Lung transplant

Definition

Lung transplant is surgery to replace one or both diseased lungs with healthy lungs from a human donor.

Alternative Names

Solid organ transplant - lung

Description

The new lung or lungs are usually donated by someone who has been declared brain-dead but remains on life-support. The donor tissue must be matched as closely as possible to your tissue type to reduce the odds that your body will reject the transplanted lung.

Lungs can also be given by living donors. Two or more people are needed. Each donates a section (lobe) of their lung to form an entire lung for the person receiving it.

During lung transplant surgery, you are unconscious and pain-free (under general anesthesia). A surgical cut is made in the chest.

• For single lung transplants, the cut is made on the side of your chest that will be receiving the lung. The operation takes 4 - 8 hours.
• For double lung transplants, the cut is made below the breast. Surgery generally takes 6 - 12 hours. Tubes are used to reroute blood to a heart-lung bypass machine to provide oxygen and move blood through the body during the surgery.

After the cut is made, the major steps during lung transplant surgery include:

• One or both of your lungs are removed. For those receiving a double lung transplant, most or all of the steps from the first transplant are completed before the second transplant is done.
• The main blood vessels and airway of the new lung are sewn to your main blood vessel and airway. The donor lung or lungs are stitched (sutured) into place. Chest tubes are inserted to drain air, fluid, and blood out of the chest for several days to allow the lungs to fully re-expand.

Sometimes heart and lung transplants are done at the same time (heart-lung transplant) if the heart is also diseased.

Why the Procedure Is Performed

A lung transplant is usually the last-resort treatment for lung failure. Lung transplants may be recommended for patients with any severe lung disease. Some examples of diseases that may require a lung transplant are:

• Cystic fibrosis
• Emphysema
• Idiopathic pulmonary fibrosis
• Pulmonary hypertension
• Sarcoidosis
• Damage to the arteries of the lung because of a defect present at birth (congenital defect)

Lung transplant is not recommended for:

• Patients who are too sick to go through the procedure
• Patients whose lung disease will likely affect the new lung
• Patients who have severe disease of other organs

Risks

Risks for any anesthesia are:

• Breathing problems
• Reactions to the medications

• Bleeding
• Infection

• Blood clots (deep venous thrombosis)
• Increased risk for infections due to anti-rejection (immunosuppression) medications
• Damage to your kidneys, liver, or other body organs from immunosuppression medications

Before the Procedure

Before the procedure is done, your doctor will determine whether you are a good candidate by performing the following tests:

• Blood typing
• Tissue typing, to help make sure your body will not reject the donated lung
• Blood tests or skin tests to check for infections
• Tests to evaluate your lungs
• Tests to evaluate your heart, such as EKG, echocardiogram, or cardiac catheterization
• Tests to look for early cancer

If your transplant team believes that you are a good candidate for lung transplantation, you will be put on a national waiting list. Your place on the waiting list is based on a number of factors. Key factors include:

• What type of lung problems you have
• The severity of your lung disease
• The likelihood that a transplant will be successful

The amount of time you spend on a waiting list usually does not determine how soon you get a lung, except possibly with children. Waiting time is often at least 2 - 3 years.

While you are waiting for a new lung, follow these guidelines:

• Follow any diet your lung transplant team recommends. Stop drinking alcohol, do not smoke, and keep your weight in the recommended range.
• Take all medicines as they were prescribed. Report changes in your medications and any new or worsening medical problems to the transplant team.
• Follow any exercise program that you were taught during pulmonary rehabilitation.
• Keep any appointments that you have made with your regular doctor and transplant team.
• Let the transplant team know how to contact you immediately if a lung becomes available. Make sure that, no matter where you go, you can be contacted quickly and easily.
• Be prepared in advance to go to the hospital.

Before the procedure, always tell your doctor or nurse:

• What drugs, vitamins, herbs, and other supplements you are taking, even ones you bought without a prescription.
• If you have been drinking a lot of alcohol (more than one or two drinks a day)

Do not eat or drink anything after midnight the night before your surgery. Take only the drugs that your doctor told you to take with a small sip of water.

After the Procedure

You should expect to stay in the hospital for 7 - 21 days after a lung transplant. You will likely spend time in the intensive care unit (ICU) right after surgery.

During your hospital stay, you will:

• Be asked to sit on the side of the bed and then walk on the same day you have surgery
• Have a tube coming out of the side of your chest to drain fluids
• Wear special stockings on your feet and legs to prevent blood clots
• Receive shots to prevent blood clots
• Receive pain medicine through a tube that goes into your vein (IV) or by mouth with pills. You may receive your pain medicine through a special machine that gives you a dose of pain medicine when you push a button. This allows you to control how much pain medicine you receive.
• Be asked to do a lot of deep breathing to help prevent pneumonia and infection, and to inflate the lung that was transplanted. Your chest tube will stay in place until your lung has fully inflated.

The recovery period is about 6 months. Often, your transplant team will ask you to stay fairly close to the hospital for the first 3 months. You will need to have regular check-ups with blood tests and x-rays for many years.

Outlook (Prognosis)

A lung transplant is a major procedure performed for patients with life-threatening lung disease or damage. Around four out of five people are still alive 1 year after the transplant. Around two out of five transplant recipients are alive at 5 years. Outcomes are similar for single and double lung transplants.

Fighting rejection is an ongoing process. The body's immune system considers the transplanted organ as an invader (much like an infection) and may attack it.

To prevent rejection, organ transplant patients must take anti-rejection (immunosuppression) drugs (such as cyclosporine and corticosteroids). These drugs suppress the body's immune response and reduce the chance of rejection. As a result, however, these drugs also reduce the body's natural ability to fight off infections.

References

Smythe WR, Reznik Si, Putnam JB Jr. Lung (including pulmonary embolism and thoracic outlet syndrome). In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008: chap 59.

Davis SQ, Garrity ER Jr. Organ allocation in lung transplant. Chest. 2007;132:1646-1651.

Aurora P, Carby M, Sweet S. Selection of cystic fibrosis patients for lung transplantation. Curr Opin Pulm Med. 2008;14:589-594.

Maurer JR, Zamel N. Lung transplantation. In: Mason RJ, Murray JF, Broaddus VC, Nadel JA, eds. Murray & Nadel's Textbook of Respiratory Medicine. 4th ed. Philadelphia, Pa: Saunders Elsevier;2005:chap 89.