Lung transplantation

Lung Transplantation for COVID-19 Acute Respiratory Distress Syndrome: The British Columbian Experience With New Disease Pathology

Lung transplantation is a life-saving treatment for patients with end-stage lung disease. COVID-19 has been associated with a severe and rapid decline in pulmonary function, in which case lung transplantation has been described to be effective. We herein describe 9 patients who underwent lung transplantation for COVID-19 acute respiratory distress syndrome, of whom 6 were bridged with extracorporeal membrane oxygenation (ECMO). The median time of pre-operative observation periods was 54 days to ensure no lung function recovery and the time to wean off extracorporeal membrane oxygenation was 3 days. Patients had comparable short-term survival outcomes to non-COVID-19 lung transplant recipients at our institution during the same time period. Lung transplantation for COVID-19-associated lung disease is feasible with comparable short-term outcomes and may liberate patients from extracorporeal supports.

Feasibility of Immediate in-Intensive Care Unit Pulmonary Rehabilitation after Lung Transplantation: A Single Center Experience

Background

Physical function may influence perioperative outcomes of lung transplantation. We investigated the feasibility of a pulmonary rehabilitation program initiated in the immediate postoperative period at an intensive care unit (ICU) for patients who underwent lung transplantation.

Methods

We retrospectively evaluated 22 patients who received pulmonary rehabilitation initiated in the ICU within 2 weeks after lung transplantation at our institution from March 2015 to February 2016. Levels of physical function were graded at the start of pulmonary rehabilitation and then weekly throughout rehabilitation according to criteria from our institutional pulmonary rehabilitation program: grade 1, bedside (G1); grade 2, dangling (G2); grade 3, standing (G3); and grade IV, gait (G4).

Results

The median age of patients was 53 years (range, 25 to 73 years). Fourteen patients (64%) were males. The initial level of physical function was G1 in nine patients, G2 in seven patients, G3 in four patients, and G4 in two patients. Patients started pulmonary rehabilitation at a median of 7.5 days (range, 1 to 29 days) after lung transplantation. We did not observe any rehabilitation-related complications during follow-up. The final level of physical function was G1 in six patients, G3 in two patients, and G4 in 14 patients. Fourteen of the 22 patients were able to walk with or without assistance, and 13 of them maintained G4 until discharge; the eight remaining patients never achieved G4.

Conclusions

Our results suggest the feasibility of early pulmonary rehabilitation initiated in the ICU within a few days after lung transplantation.

Pre-anaesthetic evaluation of the patient with end-stage lung disease

Lung transplantation is a viable alternative for end-stage lung diseases, which offers good quality of life and survival outcomes for recipients. The aims of pre-assessment for potential lung transplant recipients are to assess fitness for surgery, optimise co-morbidities, commence interventions or investigations, weigh risk-benefit ratio, plan appropriate analgesia and obtain informed consent. The assessment information is gathered from the medical record, patient interview, physical examination and pre-operative tests. A comprehensive workup includes cardiopulmonary evaluation, haematological, biochemical, microbiological and immunological investigations. Most of the evidence regarding lung transplantation is gleaned from retrospective data from single, multi-centre or multinational registries. The lack of good quality evidence means that the guidelines are based on expert consensus.

Extracorporeal life support as bridge to lung transplantation: a systematic review

INTRODUCTION

Patients with acute respiratory failure requiring respiratory support with invasive mechanical ventilation while awaiting lung transplantation are at a high risk of death. Extracorporeal membrane oxygenation (ECMO) has been proposed as an alternative bridging strategy to mechanical ventilation. The aim of this study was to assess the current evidence regarding how the ECMO bridge influences patients' survival and length of hospital stay.

METHODS

We performed a systematic review by searching PubMed, EMBASE and the bibliographies of retrieved articles. Three reviewers independently screened citation titles and abstracts and agreement was reached by consensus. We selected studies enrolling patients who received ECMO with the intention to bridge lung transplant. We included randomized controlled trials (RCTs), case-control studies and case series with ten or more patients. Outcomes of interest included survival and length of hospital stay. Quantitative data summaries were made when feasible.

RESULTS

We identified 82 studies, of which 14 were included in the final analysis. All 14 were retrospective studies which enrolled 441 patients in total. Because of the broad heterogeneity among the studies we did not perform a meta-analysis. The mortality rate of patients on ECMO before lung transplant and the one-year survival ranged from 10% to 50% and 50% to 90%, respectively. The intensive care and hospital length of stay ranged between a median of 15 to 47 days and 22 to 47 days, respectively. There was a general paucity of high-quality data and significant heterogeneity among studies in the enrolled patients and technology used, which confounded analysis.

CONCLUSIONS

In most of the studies, patients on ECMO while awaiting lung transplantation also received invasive mechanical ventilation. Therefore, whether ECMO as an alternative, rather than an adjunction, to invasive mechanical ventilation is a better bridging strategy to lung transplantation still remains an unresolved issue. ECMO support as a bridge for these patients could provide acceptable one-year survival. Future studies are needed to investigate ECMO as part of an algorithm of care for patients with end-stage lung disease.

Appropriate Ventilatory Settings for Thoracic Surgery: Intraoperative and Postoperative

Mechanical ventilation of patients undergoing thoracic surgery is often challenging. These patients frequently have significant underlying comorbidities, including cardiopulmonary disease, and often must undergo 1-lung ventilation. Perioperative respiratory complications are common and are multifactorial in etiology. Increasing evidence suggests that mechanical ventilation is associated with, and may even cause, lung damage in both sick and healthy patients. Gas exchange to provide acceptable end-organ oxygenation remains a primary goal but so too is minimization of risks for acute lung injury. Every ventilator strategy is associated with potential beneficial and adverse side effects. Understanding the impact of various ventilation strategies allows clinicians to provide optimal care for patients.