Airway complications after lung transplantation

The pathophysiology of dysphagia post-lung transplant: A systematic review

Purpose

One major consequence of lung transplantation is the development of oropharyngeal dysphagia. This systematic review aims to appraise and synthesize the available evidence of the use of instrumental assessments to outline the characteristics of post-lung transplant dysphagia.

Methods

Following the identification of appropriate search terms for the question, a literature search was conducted in PubMed, Scopus, and the Health and Medical Collection of Proquest Research Library and included records between inception and September 14, 2023. Search strategies included the use of text words and subject headings (e.g., MeSH and Index terms) related to (1) dysphagia or swallowing (swallow*, deglutition disorder*), (2) lung transplant (lung transplant*, post-operative, post-lung), and (3) complications (adverse effects, *complications, treatment outcome).

Results

The literature search strategy yielded a total of 883 studies from the electronic database search, with no additional records identified through other sources. After the removal of duplicates (n = 96), a total of 787 studies were screened through title and abstracts which eliminated 775 studies. Six studies were ultimately included in the systematic review. The selected articles included patients who underwent lung transplantation and all but one study utilized a retrospective design. A lack of transparency regarding instrumental evaluation protocols (videofluoroscopic [VFSS] and Flexible Endoscopic Evaluation of Swallowing [FEES]) including the number and bolus types used during the instrumental evaluations appeared as a theme in the studies included. The Penetration-Aspiration Scale (PAS) was systematically utilized to measure dysphagia safety outcome. Handling of the PAS scale was not consistent across studies, however penetration or aspiration ranged from 52.4% up to 100%. Additionally, silent aspiration rates ranged from 14.2% to 61.9%.

Conclusions

This review sought to describe the post-operative swallowing function and its physiological parameters following lung transplantation. We examined the results reported and the methods utilized in obtaining these results in the existing literature. Limited reporting practices for physiological parameters were found, however the airway invasion was reported in all studies with variation in degrees of swallowing safety related deficits, with PAS being the most widely used scale to describe airway invasion depth and response. Future studies exploring dysphagia outcomes post-lung transplant should comment on the altered physiological mechanisms of the swallow to further expand on the physiological deficits observed following transplantation in this group and allow for treatment planning.

Level of evidence

Level 1.

Postoperative conditions of rehabilitative interest in lung transplantation: a systematic review

Lung transplantation is an elective treatment option for end-stage respiratory diseases in which all medical therapy options have been exhausted. The current study aimed to identify updated information on the postoperative conditions that may impair rehabilitation after lung transplantation and to provide specific considerations of their clinical relevance during the recovery process. The present study is a systematic review conducted by searching three primary databases: the United States National Library of Medicine PubMed system, Scopus, and the Cochrane Library. The databases were searched for articles published from database inception until May 2024; at the end of the selection process, 27 documents were included in the final analysis. The retrieved material identified 19 conditions of rehabilitative interest that potentially affect the postoperative course: graft dysfunction, dysphagia, postsurgical pain, cognitive impairment, chronic lung allograft dysfunction-bronchiolitis obliterans syndrome, phrenic nerve injury, delayed extracorporeal membrane oxygenation weaning, airway clearance, refractory hypoxemia, mediastinitis, reduced oxidative capacity, sternal dehiscence, coronavirus disease 2019 (COVID-19), gastroparesis, ossification of the elbow, Takotsubo cardiomyopathy, airway dehiscence, recurrent pleural effusion, and scapular prolapse. Although some patients are not amenable to rehabilitation techniques, others can significantly improve with rehabilitation.

Machine learning model predicts airway stenosis requiring clinical intervention in patients after lung transplantation: a retrospective case-controlled study

BACKGROUND

Patients with airway stenosis (AS) are associated with considerable morbidity and mortality after lung transplantation (LTx). This study aims to develop and validate machine learning (ML) models to predict AS requiring clinical intervention in patients after LTx.

METHODS

Patients who underwent LTx between January 2017 and December 2019 were reviewed. The conventional logistic regression (LR) model was fitted by the independent risk factors which were determined by multivariate LR. The optimal ML model was determined based on 7 feature selection methods and 8 ML algorithms. Model performance was assessed by the area under the curve (AUC) and brier score, which were internally validated by the bootstrap method.

RESULTS

A total of 381 LTx patients were included, and 40 (10.5%) patients developed AS. Multivariate analysis indicated that male, pulmonary arterial hypertension, and postoperative 6-min walking test were significantly associated with AS (all P < 0.001). The conventional LR model showed performance with an AUC of 0.689 and brier score of 0.091. In total, 56 ML models were developed and the optimal ML model was the model fitted using a random forest algorithm with a determination coefficient feature selection method. The optimal model exhibited the highest AUC and brier score values of 0.760 (95% confidence interval [CI], 0.666-0.864) and 0.085 (95% CI, 0.058-0.117) among all ML models, which was superior to the conventional LR model.

CONCLUSIONS

The optimal ML model, which was developed by clinical characteristics, allows for the satisfactory prediction of AS in patients after LTx.

Impact of Early Tracheostomy After Lung Transplantation: A National Analysis

BACKGROUND

Prolonged mechanical ventilation is common among lung transplant recipients, affecting nearly one-third of patients. Tracheostomy has been shown as a beneficial alternative to endotracheal intubation, but delays in tracheostomy tube placement persist. To date, no large-scale study has investigated the effect of tracheostomy timing on posttransplant outcomes.

METHODS

All adults receiving tracheostomy after primary, isolated lung transplantation were identified in the 2016 to 2020 Nationwide Readmissions Database. Early tracheostomy was defined as placement before postoperative day 8 based on exploratory cohort analysis. Multivariable regression was used to evaluate the association of early tracheostomy with in-hospital mortality, select posttransplant complications, and resource utilization.

RESULTS

Of an estimated 11,048 patients undergoing first-time lung transplantation, 1509 required a tracheostomy in the postoperative period, with 783 (51.9%) comprising the early cohort. After entropy balancing and risk adjustment, early tracheostomy placement was associated with reduced odds of death (adjusted odds ratio, 0.59; 95% CI, 0.36-0.97) and posttransplant infection (adjusted odds ratio, 0.54; 95% CI, 0.35-0.82). Further, tracheostomy within 1 week of transplantation was associated with decreased length of stay (β-coefficient, -16.5 days; 95% CI, -25.3 to -7.6 days) and index hospitalization costs (β-coefficient, -$97,600; 95% CI, -$153,000 to -$42,100).

CONCLUSIONS

The present study supports the safety of early tracheostomy among lung transplant recipients and highlights several potential benefits. Among appropriately selected patients, tracheostomy placement before postoperative day 8 may facilitate early discharge, lower costs, and reduced odds of posttransplant infection.

Effect of antifibrotic agents on postoperative complications after lung transplantation for idiopathic pulmonary fibrosis

BACKGROUND

Antifibrotic agents (AFAs) are now standard-of-care for idiopathic pulmonary fibrosis (IPF). Concerns have arisen about the safety of these drugs in patients undergoing lung transplantation (LTx).

METHODS

We performed a multi-centre, nationwide, retrospective, observational study of French IPF patients undergoing LTx between 2011 and 2018 to determine whether maintaining AFAs in the peri-operative period leads to increased bronchial anastomoses issues, delay in skin healing and haemorrhagic complications. We compared the incidence of post-operative complications and the survival of patients according to AFA exposure.

RESULTS

Among 205 patients who underwent LTx for IPF during the study period, 58 (28%) had received AFAs within 4 weeks before LTx (AFA group): pirfenidone in 37 (18.0%) and nintedanib in 21 (10.2%). The median duration of AFA treatment before LTx was 13.8 (5.6-24) months. The AFA and control groups did not significantly differ in airway, bleeding or skin healing complications (p = 0.91, p = 0.12 and p = 0.70, respectively). Primary graft dysfunction was less frequent in the AFA than control group (26% vs. 43%, p = 0.02), and the 90-day mortality was lower (7% vs. 18%, p = 0.046).

CONCLUSIONS

AFA therapy did not increase airway, bleeding or wound post-operative complications after LTx and could be associated with reduced rates of primary graft dysfunction and 90-day mortality.

Critical Care Management of the Lung Transplant Recipient

Lung transplantation is often the only treatment option for patients with severe irreversible lung disease. Improvements in donor and recipient selection, organ allocation, surgical techniques, and immunosuppression have all contributed to better survival outcomes after lung transplantation. Nonetheless, lung transplant recipients still experience frequent complications, often necessitating treatment in an intensive care setting. In addition, the use of extracorporeal life support as a means of bridging critically ill patients to lung transplantation has become more widespread. This review focuses on the critical care aspects of lung transplantation, both before and after surgery.

Alterations in Pulmonary Physiology with Lung Transplantation

Lung transplant is a treatment option for patients with end-stage lung diseases; however, survival outcomes continue to be inferior when compared to other solid organs. We review the several anatomic and physiologic changes that result from lung transplantation surgery, and their role in the pathophysiology of common complications encountered by lung recipients. The loss of bronchial circulation into the allograft after transplant surgery results in ischemia-related changes in the bronchial artery territory of the allograft. We discuss the role of bronchopulmonary anastomosis in blood circulation in the allograft posttransplant. We review commonly encountered complications related to loss of bronchial circulation such as allograft airway ischemia, necrosis, anastomotic dehiscence, mucociliary dysfunction, and bronchial stenosis. Loss of dual circulation to the lung also increases the risk of pulmonary infarction with acute pulmonary embolism. The loss of lymphatic drainage during transplant surgery also impairs the management of allograft interstitial fluid, resulting in pulmonary edema and early pleural effusion. We discuss the role of lymphatic drainage in primary graft dysfunction. Besides, we review the association of late posttransplant pleural effusion with complications such as acute rejection. We then review the impact of loss of afferent and efferent innervation from the allograft on control of breathing, as well as lung protective reflexes. We conclude with discussion about pulmonary function testing, allograft monitoring with spirometry, and classification of chronic lung allograft dysfunction phenotypes based on total lung capacity measurements. We also review factors limiting physical exercise capacity after lung transplantation, especially impairment of muscle metabolism. © 2023 American Physiological Society. Compr Physiol 13:4269-4293, 2023.

Incidence, risk factors, and clinical characteristics of airway complications after lung transplantation

Airway complications may occur after lung transplantation and are associated with considerable morbidity and mortality. We investigated the incidence, risk factors, and clinical characteristics of these complications. We retrospectively reviewed the medical records of 137 patients who underwent lung transplantation between 2008 and 2021. The median follow-up period was 20 months. Of the 137 patients, 30 (21.9%) had postoperative airway complications, of which 2 had two different types of airway complications. The most common airway complication was bronchial stenosis, affecting 23 patients (16.8%). Multivariable Cox analysis revealed that a recipient's body mass index ≥ 25 kg/m² (hazard ratio [HR], 2.663; p = 0.013) was a significant independent risk factor for airway complications, as was postoperative treatment with extracorporeal membrane oxygenation (ECMO; HR, 3.340; p = 0.034). Of the 30 patients who had airway complications, 21 (70.0%) were treated with bronchoscopic intervention. Survival rates did not differ significantly between patients with and without airway complications. Thus, our study revealed that one fifth of patients who underwent lung transplantation experienced airway complications during the follow-up period. Obesity and receiving postoperative ECMO are risk factors for airway complications, and close monitoring is warranted in such cases.

Is there life on the airway tree? A pilot study of bronchial cell vitality and tissue morphology in the ex vivo lung perfusion (EVLP) era of lung transplantation

BACKGROUND

Ex vivo lung perfusion (EVLP) is a relevant procedure to increase the lung donor pool but could potentially increase the airway tree ischemic injury risk.

METHODS

This study aimed to evaluate the direct effect of EVLP on the airway tree by evaluating bronchial cell vitality and tissue signs of injury on a series of 117 bronchial rings collected from 40 conventional and 19 EVLP-treated lung grafts. Bronchial rings and related scraped bronchial epithelial cells were collected before the EVLP procedure and surgical anastomosis.

RESULTS

The preimplantation interval was significantly increased in the EVLP graft group (p < 0.01). Conventional grafts presented cell viability percentages of 47.07 ± 23.41 and 49.65 ± 21.25 in the first and second grafts which did not differ significantly from the EVLP group (first graft 50.54 ± 25.83 and second graft 50.22 ± 20.90 cell viability percentage). No significant differences in terms of histopathological features (edema, inflammatory infiltrate, and mucosa ulceration) were observed comparing conventional and EVLP samples. A comparison of bronchial cell viability and histopathology of EVLP samples retrieved at different time intervals revealed no significant differences. Accordingly, major bronchial complications after lung transplant were not observed in both groups.

CONCLUSIONS

Based on these data, we observed that EVLP did not significantly impact bronchial cell vitality and airway tissue preservation nor interfere with bronchial anastomosis healing, further supporting it as a safe and useful procedure.

Critical Care of the Lung Transplant Patient

Lung transplantation is a therapeutic option for end-stage lung disease that improves survival and quality of life. Prelung transplant admission to the intensive care unit (ICU) for bridge to transplant with mechanical ventilation and extracorporeal membrane oxygenation (ECMO) is common. Primary graft dysfunction is an important immediate complication of lung transplantation with short- and long-term morbidity and mortality. Later transplant-related causes of respiratory failure necessitating ICU admission include acute cellular rejection, atypical infections, and chronic lung allograft dysfunction. Lung transplantation for COVID-19-related ARDS is increasingly common..

Technical Aspects of Lung Transplantation: General Considerations

Surgical approaches to lung transplantation in adults vary substantially among surgeons and institutions, but the underlying principles are consistent. This article provides a surgical overview of bilateral sequential lung transplantation.

Surgical Complications of Lung Transplantation

Lung transplantation is a life-saving intervention and the most effective therapy for select patients with irreversible lung disease. Despite the effectiveness of lung transplantation, it is a major operation with several opportunities for complications. For example, recipient and donor factors, technical issues, early postoperative events, and immunology can all contribute to potential complications. This article highlights some of the key surgery-related complications that can undermine a successful lung transplantation. The authors offer their expert opinion and experience to help practitioners avoid such complications and recognize and treat them early should they occur.

Early Postoperative Management of Lung Transplant Recipients

The early postoperative period after lung transplantation is a critical time. Prompt recognition and treatment of primary graft dysfunction can alter long-term allograft function. Cardiovascular, gastrointestinal, renal, and hematologic derangements are common and require close management to limit their negative sequelae.

Epidemiology and Prognosis of Invasive Fungal Disease in Chinese Lung Transplant Recipients

This study explored the epidemiology, risk factors, and prognosis of invasive fungal disease (IFD) in Chinese lung transplant recipients (LTRs). This retrospective cohort study included patients who received lung transplants at four hospitals in South China between January 2015 and June 2019. The participants were divided into IFD and non-IFD (NIFD) groups. The final analysis included 226 LTRs (83.2% males) aged 55.0 ± 14.2 years old. Eighty-two LTRs (36.3%) developed IFD (proven or probable diagnosis). The most common pathogens were Aspergillus (57.3%), Candida (19.5%), and Pneumocystis jiroveci (13.4%). Multivariate logistic regression revealed that anastomotic disease [odds ratio (OR): 11.86; 95% confidence interval (95%CI): 4.76–29.54; P < 0.001], cytomegalovirus (CMV) pneumonia (OR: 3.85; 95%CI: 1.88–7.91; P = 0.018), and pre-transplantation IFD (OR: 7.65; 95%CI: 2.55–22.96; P < 0.001) were associated with higher odds of IFD, while double-lung transplantation (OR: 0.40; 95%CI: 0.19–0.79; P = 0.009) was associated with lower odds of IFD. Logistic regression analysis showed that anastomotic disease was associated with higher odds of death (OR: 5.01; 95%CI: 1.24–20.20; P = 0.02) and that PJP prophylaxis was associated with lower odds of death (OR: 0.01; 95%CI: 0.001–0.11; P < 0.001). Invasive fungal disease is prevalent among LTRs in southern China, with Aspergillus the most common pathogen. Prophylaxis should be optimized based on likely pathogens.

Surgical management of post-transplant bronchial stenoses: a single-center experience

Purpose

Bronchial stenoses are challenging complications after lung transplantation and are associated with high rates of morbidity and mortality. We report a series of patients who underwent bronchoplasty or sleeve resection for bronchial stenoses that did not resolve with endoscopic treatment after lung transplantation.

Methods

Between 1995 and 2020, 497 patients underwent lung transplantation at our Institution. 35 patients (7.0%) experienced bronchial stenoses with a median time from transplantation of 3 months. Endoscopic management was effective in 28 cases (5.6%) while 1 patient required re-transplantation. Six patients (1.2%) underwent bronchoplasty or sleeve resection.

Results

The procedures of the six patients who underwent bronchoplasty or sleeve resection were as follows: lower sleeve bilobectomy (n = 3), wedge bronchoplasty of the bronchus intermedius (n = 1), isolated sleeve resection of the bronchus intermedius (n = 1), and isolated sleeve resection of the bronchus intermedius (n = 1), associated with a middle lobectomy. All patients were discharged after a median time of 11 days. At a median of 12 months from surgery, two patients remain alive with a preserved pulmonary function. Four patients died after a median time of 56 months from bronchoplasty of causes that were not related to surgery.

Conclusions

Bronchial reconstructions are challenging procedures that can be performed in highly specialized centers. Despite this, they can be considered a good strategy to obtain a definitive resolution of stenosis after lung transplantation.

Factors affecting complications development and mortality after single lung transplant

Lung transplantation (LT) is a life-saving therapeutic procedure that prolongs survival in patients with end-stage lung disease. Furthermore, as a therapeutic option for high-risk candidates, single LT (SLT) can be feasible because the immediate morbidity and mortality after transplantation are lower compared to sequential single (double) LT (SSLTx). Still, the long-term overall survival is, in general, better for SSLTx. Despite the great success over the years, the early post-SLT period remains a perilous time for these patients. Patients who undergo SLT are predisposed to evolving early or late postoperative complications. This review emphasizes factors leading to post-SLT complications in the early and late periods including primary graft dysfunction and chronic lung allograft dysfunction, native lung complications, anastomosis complications, infections, cardiovascular, gastrointestinal, renal, and metabolite complications, and their association with morbidity and mortality in these patients. Furthermore, we discuss the incidence of malignancy after SLT and their correlation with immunosuppression therapy.

Imaging Course of Lung Transplantation: From Patient Selection to Postoperative Complications

Lung transplant is increasingly performed for the treatment of end-stage lung disease. As the number of lung transplants and transplant centers continues to rise, radiologists will more frequently participate in the care of patients undergoing lung transplant, both before and after transplant. Potential donors and recipients undergo chest radiography and CT as part of their pretransplant assessment to evaluate for contraindications to transplant and to aid in surgical planning. After transplant, recipients undergo imaging during the postoperative hospitalization and also in the long-term outpatient setting. Radiologists encounter a wide variety of conditions leading to end-stage lung disease and a myriad of posttransplant complications, some of which are unique to lung transplantation. Familiarity with these pathologic conditions, including their imaging findings and their temporal relationship to the transplant, is crucial to accurate radiologic interpretation. Knowledge of the surgical techniques and expected postoperative appearance prevents confusing normal posttransplant imaging findings with complications. A basic understanding of the indications, contraindications, and surgical considerations of lung transplant aids in imaging interpretation and protocoling and also facilitates communication between radiologists and transplant physicians. Despite medical and surgical advances over the past several decades, lung transplant recipients currently have an average posttransplant life expectancy of only 6.7 years. As members of the transplant team, radiologists can help maximize patient survival and hopefully increase posttransplant life expectancy and quality of life in the coming decades. ^©RSNA, 2021 An invited commentary by Bierhals is available online. Online supplemental material is available for this article.

Use of a covered self-expanding metal airway stent for severe dynamic collapse within a bronchial aortic graft conduit in a post-lung transplant patient

We present a novel case in which a self-expanding, covered metal airway stent was utilized for severe dynamic collapse within a cadaveric aortic bronchial graft conduit in a post-lung transplant recipient with thoracic situs inversus.

Repair of Bronchial Anastomosis Following Lung Transplantation

BACKGROUND

 Bronchial anastomotic complications are reported in 2 to 18% of patients after lung transplantation. The majority of complications can be managed with bronchoscopic intervention. When extensive dehiscence is present, surgical intervention can be entertained.

MATERIALS AND METHODS

 Between March 1, 2006, and December 31, 2019, our program performed 244 lung transplantations. We conducted a retrospective review of our patient cohort and identified patients who suffered from significant anastomotic complications that required surgical interventions.

RESULTS

 Twenty-eight and 216 patients underwent single and bilateral lung transplantations, respectively. Eighteen patients developed airway complications (7.4%). The incidence of anastomotic complications was 5.2% (24 complications for a total of 460 bronchial anastomoses). Four patients were managed conservatively. The majority of the bronchial anastomotic complications were managed endoscopically (eight patients). Four patients with associated massive air leak underwent repair of the bronchial anastomosis and two patients were retransplanted because they developed severe distal airway stenosis.

CONCLUSION

 Bronchial anastomotic complications are a major cause of morbidity in lung transplantation. The majority of cases can be managed bronchoscopically. In more severe cases associated with massive air leak or imminent massive hemoptysis from bronchopulmonary arterial fistula, surgical intervention is necessary. Aortic homograft interposition along with vascularized pedicle wrapping may be a viable option to re-establish airway continuity when tension-free bronchial anastomotic revision is not possible. In cases with smaller bronchial defects, primary repair with utilization of a vascularized flap can be effective as treatment option.

Submucosal Injection of Mitomycin C in a Case of Vanishing Bronchus After Lung Transplant

Segmental nonanastomotic stenosis, also known as vanishing bronchus intermedius syndrome (or simply, "vanishing bronchus"), is a rare complication that can occur after a lung transplant. It usually occurs in the first posttransplant year and often develops in the intermediate bronchus. Definitive diagnosis is established by bronchoscopy. The treatment management primarily includes bronchoscopic dilatation and stenting. In patients who do not benefit from these applications, lung resection or retransplant may be indicated. Our 58-year-old patient developed vanishing bronchus after lung transplant, and recurrence could not be prevented despite repeated bronchoscopic interventions. We applied submucosal mitomycin C injection to the bronchial wall of the stenotic segment and achieved significant benefit for reduction of recurrence. Our aim was to document the first reported case of a patient with vanishing bronchus who was treated with submucosal administration of mitomycin C, a strong fibroblast inhibitor, and to report the outcomes of submucosal mitomycin C administration with regard to recurrence.

Imaging Evaluation of Airway Complications After Lung Transplant

Airway complications (ACs) after lung transplant remain a challenge and include bronchial dehiscence, bronchial stenosis, tracheobronchomalacia, infections, and bronchial fistulas. The spectrum of complications may coexist along a continuum and can be classified as early (<1 month after transplant) or late (>1 month), and anastomotic or nonanastomotic. Bronchiolitis obliterans is the most common form of chronic lung allograft rejection. Airway compromise is seen in rare instances of lung torsion, and imaging may provide helpful diagnostic clues. Computed tomography (CT) and bronchoscopy play major roles in the diagnosis and treatment of ACs after lung transplant. Chest CT with advanced postprocessing techniques is a valuable tool in evaluating for airways complications, for initial bronchoscopic treatment planning and subsequent posttreatment assessment. Various bronchoscopic treatment options may be explored to maintain airway patency. The goal of this article is to review imaging findings of ACs after lung transplantation, with emphasis on chest CT and bronchoscopic correlation.

Endobronchial removal of uncovered stent using argon plasma coagulation via fibreoptic bronchoscopy

Bronchial stenosis is a complication of lung transplantation that often requires repeated balloon dilation, endobronchial treatments, and possibly stent placement. Endobronchial stents, particularly uncovered ones, may have several complications including excessive granulation tissue that cause airways obstruction and impaired mucociliary clearance, which may lead to inflammation and infections. Removal of epithelized endobronchial stents is usually done in the operating room using rigid bronchoscopy. Argon plasma coagulation (APC) has been used for removal of biliary stents. One case report described an endotracheal uncovered stent removal using this technique. APC can be used via flexible bronchoscopy, which may carry less risk of complications and can be done in an outpatient setting. In this case, we report using APC, at a low energy level, for complete removal of a totally epithelialized endobronchial uncovered stent in a patient experiencing stent-related complications.

Greater survival despite increased complication rates following lung transplant for alpha-1-antitrypsin deficiency compared to chronic obstructive pulmonary disease

Background

Alpha-1-antitrypsin (A1AT) deficiency (A1ATD) is characterized by accelerated degradation of lung function. We examined our experience with lung transplantation for chronic obstructive pulmonary disease (COPD) with and without A1ATD to compare survival and rates of postoperative surgical complications.

Methods

Patients with A1ATD and non-A1ATD COPD undergoing lung transplantation from 1988-2015 at our institution were analyzed. Complications were categorized into non-gastroenteritis gastrointestinal (GI), wound, airway, and reoperation for bleeding. Overall and complication-free survival were evaluated using Kaplan-Meier curves and Cox proportional hazards models.

Results

Three hundred and eighty-five patients underwent lung transplant for COPD (98 A1ATD). For A1ATD, 56.1% underwent single lung transplantation (80.6% for COPD). Early overall and complication-free survival was worse for A1ATD, but this trend reversed at longer follow up. Unadjusted estimated survival showed advantage for COPD at 90 days and 1 year, which attenuated by 5 years and reversed at 10 years (P<0.001). On adjusted analysis, A1ATD was associated with a trend toward lower complication-free survival at 90 days and 1 year, due partly to increased rates of post-transplant GI pathology, particularly in the era of the lung allocation score (LAS).

Conclusions

A1ATD lung recipients had worse short-term complication-free survival but improved long-term survival compared to COPD patients. A1ATD was associated with greater risk of new GI pathology after transplant. Close monitoring of A1ATD patients with timely evaluation of GI complaints after transplant is warranted.

Effect of pirfenidone on wound healing in lung transplant patients

Background

The drug pirfenidone has been shown to slow the progression and decrease mortality of idiopathic pulmonary fibrosis (IPF). Its exact mechanism is unknown, but it likely inhibits pro-fibrotic cytokine transforming growth factor beta, a known contributor to wound healing. We evaluated whether patients taking pirfenidone until lung transplantation had increased risk of impaired wound healing post-transplant. This information could determine whether pirfenidone should be discontinued prior to listing to allow for a wash-out period.

Methods

We retrospectively reviewed patients who underwent lung transplantation for pulmonary fibrosis at Norton Thoracic Institute in Phoenix, Arizona, from January 2014 to December 2015.

Results

We describe 18 patients who took pirfenidone up to a month before transplant. Aside from one patient who experienced sternal dehiscence due to a surgical issue, all remaining patients did well with no evidence of airway dehiscence. Each of these 17 patients had been on pirfenidone for at least 30 days; nine patients had been on pirfenidone for over 90 days. Baseline characteristics including age, sex, body mass index, renal function, liver function, glucose level, pre-transplant corticosteroid use, and post-transplant immunosuppressant therapy were similar.

Conclusions

In our experience, pirfenidone may be safely continued until lung transplantation. Only one patient in our series experienced impaired wound healing related to a surgical issue, even when pirfenidone was continued until lung transplantation. We found no evidence of impaired wound healing or airway complications after lung transplantation in patients who were treated with pirfenidone before lung transplantation.

ISHLT Consensus Statement on adult and pediatric airway complications after lung transplantation: Definitions, grading system, and therapeutics

Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications varies widely, contributed to by the lack of a universally accepted grading system and standardized definitions. Furthermore, the majority of the existing classification systems fail to integrate the wide range of possible bronchial complications that may develop after lung transplant. Hence, a Working Group was created by the International Society for Heart and Lung Transplantation with the aim of elaborating a universal definition of adult and pediatric airway complications and grading system. One such area of focus is to understand the problem in the context of a more standardized consensus of classifying airway ischemia. This consensus definition will have major clinical, therapeutics, and research implications.

Treatment of distal bronchial stenosis after bilateral lung transplantation

The effi ciency of lung transplantation is considerably limited by the complications associated with the bronchial pathologies. Despite the progress of the treatment methods, bronchial complications are still remaining as an actual problem in the postoperative period with frequency of occurrence from 7 to 29%. However, the bronchial stenosis are the most common bronchial complications after lung transplantation with mortality from 2 to 4%.

Aim. To study an experience of our center of bronchial stenosis treatment in lung recipients. Materials and methods. 34 patients underwent lung transplantation from September 2014 to January 2017. 6 (16%) of them had a stenosis of lobar or segmental bronchi from 84 to 494 postoperative day. 5 (83%) of them have demonstrated multifocal lesions. In all of the cases there was performed an endoscopic bougienage, which involved a balloon dilatation and electrocoagulated incision of granular tissue under X-ray control. After that the patients were administrated by everolimus.

Results. Restenosis was formed in 132,0 ± 94,2 postoperative day after primary treatment in all patients. In four cases (67%) we used nitinol stent placement under X-ray control. There were no complications. In 3 cases stents were dislocated distally, so we needed to use repeated endoscopic bougienage to replace the stent. Using of everolimus has allowed to decrease the rate of restenosis, but it need future research.

Conclusion. Distal bronchial stenosis after lung transplantation can be managed with endoscopic bougienage and stent placement. Adding everolimus has not signifi cantly affected the risk of frequency of restenosis.

Multimodality multistaged management of large endobronchial carcinoid causing respiratory failure: A case report with review of literature

We report the case of a 58-year-old female presenting with central airway obstruction leading to airway compromise thrice, first two times from endobronchial growth of typical carcinoid tissue and subsequently from granulation tissue at anastomotic site after left carinal pneumonectomy. Bronchoscopic resection of carcinoid tumor and granulation tissue was performed successfully with electrosurgical snaring through rigid bronchoscope. Cryodebridement using flexible cryoprobe of the tumor was done postembolization and of the remnant granulation tissue without any complication. A multimodality approach is required for favorable outcome as observed in this case.

Lung Transplantation: The State of the Airways

CONTEXT

Lung transplantation has become a viable option for definitive treatment of several end-stage lung diseases for which there are no other options available. However, long-term survival continues to be limited by chronic lung allograft dysfunction, which primarily affects the airways.

OBJECTIVE

To highlight the complications occurring mainly in the airways of the lung transplant recipient from the early to late posttransplant periods.

DATA SOURCES

Review literature focusing on the airways in patients with lung transplants and clinical experience of the authors.

CONCLUSIONS

Postsurgical complications and infections of the airways have decreased because of better techniques and management. Acute cellular rejection of the airways can be distinguished from infection pathologically and on cultures. Separating small from large airways need not be an issue because both are risk factors for bronchiolitis obliterans. Grading of airway rejection needs to be standardized. Chronic lung allograft dysfunction consists of both bronchiolitis obliterans and restrictive allograft syndrome, neither of which can be treated very effectively at present.

Donor to recipient sizing in thoracic organ transplantation

Donor-to-recipient organ size matching is a critical aspect of thoracic transplantation. In the United States potential recipients for lung transplant and heart transplant are listed with limitations on donor height and weight ranges, respectively. Height is used as a surrogate for lung size and weight is used as a surrogate for heart size. While these measures are important predictors of organ size, they are crude surrogates that fail to incorporate the influence of sex on organ size. Independent of other measures, a man’s thoracic organs are approximately 20% larger than a woman’s. Lung size can be better estimated using the predicted total lung capacity, which is derived from regression equations correcting for height, sex and age. Similarly, heart size can be better estimated using the predicted heart mass, which adjusts for sex, age, height, and weight. These refined organ sizing measures perform better than current sizing practice for the prediction of outcomes after transplantation, and largely explain the outcome differences observed after sex-mismatch transplantation. An undersized allograft is associated with worse outcomes. In this review we examine current data pertaining to size-matching in thoracic transplantation. We advocate for a change in the thoracic allocation mechanism from a height-or-weight-based strategy to a size-matching process that utilizes refined estimates of organ size. We believe that a size-matching approach based on refined estimates of organ size would optimize outcomes in thoracic transplantation without restricting or precluding patients from thoracic transplantation.

Lung Transplantation

The therapeutic options for patients with advanced pulmonary parenchymal or vascular disorders are currently limited. Lung transplantation remains one of the few viable interventions, but on account of the insufficient donor pool only a minority of these patients actually undergo the procedure each year. Following transplantation there are a number of early and late allograft complications such as primary graft dysfunction, allograft rejection, infection, post-transplant lymphoproliferative disorder and late injury that is now classified as chronic lung allograft dysfunction. The pathologist plays an essential role in the diagnosis and classification of these myriad complications. Although the transplant procedures are performed in selected centers patients typically return to their local centers. When complications arise it is often the responsibility of the local pathologist to evaluate specimens. Therefore familiarity with the pathology of lung transplantation is important.

Lung transplantation in IIP: A review

The idiopathic interstitial pneumonias (IIP) encompass a large and diverse subtype of interstitial lung disease (ILD) with idiopathic pulmonary fibrosis (IPF) and non-specific interstitial pneumonia (NSIP) being the most common types. Although pharmacologic treatments are available for most types of IIP, many patients progress to advanced lung disease and require lung transplantation. Close monitoring with serial functional and radiographic tests for disease progression coupled with early referral for lung transplantation are of great importance in the management of patients with IIP. Both single and bilateral lung transplantation are acceptable procedures for IIP. Procedure selection is a complex decision influenced by multiple factors related to patient, donor and transplant centre. While single lung transplant may reduce waitlist time and mortality, the long-term outcomes after bilateral lung transplantation may be slightly superior. There are numerous complications following lung transplantation including primary graft dysfunction, chronic lung allograft dysfunction (CLAD), infections, gastroesophageal reflux disease (GERD) and airway disease that limit post-transplant longevity. The median survival after lung transplantation is 4.7 years in patients with ILD, which is less than in patients with other underlying lung diseases. Although long-term survival is limited, this intervention still conveys a survival benefit and improved quality of life in suitable IIP patients with advanced lung disease and chronic hypoxemic respiratory failure.

MECHANICAL VENTILATION FOR THE LUNG TRANSPLANT RECIPIENT

Mechanical ventilation (MV) is an important aspect in the intraoperative and early postoperative management of lung transplant (LTx)-recipients. There are no randomized-controlled trials of LTx-recipient MV strategies; however there are LTx center experiences and international survey studies reported. The main early complication of LTx is primary graft dysfunction (PGD), which is similar to the adult respiratory distress syndrome (ARDS). We aim to summarize information pertinent to LTx-MV, as well as PGD, ARDS, and intraoperative MV and to synthesize these available data into recommendations. Based on the available evidence, we recommend lung-protective MV with low-tidal-volumes (≤6 mL/kg predicted body weight [PBW]) and positive end-expiratory pressure for the LTx-recipient. In our opinion, the MV strategy should be based on donor characteristics (donor PBW as a parameter of actual allograft size), rather than based on recipient characteristics; however this donor-characteristics-based protective MV is based on indirect evidence and requires validation in prospective clinical studies.