Lung transplantation for interstitial lung diseases:

Inescapable Fibrosis: The Development of Desquamative Interstitial Pneumonia Post-Lung Transplantation Performed for a Patient with Idiopathic Pulmonary Fibrosis

Interstitial lung disease is characterised by a combination of cellular proliferation, inflammation of the interstitium and fibrosis within the alveolar wall. A 58-year-old man was referred for lung transplantation after developing worsening dyspnoea and progressive hypoxaemic respiratory failure from idiopathic pulmonary fibrosis. Three years later, he developed desquamative interstitial pneumonia in his transplanted lungs, and despite augmentation of immune suppression, he had a progressive decline in his lung function and exercise capacity. Interestingly, in our case, the histopathology obtained post transplant strongly goes against the recurrence of usual interstitial pneumonia/idiopathic pulmonary fibrosis; rather, two separate interstitial disease processes have been identified.

Granulomatous fungal and non-tuberculous mycobacterial infestation complicating chronic lung disease: Outcomes in patients undergoing lung transplantation

INTRODUCTION

Granulomatous infections are common in patients with chronic lung disease. We aim to study the incidence and clinicopathological features of granulomatous infections in a cohort of patients undergoing lung transplantation for end-stage chronic lung disease.

METHODS

Pathology reports of 50 explanted native lungs of patients who underwent lung transplantation since 2015 at our institution were reviewed. Four cases with granulomatous lesions were identified. Correlation was made with clinical findings in the 4 cases.

RESULTS

The granulomatous infections include non-necrotizing cryptococcal pneumonitis (case 1), necrotizing pneumonia due to Scedosporium sp. and Mycobacterium avium Complex (MAC) (Cases 2 and 3), and invasive Aspergillus pneumonia (Case 4). One patient received pre-transplant fungal prophylaxis (Case 4). Post-transplant infectious complications included invasive (Cases 2 and 4) and non-invasive (Case 1) fungal infections and bacterial pneumonia (Cases 1 and 2). Two patients (Cases 3 and 4) developed acute cellular rejection (ACR) in the first 30 days. The third patient (Case 1) was identified with ACR in the 9 months post-transplant and chronic lung allograft dysfunction at 29 months. In terms of mortality, 1 patient (Case 1) died at 30 months post-transplant from pseudomonal sepsis and chronic graft failure. Two patients with invasive fungal infections (Cases 2 and 4) are on secondary prophylaxis and doing well. One patient (Case 3) remains infection-free and on MAC prophylaxis.

CONCLUSIONS

In our case series, patients with chronic lung diseases with superimposed granulomatous infestations frequently experienced post-transplant complications. These include invasive infections and repeat ACRs that predispose patients to chronic graft dysfunction. Pre- and post-transplant antifungal prophylaxis reduces fungal load and complication risk post-transplant.

The Role of Palliative Care in Reducing Symptoms and Improving Quality of Life for Patients with Idiopathic Pulmonary Fibrosis: A Review

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease with a median survival of 3-4 years from time of initial diagnosis, similar to the time course of many malignancies. A hallmark of IPF is its unpredictable disease course, ranging from long periods of clinical stability to acute exacerbations with rapid decompensation. As the disease progresses, patients with chronic cough and progressive exertional dyspnea become oxygen dependent. They may experience significant distress due to concurrent depression, anxiety, and fatigue, which often lead to increased symptom burden and decreased quality of life. Despite these complications, palliative care is an underutilized, and often underappreciated, resource before end-of-life care in this population. While there is growing recognition about early palliative care in IPF, current data suggest referral patterns vary widely based on institutional practices. In addition to focusing on symptom management, there is emphasis on supplemental oxygen use, pulmonary rehabilitation, quality of life, and end-of-life care. Importantly, increased use of support groups and national foundation forums have served as venues for further disease education, communication, and advanced care planning outside of the hospital settings. The purpose of this review article is to discuss the clinical features of IPF, the role of palliative care in chronic disease management, current data supporting benefits of palliative care in IPF, its role in symptom management, and practices to help patients and their caregivers achieve their best quality of life.

Use of systemic lidocaine for postoperative acute pain management in single-lung transplantation: Case report

Introduction: Lung transplantation is associated with severe pain, which can delay recovery. Systemic lidocaine has useful analgesic properties for managing acute pain, however little is known on its use after lung transplantation. Due to pharmacological alterations during the postoperative period, the use of analgesics implies a demanding process to avoid toxicity, so lidocaine may play a role in this scenario. In this sense, the purpose of this case report is to present the use of systemic lidocaine as an option for the management of acute pain when other analgesics have failed to do so.Case presentation: The case of a male patient with acute pain in the postoperative period of single-lung transplantation is presented. Opioids and non-opioid analgesics showed limited efficacy, so the systematic administration of lidocaine was decided. Systemic lidocaine was effective for pain control, functional recovery and opioid decrease during the postoperative period.Conclusions: Systemic lidocaine was a useful drug for postoperative pain management in lung transplantation, since it allowed adequate analgesia and lung function recovery with decreased use of opioids. This drug may be a component of multimodal analgesia in selected patients when other options have failed; however its routine use is not recommended.

Lung Transplantation in Idiopathic Pulmonary Fibrosis

Despite the advances in recent years in the treatment of idiopathic pulmonary fibrosis (IPF), it continues to be a progressive disease with poor prognosis. In selected patients, lung transplantation may be a treatment option, with optimal results in survival and quality of life. Currently, pulmonary fibrosis is the main cause of lung transplantation. However, mortality on the waiting list of these patients is high, since many patients are referred to the transplant units with advanced disease. There is not a parameter that can predict the survival of a specific patient. Different variables are to be considered in order to decide the right time to send them to a transplant unit. It is also very difficult to decide when to include these patients on the waiting list. Every patient diagnosed with IPF, without contraindications for surgery, should be referred early to a transplant unit for assessment. A uni or bilateral transplantation will be decided based on the characteristics of the patient and the experience of each center. The post-transplant survival of recipients with IPF is lower than that observed in other diseases, such as cystic fibrosis or chronic obstructive pulmonary disease as a consequence of their older age and the frequent presence of associated comorbidity. Post-transplant follow-up must be tight in order to assure optimal level of immunosuppressive treatment, detect complications associated with it, and avoid graft rejection. The main cause of long-term mortality is late graft dysfunction as a consequence of chronic rejection. Other complications, such as infections and tumors, must be considered.

Referral to Palliative Care Infrequent in Patients with Idiopathic Pulmonary Fibrosis Admitted to an Intensive Care Unit

BACKGROUND

Palliative care has been recommended as a means to assist patients with idiopathic pulmonary fibrosis (IPF) in managing symptom burden and advanced care planning. Timing of referral is important because although most patients display a gradually progressive course, a minority experience acute deterioration, an outcome associated with high mortality.

AIM

To describe characteristics of IPF patients referred to a specialty lung disease center over a 10-year period who experienced acute deterioration and subsequent intensive care unit (ICU) admission, including frequency and timing of referral to palliative care.

DESIGN

Retrospective review.

SETTING/PARTICIPANTS

We identified 106 patients admitted to the ICU with acute deterioration due to a respiratory or nonrespiratory cause. Variables examined included demographics, date of first center visit, forced vital capacity, diffusing capacity of the lung for carbon monoxide (DLCO), and palliative care referral.

RESULTS

ICU admission occurred early (median 9.5 months) and, for 34%, within four months of their first center visit. For nearly one-half of these patients, ICU admission occurred before their third clinic visit. Only 4 (3.8%) patients received a palliative care referral before ICU admission. The majority (77%) died during ICU admission. With exception of the relationship between DLCO% predicted at first visit and time to ICU admission (r = 0.32, p = 0.005), no variables identified those most likely to experience acute deterioration.

CONCLUSION

Due to high mortality associated with ICU admission, patients and families should be informed about palliative care early following diagnosis of IPF.

Idiopathic pulmonary fibrosis: current treatment options and critical appraisal of nintedanib

Idiopathic pulmonary fibrosis (IPF) is the most common type of idiopathic interstitial pneumonia and is characterized by a poor prognosis, with an estimated 5-year survival of approximately 20%. Progressive and irreversible lung functional impairment leads to chronic respiratory insufficiency with a severely impaired quality of life. In the last 2 decades, novel treatments for IPF have been developed as a consequence of an increasing understanding of disease pathogenesis and pathobiology. In IPF, injured dysfunctional alveolar epithelial cells promote fibroblast recruitment and proliferation, resulting in scarring of the lung tissue. Recently, pirfenidone and nintedanib have been approved for the treatment of IPF, having shown efficacy to slow functional decline and disease progression. This article focuses on the pharmacologic characteristics and clinical evidence supporting the use of nintedanib, a potent small-molecule tyrosine kinase inhibitor, as therapy for IPF. After introducing the mechanism of action and pharmacokinetics, an overview of the safety and efficacy results from the most recent clinical trials of nintedanib in IPF is presented.

Endobronchial ultrasonography-guided transbronchial needle aspiration, an effective modality for sampling targeted thoracic lesions in adult lung transplant recipients

INTRODUCTION

Lung transplantation (LTx) is performed for end-stage lung diseases that would be otherwise fatal. Pulmonary allograft recipients are a unique patient population as they are at high risk for malignancy and infectious complications due to the need for immunosuppression. Endobronchial ultrasonography (EBUS)-guided fine-needle aspiration (FNA) is a minimally invasive technique for evaluating abnormalities of the mediastinum/lungs. To our knowledge, this report is the first in the literature addressing targeted EBUS-FNA biopsies in patients who have undergone LTx.

MATERIAL AND METHODS

During 5 years from May 1, 2009 to May 1, 2014, 582 patients underwent LTx at the Cleveland Clinic. A review of records indicated that 14 of these patients later underwent EBUS-FNA. Demographic and diagnostic parameters were recorded.

RESULTS

A total of 14 patients (mean age 64 years) underwent EBUS-FNA after LTx. The mean interval between LTx and EBUS-FNA was 15 months. EBUS-FNA yielded cytologic material diagnostic of malignancy in 10 patients (71%) with one-half of those cases being squamous carcinomas.

CONCLUSIONS

EBUS-FNA is a useful diagnostic modality in lung allograft recipients and is of value in confirming and staging thoracic malignancies in this population. Carcinoma subtyping is feasible by EBUS-FNA, and performance of ancillary studies to confirm clonality in post-transplant lymphoproliferative disorders is possible.