Lung Transplant: Types, Requirements, Procedure, And Everything To Know

Lung Transplant: Types, Requirements, Procedure, And Everything To Know

The first lung transplant was performed in 1963 in USA. Since then, this practice has spread worldwide and the transplant process has evolved manifolds. There have been modifications in the surgical procedure and new technology has been put to use for diagnosis and surgery. This has increased the accuracy of the transplant process and worked in favor of increasing patient survival.

The article below gives you a detailed account of the procedure of lung transplant and what can be expected after this major surgery.

Introduction To Lung Transplant

A lung transplant is a major surgery prescribed in cases where the lungs are unable to sustain the life of the individual. This could either be due to a congenital condition, a disease, an injury, infection, chronic inflammation, or other damage. It is worth noting that a transplant is the final option for the doctor and is performed when the patient is not properly responding to any other form of treatment.

This surgery consists of multiple steps involving diagnostic tests, donor search, surgery, recovery, and post-operative care. Considering the vitality of the surgery, the recipient needs to incorporate a healthy lifestyle and habitual changes. Under proper care and precautions, there are higher chances of a successful transplant with a higher life expectancy.

What Health Conditions Require Lung Transplantation?

A doctor prescribes a lung transplant only when other treatment methods including medications and therapy do not work. This happens when the lungs have suffered irreversible damage. Due to this, they not only resist treatment but also do not function well enough to sustain the life of the individual. There are several health conditions that can lead up to this. Some of the most common conditions that require a lung transplant include:

1. Pulmonary Fibrosis

This condition involves scarring of the lung tissues. The tissues are irreversibly damaged and become thick and stiff. This disrupts the exchange of gases through the walls of the lungs.

Pulmonary fibrosis is often caused by interstitial lung disease, connective tissue diseases, or long-term exposure to toxic chemicals. This condition is characterized by shortness of breath and chronic dry cough.

2. Chronic Obstructive Pulmonary Disease (COPD)

This is a condition characterized by the "obstruction" or the partial or complete blockage of the pulmonary channels. It disrupts the airflow through the windpipe and makes it difficult for the person to breathe.

COPD involves diseases like emphysema and chronic bronchitis. The most common symptoms include wheezing, breathing difficulty, dry or wet cough, frequent respiratory infections, and fatigue.

3. Cystic Fibrosis

Cystic fibrosis of the lungs involves defect of the mucus clearing mechanism leading to accumulation of mucus plugs, infection, areas of tissue destruction and ultimately fibrosis. The viscid secretions often block the respiratory passages. This condition is characterized by difficulty in breathing, wheezing, and chronic sinusitis.

4. Pulmonary Hypertension

Pulmonary hypertension refers to the higher than normal blood pressure in the arteries of the lungs that disrupts the exchange of gases through the blood. The obvious cause of secondary to diseases of the heart or lungs. Symptoms include occasional chest pain, chronic cough, and shortness of breath.

Types Of Lung Transplant

A lung transplant could be performed in the form of a single lung, both lungs, or a lobe each of both the lungs. In some cases, this could be combined with transplant of the heart also (Heart Lung Transplant) . Occasionally, it has been combined with kidney transplant also. It depends on the condition of the recipients lungs.

Where do lungs come from?

There are two type of lung donors:

  1. The cadaveric (dead) donors : these are of two types
    1. Donation after brain death : the human organ transplantation act 1994 (modified in 2014) has defined the brain stem death as death. The brain stem death is to be certified based on clinical parameters and tests to be performed by qualified medical practitioners as defined in the act. So a person who is certified to have brain stem death (hence dead) can be a donor if the family consents for the same. It is to be clarified that these “Brain dead donors will still have heart beating (which sometimes creates confusion in the minds of the patient’s relatives as the patient being alive). It is to be re- clarified that a person with certified brain stem death is dead as approved by law. This happens in patients of Road Traffic accidents with head injury, stroke and other brain disorders. World wide, this is the largest pool of cadaveric donors and is responsible for the bulk of the cadaveric donor organ transplant activity. There is a strong need to increase awareness and acceptance amongst the doctors as well as the community at large about the importance of Organ donation in this subset of individuals who are dead (brain stem death) but still have a beating heart. There are large number of such brain stem dead-beating heart ie dead individuals on life support systems in various ICUs across the country and if there was heightened awareness amongst medical community to give the option of organ donation to the family and acceptance of the same by the families, a large number of organ recipients can benefit. One such donor can benefit at least 8 individuals by donating heart, lungs, liver, two kidneys, pancreas, intestines and the two corneas.
    2. Donation after Cardiac Death: These are individuals who have suffered cardiac arrest due to one reason or the other and the organs are donated as soon as possible after the death. These are also known as non-heart beating donors as opposed to the group mentioned above which is known as brain dead-heart beating donors. This may happen in a controlled or an uncontrolled environment. These donors can donate all the above mentioned organs except the heart.

  1. Living Related Donor :

Unlike liver and kidney where living relative donating an organ is the major donation activity in our country, in the case of lungs the same is not possible because donating one lung affects the life of the donor and hence, legally not allowed. Donating a lobe (half part of one lung) is permitted and does not adversely impact the life of the donor but is inadequate to sustain life of the recipient on its own. However, a lobe each from two related donors implanted on either side in the recipient will do no harm to the two donors but will be sufficient for the recipient. This procedure called as “living related bilateral lobar lung transplantation” has ethical issues of two normal people being subjected to a surgery to benefit one individual and has not yet been started in our country. As of today, it is practiced at one centre in Japan on a limited basis.

The lung transplant process: it involves three components:

  • A recipient : a recipient is a person with end stage lung diseases for which no medical or surgical therapy is available and has a limited chance of survival if left untreated. The diseases which lead to this situation have already been described above.
  • Donor: the donor could be Cadaveric (brain dead or cardiac death as mentioned above) or live related (as mentioned above)
  • The Process of transplantation: carried out by an accredited lung transplant centre.

The steps involved in the lung transplantation process are as below:

  • Recipient identification : a person with end stage lung disease is identified by his treating physician and referred to a lung transplant centre.
  • Recipient work-up: the above patient is evaluated by a transplant pulmonologist at the lung transplant centre and if he meets the selection criteria for lung transplant, he is admitted for a series of tests and examinations to evaluate his physical and mental fitness for the same.
  • Recipient notified on the NOTTO site: after complete workup, patients who are considered eligible and are fit for lung transplant and where the family consents for the same, the patient is notified on the lung transplant recipient waiting list of the state or regional of national transplant organization (NOTTO / SOTTO / ROTTO). These are government agencies which control and coordinate the distribution of organs as per law.
  • Recipient relocation: after being notified on the waiting list the recipient is requested to move to the same city as the lung transplant centre. The medical treatment, nutritional support and physiotherapy is continued under the supervision of the transplant team.
  • Donor Offer: whenever, the family of a brain dead or a cardiac death person consents to organ donation, the details of the donor are provided to the state of regional or national organ transplant organization which matches it with the waiting list and allocates the organ using blood group, size matching and geographical location as the criteria. An offer regarding the same is made to the team at the recipient hospital.
  • Recipient - donor matching and acceptance of the offer: Once the team at the recipient centre receives a lung offer from the transplant organization, they connect directly with the team at the donor hospital and look critically at the blood group and size matching and also look at the oxygenation (i.e. blood gases) and CT Scan of the lungs to check the fitness of the lungs on offer. This is a very important step and needs a lot of coordination between the teams at the donor hospital and the recipient hospital. The provisional acceptance is given on the basis of this telephonic exchange of information although, the final call on accepting the lungs on offer is made on the table when the recipient hospital team reaches the donor hospital, looks at the blood gases and bronchoscopic pictures and opens the chest of the donor and looks at the lungs physically
  • Removal of Donor Lungs: after accepting the lungs on offer (as per steps mentioned above), the recipient hospital surgeons team removes the lungs from the donor (called explantation) as per a laid down procedure and packs them into an ice box for transport back to the recipient hospital again as per a laid down procedure.
  • Recipient admission into hospital: while the recipient team is moving towards the donor hospital, another team at the recipient hospital admits the recipient and prepares him for the transplant process. As soon as the lungs on the offer are accepted (and also depending on the travel time from the donor hospital to the recipient hospital) the recipient is wheeled into the operation room and anesthetized and operation started .
  • The Transplantation of the Lungs : as soon as the recipient hospital team arrives in the operation room with the donor lungs, the recipient’s native lungs are removed from his body and the donor lungs are implanted in a sequential manner.
  • Post operative Care: As per the current evidence, most of the recipients are put on artificial support (ECMO) during the transplantation process. This has been shown to help in the quick recovery of the transplanted lungs. This kind of ECMO support is slowly withdrawn and thereafter, the ventilator support to the recipient is slowly withdrawn in the postoperative period over the next few days. Depending on how the implanted lungs function, the recipient needs to be in ICU from a few days to a few weeks. Thereafter, they are shifted to the ward and managed accordingly.
  • Immunosuppression and Infection prevention medicines: as the donor lungs are considered a “foreign body” by the immune system of the recipient, it mounts a massive immune response which destroys the donor lungs very fast. Inorder to prevent this from happening the recipient is started on Immunosuppression i.e. medicines to reduce the immune response of the recipient. These medicines are started before the operations and are continued post operatively, forever. While they reduce the immune response from the recipient body and allow the donor lungs in his/her body and function, it comes at the cost of markedly decreased resistance to various bacteria, viruses and fungus present in the ambient air. Thus, the recipients are at a high risk of various infections because of being immunosuppressed. To face this risk they are given various antiviral and anti-fungal medicines as a preventive measure and also advised certain physical measures to limit exposure to these pathogens. Thus, infections are a major issue in the long term postoperative period of these patients due to Immuno-suppression medicines. Treating doctors have to walk a tightrope between immunosuppression medicines dosages and the risk of infections.
  • Long Term follow-up: rejection and infection are the two major issues in the long term follow-up of these patients for which the patient needs to visit the hospital on a regular basis, undergo various tests at regular intervals and take immunosuppression and infection prevention medicines on a regular basis, life long. This does impose a recurring monthly expense as well as inconvenience to the recipient and must be understood well and accepted before the proposed recipient and family accepts the lung Transplantation offer from the treating doctors.