Lung transplant

Overview

A lung transplant involves surgically replacing one or both diseased or failing lungs with a healthy lung, typically obtained from a deceased donor. This procedure is considered when medications and other treatments have been ineffective in improving the patient’s condition.

A lung transplant can greatly improve your health and general quality of life, despite being a complicated procedure with possible side effects. The transplant may involve replacing one or both of your lungs, depending on your medical condition. In certain instances, a donor heart is also transplanted together with the lungs.

It’s important that you understand every step of the procedure while thinking about a lung transplant, including the surgical procedure, any possible risks, and the necessary follow-up.

Types

There are three primary types of lung transplants:

• Single lung transplant: Involves replacing one diseased or damaged lung with a donated lung.
• Double lung transplant: Involves replacing either diseased or damaged lungs with donated lungs.
• Heart-lung transplant: This involves the removal of your heart and both lungs, which are then replaced with a donated heart and lungs.

Reasons for undergoing the procedure

A lung transplant may be recommended by your healthcare provider if you have a lung condition or injury that hasn’t responded to medications or other treatments. When lungs are damaged, they can struggle to provide the essential oxygen your body needs to survive. Several diseases and conditions can affect lung function and diminish their effectiveness.

Here are some common causes of lung damage that may necessitate a lung transplant for treatment:

• Bronchiectasis.
• Chronic obstructive pulmonary disease (COPD), such as emphysema.
• COVID-19.
• Cystic fibrosis.
• Interstitial lung disease (ILD).
• Lung injuries.
• Scarring of the lungs (pulmonary fibrosis).
• Pulmonary hypertension or high blood pressure in the lungs.

While medications and special breathing devices can often manage lung damage, they may become ineffective over time or when lung function becomes life-threatening. In such cases, your healthcare provider might recommend either a single-lung transplant or a double-lung transplant.

Individuals with coronary artery disease may require a procedure to restore blood flow to a blocked or narrowed artery in the heart, along with a lung transplant. In more severe cases involving both heart and lung conditions, a combined heart-lung transplant may be necessary.

A lung transplant may not be suitable for everyone. Factors that could disqualify a person from undergoing a lung transplant include:

• Active infection
• Recent personal medical history of cancer
• Serious conditions like kidney, liver, or heart diseases
• Unwillingness or inability to make necessary lifestyle changes to maintain the health of the donor lung, such as abstaining from alcohol or smoking
• Lack of a supportive network of family and friends

Each case is evaluated individually by a transplant center to determine candidacy for a lung transplant.

Risk

Risks related to lung transplants can be severe and occasionally life-threatening. The following are risk of lung transplant:

• Infection: Immunosuppressive medications are intended to reduce or stop the immune system from attacking your newly acquired lung. However, fighting off infections is challenging when the immune system is weakened. You run a higher chance of developing serious infections such bloodstream, fungal, skin, and respiratory infections while using these medications.
• Surgical risks: Like all surgeries, lung transplants carry inherent risks. These risks may involve complications related to anesthesia, bleeding, blood clots, scarring, infections, and in extreme cases, death.
• Transplant rejection: Your body’s defense against foreign substance is greatly assisted by your immune system. Your immune system will naturally try to attack and reject your new lung or lungs, even with greatest efforts to match you with the donor. Shortly after the lung transplant, there is an increased risk of rejection, which usually goes down when medications and treatments are given.

Transplant rejection is most frequent within the first 12 months after surgery, known as acute rejection. Your healthcare provider can typically reverse acute rejection by administering additional immunosuppressive medications. However, chronic rejection is another form that may develop in individuals more than three years post-transplant. Chronic rejection is challenging to treat and can potentially result in death or necessitate a subsequent transplant.

Immunosuppressant medication will be part of your post-transplant treatment routine. These medications are necessary because they lower your immune system, which keeps your body from rejecting the donated organ. For the rest of your life, you will have to take these anti-rejection drugs.

Certain anti-rejection medications may also increase your chance of acquiring new conditions or making pre-existing ones worse, including:

• Cancer
• Diabetes
• Fever.
• High blood pressure
• Kidney damage
• Osteoporosis

Before the procedure

A lung transplant typically involves thorough planning before the actual procedure to secure a donated lung. The preparation phase can begin weeks, months, or even years in advance, depending on how long you may have to wait for a suitable donor lung.

Before the transplant, you’ll undergo an extensive pre-transplant screening. This initial assessment helps determine if a lung transplant is the right treatment for you. During this process, a transplant coordinator—a specialized healthcare provider—will collect detailed medical information about your condition.

The following pre-transplant screening includes:

• The overall general health.
• Family health history.
• Blood tests.
• Bone density test (DEXA scan).
• Cardiac tests includes electrocardiogram, echocardiogram and cardiac catheterization.
• Prescribed medications, including blood thinners.
• Pulmonary function tests.
• Recent computed tomography (CT) scans and chest X-rays.
• Sigmoidoscopy or colonoscopy.
• Tissue typing test is performed to ensure compatibility between your body tissues and those of the lung donor.
• Ventilation-perfusion scan is a diagnostic test that evaluates both the airflow (ventilation) and blood flow (perfusion) in the lungs.

Your healthcare provider will conduct a Pap smear and a mammogram for women. For men, your healthcare provider will perform a prostate exam. These exams are part of the routine medical assessments before a lung transplant to ensure overall health and readiness for surgery.

Following your pre-transplant screening, your transplant coordinator and other members of your lung transplant team will convene to review your tests and collectively assess whether a lung transplant is the most suitable treatment option for you.

Your transplant team will also discuss with you the advantages and potential risks of undergoing a transplant, as well as what to anticipate before, during, and after the procedure. This comprehensive discussion ensures that you are well-informed and prepared for every aspect of the transplant journey.

Your transplant team will register you and put your name on a waiting list at the transplant facility if they determine you are a good candidate for a lung transplant. Due to the large number of individuals on the lung transplant waiting list, it’s possible that you may remain on the list for months or even years before a suitable donor lung becomes available. It’s important to remember that there is a much greater need for lung transplants than there are donor lungs available.

While on the waiting list, your healthcare team will monitor your condition closely and adjust your treatment as necessary. They may advise you the following:

• Lifestyle change: It’s essential to cease drinking alcohol, particularly if you previously consumed two or more alcoholic drinks per day. Additionally, maintaining a stable weight is important, and in some cases, weight loss may be recommended if you have obesity. You will also be advised to stop from using any tobacco products.
• Engaging in regular exercise: Your physical therapist will collaborate with you to create an exercise regimen aimed at maintaining optimal physical condition before your transplant.
  Your healthcare providers may suggest that you participate in a pulmonary rehabilitation program while waiting for a donor lung. This program is designed to help maintain and improve your lung function, overall physical conditioning, and quality of life during the waiting period. This will assist you in developing a breathing exercise program to promote the healthiest possible lung function. These coordinated efforts are designed to prepare you effectively for the transplant procedure.
• Medications: It’s important to adhere strictly to the medications prescribed by your healthcare providers. If another healthcare provider prescribes antibiotics or adjusts your steroid dosages, notify your transplant coordinator promptly. This ensures coordinated care and helps manage your medication regimen effectively during the transplant process.
• Preparation: A donor lung can become available unexpectedly, so it’s important to have a transportation plan ready to get to the hospital promptly. It’s also wise to prepare an emergency bag with items that will make your hospital stay more comfortable. Consider including comfortable clothing, toiletries, and reading materials in your bag. Being prepared in this way can help reduce stress and ensure you have essential comforts during your hospital stay for the transplant procedure.

When a donor organ becomes available, the transplant center will administers a matching system to find an appropriate recipient based on specific criteria, including:

• Blood type compatibility
• Size of the organ compared to the recipient’s chest cavity
• Geographic distance between the donor organ and the transplant recipient
• Severity of the recipient’s lung disease
• Recipient’s overall health status
• Likelihood of a successful transplant outcome

These factors help ensure that the best possible match is made between donor and recipient for a successful lung transplant.

It’s essential to keep your packed hospital bag readily accessible, which should include an additional 24-hour supply of your medications. Arrange transportation to the transplant center well in advance, as you may be required to arrive at the hospital within a short notice, typically within a few hours, once a donor lung becomes available. This preparation ensures you are ready for timely and efficient transport to the hospital for the transplant procedure.

Upon arrival at the hospital, you will undergo tests to confirm that the donor lung is a suitable match and that you are in good enough health to undergo the surgery. The donor lung must also meet specific health criteria; otherwise, it may be rejected by the transplant team. If it is determined that the surgery would not likely be successful, the transplant may be canceled. This thorough evaluation process ensures the best possible outcome for the transplant procedure.

During the procedure

During the lung transplant procedure, you will be under general anesthesia, ensuring you are unconscious and do not experience any pain. Your heart and blood pressure will be continuously monitored using an electrocardiogram (EKG). To assist with breathing, a tube will be inserted through your mouth and into your windpipe. This ensures adequate ventilation throughout the surgery.

The positioning on the operating table during a lung transplant can vary depending on the type of transplant needed. For a single lung transplant, you may lie on your side or on your back. In contrast, for a double lung transplant or a heart-lung transplant, you will typically lie on your back during the procedure.

Your procedure may necessitate the use of a mini heart-lung machine known as ECMO (extracorporeal membrane oxygenation). ECMO enables your transplant surgeon to divert blood flow away from your heart and lungs temporarily. It pumps blood through your body, removing carbon dioxide and infusing it with oxygen to maintain the health of your tissues

For a single lung transplant, your healthcare provider will use a sterile scalpel to make an incision on the side of your chest where the damaged lung will be replaced. Occasionally, a single lung transplant can also be carried out through a breastbone incision, much like heart surgery.

For a double lung transplant, your healthcare provider will use a scalpel to create a horizontal incision across your entire chest, typically below your breast tissue. Alternatively, an incision similar to that used in heart surgery (sternotomy) may also be employed for a double lung transplant.

Your healthcare providers will remove your diseased or damaged lung and replace it with the donor’s lung. They will carefully connect the blood vessels and airways using small surgical needles and thread. This process ensures that the transplanted lung receives blood (vascularization), which is important for maintaining the health and function of your tissues.

After confirming adequate blood flow to your transplanted lung and proper airflow through your airways, your healthcare providers will insert small silicone tubes into the surgical sites. These tubes serve to drain blood, fluid, and air from your chest cavity. Additionally, they assist in allowing your new lungs to fully expand and function effectively.

Following the lung transplant surgery, your healthcare providers will disconnect you from any surgical support machines. However, they will not remove the mechanical ventilator or the catheter at this stage. They will proceed to suture your incision closed and apply bandages to cover the surgical site. This completes the surgical procedure, preparing you for the recovery phase.

A lung transplant is a complex and time-consuming procedure that varies in duration depending on whether it involves a single lung transplant or a double lung transplant:

• A single lung transplant typically lasts between four to eight hours.
• A double lung transplant generally takes longer, ranging from six to 12 hours.

The duration of the surgery is a reflection of how careful the process is and how much thoroughness is needed to guarantee the patient has the best potential outcome.

After the procedure

Immediately following the surgery, you will spend several days in the hospital’s intensive care unit (ICU). During this time, you will be supported by a mechanical ventilator to assist with breathing. Additionally, tubes will be placed in your chest to drain fluids from around your lungs and heart.

Potent medications will be injected through a venous tube after a lung transplant to control pain and stop the new lung from rejecting the donor organ. As your health improves, the mechanical ventilator will not be necessary, and you will be moved out of the intensive care unit. A typical healing process includes a one- to three-week hospital stay. The length of ICU and hospital stays can differ depending on the patient’s specific condition and pace of recovery.

As you recover in the post-transplant unit, you will begin working with physical therapists and respiratory therapists to regain strength in your body and lungs. Once you have made sufficient progress and your healthcare team determines it is safe, they will discharge you from the hospital and allow you to return home.

The lung transplant team will need to check on you on a frequent basis for around three months after you leave the hospital in order to assess your lung function and avoid, identify, and treat problems. Staying close to the transplant center during this time is usually advised for convenient access to medical treatment. The frequency of follow-up visits then decreases, giving you more freedom to schedule your appointments and get to and from the transplant center.

Laboratory testing, chest X-rays, electrocardiograms (ECGs), lung function tests, lung biopsies, and specialist check-ups could all be part of your follow-up appointments.

During a lung biopsy, your healthcare provider extracts tiny samples of lung tissue to examine for signs of rejection or infection. This procedure often takes place during a bronchoscopy, where a flexible tube called a bronchoscope is inserted through your mouth or nose and into your lungs. The bronchoscope is equipped with a light and a small camera, enabling the provider to visually inspect the airways inside your lungs. Additionally, special tools may be used through the bronchoscope to gather small tissue samples for laboratory testing.

Your transplant team will keep a careful eye on you and help you cope with the side effects of immunosuppressants. Infections will also be monitored for and treated as necessary. To stop infections, your healthcare provider might recommend antivirals, antifungals, or antibiotics. Your transplant team will also offer advice on precautions you can take at home to lower your risk of infection.

You will also undergo regular monitoring for any signs or symptoms of rejection. It’s crucial to promptly inform your transplant team if you observe any indications of rejection.

Outcome

Your quality of life can be greatly improved with a lung transplant. The following are the main advantages of receiving a lung transplant:

• Increased lifespan: Approximately 55% of lung transplant recipients survive for at least five years post-transplant, with some individuals living up to 10 or even 20 years.
• Improved energy levels: Many recipients experience higher energy levels, enabling them to engage in daily activities and exercise more effectively.
• Increased fertility: After a lung transplant, it is generally safe for women to conceive. Many report improved fertility post-transplant. It is important to discuss the potential risks with your healthcare provider before planning a pregnancy after a lung transplant.

After your lung transplant, you will typically need to make long-term adjustments, which may include:

• Immunosuppressants: You will need to take immunosuppressant medications for life to suppress your immune system and prevent rejection of the donor lung or lungs.
• Management of medications, therapies and a lifelong care plan: Your healthcare provider will provide specific instructions to follow after your transplant. It’s crucial to take all medications as prescribed and monitor your lung function at home according to your provider’s guidance. Attend scheduled follow-up appointments and diligently follow your personalized lifelong care plan to optimize your post-transplant health and well-being.
  To guarantee that you never miss a dose of your medication, it’s important to establish a daily routine. Always carry a complete inventory of all the prescriptions you use, particularly in case of medical emergencies. Every time another medicine is prescribed, let your healthcare providers know about your current medication.
• Having a healthy lifestyle: Maintaining a healthy lifestyle is essential for preserving the health of your new lung. Your healthcare provider may recommend abstaining from tobacco products and moderating alcohol consumption. Additionally, adhering to a balanced and nutritious diet can contribute significantly to your overall health and well-being post-transplant.
  Exercise usually begins quickly after surgery and is important for your recovery from a lung transplant. Together, you and your healthcare team will create a personalized fitness program that meets your needs. They might also advise pulmonary rehabilitation, which mixes physical activity and instruction to improve your daily functioning after the transplant and your ability to breathe.
• Emotional support: Adjusting to new medical therapies and the emotional impact of a lung transplant can be overwhelming for many individuals. It’s common to experience these feelings after undergoing such a significant procedure.
  If you find yourself feeling stressed or overwhelmed, it’s important to talk to your healthcare provider. Transplant centers often offer support groups and other resources specifically designed to assist you in managing your condition and emotional well-being during this transitional period.

After undergoing a lung transplant, it’s important to maintain scheduled follow-up appointments with your healthcare providers. These appointments may involve multiple visits each week for testing and therapy during the initial six months post-procedure. These regular check-ins are vital for monitoring your recovery progress and ensuring the health of your newly transplanted lung.

If you experience any symptoms of illness, discomfort, or notice changes at your transplant site, it’s crucial to contact your healthcare provider immediately.

Before starting any new medications, including prescribed medications, over-the-counter drugs, or herbal supplements, consult your healthcare provider. They can offer guidance on potential interactions with your current medication regimen and ensure that any new treatments align with your post-transplant care strategy.