge is for you to achieve all your dreams once you are free of oxygen and more mobile.

Risks

Rejection and infection are the two major complications post lung transplantation. Because your transplanted lung(s) is foreign to your body, your body's immune system will seek to remove it. This is termed as rejection. You can know you are experiencing rejection when you undergo

  • Fever, cough, difficulty breathing
  • Decrease in pulmonary function tests (FVC and FEVl)
  • Elevated white blood cell count (WBC)
  • Abnormal chest x-ray (pleural effusion or pneumonia-like changes, or both)

You will be prescribed immunosuppressive medication to help slow down the immune system and control the rejection process. This will be a combination of Tacrolimus, Mycophenolate or Azathioprine, and Prednisolone or other medications. The dosages of the drugs may need to be frequently checked and adjusted in response to rejection or side effects.

Infection

Because you are taking immunosuppressive medications, your immune system will be less able to fight invading infections, thereby making you more susceptible to infective diseases. To prevent this, the immunosuppression is balanced with anti-infective prophylaxis, and you will be given instructions to avoid exposure to infections.

What you expect on the day of surgery

When an alert for a potential matching organ for you is received by the hospital through the authorities, you will be immediately alerted to become nil per oral i.e. stop eating / drinking till further notice. The retrieval team travels to the donor hospital to assess the quality of the organ. They perform a series of tests including Bronchoscopy, Tran’s esophageal echo, gram stain and other tests to rule out colonization and airway infections, also serial blood gas assessments before finally verifying its physical and structural integrity. On confirmed allotment of organ (based on waitlist status, blood group, size match and most importantly the quality of the organ) you will be called to the hospital and once again explained in detail about the risk and benefit of lung transplant surgery, its attendant risks. Once your consent obtained, you are shifted to ICU in preparation for the surgery which involves collection of blood sample, placement of IV access lines, shaving and clearing of body parts and before you will be shifted to Operation Theater for surgery.

Recovery matters

You should not lift anything greater than 5 kgs for six weeks after surgery and not participate in strenuous activity for six weeks. We will have you follow up for physical therapy twice a week to help with accomplishing the proper types of exercise. Check your chest incision every day. If there is unusual redness or swelling, pus, drainage, or pain, contact the transplant nurse immediately. Clean the incision daily with warm water and soap. Call the transplant nurse, or on call physician immediately, if you experience any of the following:

  • Fever over 99.6oF
  • Progressive or acute drop in FEV1
  • Chest tightness and/or acute reduction in walk distance
  • Flu-like symptoms (aches, nausea, vomiting, runny nose, etc.)
  • Cough or shortness of breath
  • Blood in the stool
  • Nausea, vomiting, or diarrhea
  • Chills
  • Redness, swelling, pus, drainage, or pain at the incision or central line site

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