Lung transplantation

Critical care issues in lung and heart transplantation

Although much has been accomplished in HTx and LTx in the past few decades, much remains to be conquered. It is an ever-changing, always fascinating field. Though science and technology know no limits, the primary limitation of HTx and LTx continues to be the availability of donor organs. One can only hope that further advances in educating the public will help close the large gap between the list of those waiting and the organs available for transplantation.

CT findings of pneumonia after lung transplantation

OBJECTIVE

The purpose of this study was to describe the CT findings of pneumonia in patients who had undergone lung transplantation and to determine if specific imaging features existed for the different infectious organisms.

MATERIALS AND METHODS

The authors retrospectively reviewed the medical records of 262 patients with transplanted lungs at two lung transplantation centers. Patients with a documented pneumonia and correlating abnormal findings on CT (39 patients with 45 pneumonias) were included in the study. RESULTS. Of 45 pneumonias, Cytomegalovirus (n = 15), Pseudomonas (n = 7), and Aspergillus (n = 8) organisms were the most common single responsible infectious agents. The most common CT findings of pneumonia consisted of consolidation (n = 37; 82%), ground-glass opacification (n = 34; 76%), septal thickening (n = 33; 73%), pleural effusion (n = 33; 73%), and multiple (n = 25; 56%) or single (n = 2; 4%) nodules. No significant difference in the prevalence of findings was revealed among bacterial, viral, and fungal pneumonias (p >.05, chisquare test). Of 25 pneumonias in patients with a single transplanted lung, parenchymal abnormalities involved both lungs in 12 (48%), only the transplanted lung in 11 (44%), and only the native lung in two (8%).

CONCLUSION

The manifestations revealed on CT of bacterial, viral, and fungal pneumonia after lung transplantation are similar, consisting of a combination of consolidation, ground-glass opacification, septal thickening, pleural effusion, or multiple nodules. Therefore, these findings cannot be used to suggest the infectious organisms in this patient population.

Preoperative and postoperative imaging in the surgical management of pulmonary emphysema

For patients with emphysema, imaging studies have been useful for diagnostic purposes and for preoperative patient selection for surgical intervention, such as bullectomy, lung transplantation, and LVRS. Chest radiography is useful in evaluating hyperinflation. Inspiratory and expiratory films are used to estimate diaphragmatic excursion and air-trapping. CT scan is used to evaluate the anatomy and distribution of emphysema throughout the lungs, providing information clinically unobtainable by other means. Both imaging techniques are useful for detecting other disease processes. Radionuclide lung scanning also provides an estimate of target areas, volume occupying but nonfunctioning lung. Cohort studies utilizing these imaging techniques have demonstrated associations between preoperative characteristics and postoperative outcome. The imaging studies, especially the chest radiograph, have also played an important role in postoperative management. Many other imaging options are available, such as HRCT scan, quantitative CT scan, and single photon emission CT scan. Other techniques, such as MR imaging, may play a future role as well.

Lung transplantation: selection of patients and analysis of outcome

Lung transplantation is an important option for patients with respiratory failure and limited life expectancy. Herein we review the current indications for and outcome after lung transplantation. These results are compared with the natural history of various respiratory diseases, estimated from available databases. Candidates for lung transplantation are generally younger than 60 years of age, have a limited life expectancy because of end-stage lung disease, and have no other major organ dysfunction. Single lung transplantation is performed most commonly for emphysema, pulmonary fibrosis, and pulmonary hypertension. Survival after single lung transplantation is approximately 70% at 1 year, 60% at 2 years, and 40% at 3 years. The median duration of survival for patients with end-stage lung diseases ranges from approximately 2 to 6 years, with wide variation based on the diagnosis and severity of illness. Currently, prolongation of the average survival has not been clearly substantiated after lung transplantation. Further evaluation of outcomes, functional status, and quality of life after lung transplantation is necessary.

[Infections in lung transplantation]

Lung transplantation has become the therapeutic hope of terminal respiratory patients. Infections are among the main causes of morbidity and mortality in these patients. We therefore analyze infections suffered after lung transplants performed at Clínica Puerta de Hierro over a two-year period. The cases of 14 transplanted patients, 6 bilateral and 8 unilateral, were analyzed. Pre-transplant data available for all included analysis of serum antibodies to several viruses, as well as bacterial and fungal cultures, and Ziehl's sputum test. All received prophylactic antibiotic, antifungal and antiviral treatment according to protocol. The bronchial aspirate of the donor, and recipient specimens of bronchial aspirate, bronchoalveolar lavage and biopsies obtained by bronchoscopy after transplantation were cultured. Bronchoscopies were performed according to protocol, based on clinical picture. Other cultures were obtained as needed. We recorded 27 respiratory infections, among which 4 were pneumonia transmitted by the donor, 3 were tuberculosis, 3 were Aspergillus infections, 5 were cytomegalovirus pneumonitis and one, P. carinii pneumonia. Lung infections have a strong impact on outcome of lung transplant patients. Knowledge of the chronological development of infections made appropriate prophylaxis and early detection possible, such that survival during the first two years after transplantation was approximately 70% in our hospital.

Nutrition support for lung transplant patients

Lung transplantation has emerged as an established and accepted therapy for patients with endstage pulmonary disease. Very little information has been published about the nutrition management of these patients during the period after transplantation. We conducted a retrospective review of the nutrition support records of 52 adult patients who had undergone lung transplantation at our institution. In addition to patient demographics, data were collected on baseline nutritional status, energy and protein goals, type of specialized nutrition support therapy, length of therapy, and incidence of metabolic complications. More than 50% of the patients receiving lung transplants had a diagnosis of cystic fibrosis. Compared with patients having other diagnoses, this group of patients had a greater incidence of malnutrition. The mean energy goal was 127 +/- 0.07% of basal energy expenditure, and the protein goal was 1.37% +/- 0.25 g/kg/d. All patients received parenteral nutrition therapy, which was begun by postoperative day 2 for more than 70% of the patients. Therapy was short-term (mean, 9 days), and patients then received oral diet. The most common metabolic complications were azotemia, hyperglycemia, and hypomagnesemia. Our experience should provide assistance to other health care professionals who are involved in the nutrition and metabolic management of patients undergoing lung transplantation.