There are several factors patients can keep in mind to help make a surgery successful.
Proper diet and nutrition plays a key role in preparing the patient for lung transplantation. Usually you will meet with a lung transplant dietitian. The patient's current weight and weight history will be factors as well as the foods they typically eat, and appetite. The patient should adhere to a strict amount of calories, protein, vitamins and minerals needed to maintain a positive nutritional status, as well as any required weight gain or weight loss.
Making sure that the patient is within his or her ideal body weight range for their height helps assure that they will be in good physical condition for the pre-transplant pulmonary rehabilitation, as well as for the transplant itself.
Certain patients with advanced pulmonary disease are unable to eat enough to maintain ideal body weight because of increased metabolic demands and breathlessness with eating. In such cases, a feeding tube be placed in the gastrointestinal tract through the abdominal wall. This procedure requires a small surgery and allows patients to receive nutrition at night and improves nutritional status both before and after the transplant.
Proper nutrition is critical to maximize the chances of a successful transplant. Occasionally, listing for transplant will be delayed until the patient's nutritional status improves. If a patient experiences a deterioration in their nutritional status after being listed with an Organ Bank, that patient will be inactivated on the list until the situation is corrected.
All lung transplant patients will have Immunizations including an annual flu shot, a pneumonia vaccine-known as pneumovax, up to date tetanus shots (within the last ten years) and H.influenza B. vaccine.
Pre-Transplantation Pulmonary Rehabilitation
As a result of your lung condition, you may have developed several associated problems that need to be addressed. These include:
Shortness of breath and increased oxygen need, Decreased activity level, Wasting of your muscle groups-including respiratory muscles, postural or trunk muscles, and your arm and leg muscles, Cardiovascular deconditioning, Fear or anxiety due to breathlessness Evaluation in a pulmonary rehabilitation program is essential for all persons considering transplantation. It is important that you be in the best physical shape as possible at the time of your surgery. Failure to reliably participate in the Pulmonary Rehabilitation program prior to lung transplantation will result in being inactivated from the list.
Lung transplantation will improve your shortness of breath and oxygen need. A comprehensive rehabilitation program will improve the other problems. Therefore, you will be introduced to the importance of exercise and activity before your transplant.
Before your surgery, you will be followed in the outpatient pulmonary rehabilitation program. Here you will be evaluated and placed on an exercise program. This will include training for your respiratory muscles as well as a biking or walking program for your general conditioning. You will need to continue this program even after your transplant occurs. It is important for you to understand that failure to reliably participate in the Pulmonary Rehabilitation program prior to lung transplantation will result in being inactivated from the list.
Typical Evaluation Criteria to be considered for a transplant: Less than 60 years old for a single lung transplant, Less than 50 years old for a double lung transplant, Less than 50 years old for a heart and lung transplant; Must be off oral steroids or on a low dose; Severe end stage lung disease with prognosis of less than 3 year survival; Acceptable cardiac function without significant coronary artery disease.
Types of Tests used to evaluate potential transplant patients"
Pulmonary Function Test
A full study with exercise is performed to determine the extent of the lung disease and to determine the amount of oxygen required by the patient to perform activities of daily living.
High resolution Chest CT Scan: to determine the extent of the lung disease and to rule out lesions.
Cardiovascular Studies: to assess right ventricular size and function, and to rule out coronary artery disease, may include:
Echocardiography (surface or dobutamine)
Right heart catheterization
Left and right heart catheterization
Pap smear and mammogram for female patients
Digital rectal prostate exam and PSA for male patients
The following tests are performed to monitor patients closely following the lung transplant to detect early signs of rejection or infection.
Pulmonary Function Tests (PFTs) are performed with each follow-up clinic visit post transplantation. Many patients are discharged with a home spirometry unit to further facilitate monitoring of pulmonary function immediately post transplant. PFTs will be done urgently with signs of shortness of breath. If FEV1 falls greater than 25% then transbronchial biopsy with bronchoalveolar lavage will be performed here at a Hospital to diagnose rejection versus infection .
Chest x-rays are performed with every clinic visit and as indicated by symptoms. The onset of septal lines and increasing pleural effusions are associated with rejection. Perihilar and basilar infiltrates corresponding to rejection may appear or progress.
Whereas with infection, the radiographic features are similar to those found in other patient populations. The most common infections that occur in lung transplant patients are cytomegalovirus, pneumocystis carinii pneumonia, mycobacteria, nocardia and aspergillus. In other words, infections that occur in other immunosuppressed patients.
Bronchoscopy: transbronchial biopsy with bronchoalveolar lavage is performed routinely here at the University of Michigan Hospital on the 3rd and 6th week post-op and then on every third month (3rd, 6th, 9th, 12th months) post operatively. They will also be performed as indicated by symptoms to diagnose early signs of rejection or infection.
The following are additional tests performed in correlation with bronchoscopies to monitor episodes of rejection.
High resolution CT chest scan: detects early signs of chronic rejection and bronchiolitis obliterans.
Exercise test: to monitor any decrease in the patient's exercise tolerance.
Blood work: Cyclosporine, BUN, creatinine levels and the white blood cell count is monitored very closely post-transplant. The Cyclosporine (lavender top tubes) must be overnight expressed a Lung Transplant Coordinator.
Immunosuppressants (anti-rejection drugs) are taken to aid the patient's body in its continued acceptance of the new organ. Immunosuppressants are taken every day for the remainder of the patient's life. There will never be a time when they can go without taking the anti-rejection medication. Rejection is a natural response of the immune system and will occur at any time when the patient discontinues taking the anti-rejection medication.
Cyclosporine is the most commonly used anti-rejection medication. The dosage is adjusted according to the patient's body weight and drug level.
The side effects of cyclosporine include an increase in susceptibility to infection (especially viral infections), renal dysfunction, hypertension, tremors, headaches, and an increase in hair growth. Cyclosporine interacts with numerous medications. Therefore, the physician and/or patient must discuss all medication changes and additions with the Transplant Center.
Steroids, such as Prednisone, are potent anti-inflammatory agents and as such help control rejection.
Imuran is an immunosuppressant used in combination with prednisone and cyclosporine. Imuran interferes with the production of blood cells, especially the white blood cells. The white blood cells recognize the new lung as a foreign body and therefore will attack the lung. The dose is determined according to the white blood count.
Rejection and infection will remain a life long problem following transplantation. Patients will present with symptoms such as coughing, dyspnea, fatigue, low grade fever and rales. The possibility of rejection or infection will be determined by pulmonary function tests which may reveal a decrease in FEV, FVC, FEF 25-75 and TLC and a chest x-ray to rule out diffuse bilateral pulmonary shadows.
Treatment of Rejection/Infection
If the diagnosis of acute rejection is rendered then immediate rescue therapy should be instituted. Therapy consists of a three day course of 1gm IV Solumedrol per day. After the three day course is completed a repeat PFT and chest x-ray will be performed to determine if the rejection or infection has resolved. If not, the three day course of Solumedrol will be repeated. In addition, a 7-10 day course of IV OKT3 may be given.
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