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Lung transplantation involves more than the operation itself. Undergoing the evaluation, waiting for transplant, and recovery afterward represent a long journey for the patient and family. While most patients have an excellent outcome, some lifestyle changes are necessary for continued health after transplantation.
Many members of the lung transplant team are involved in evaluating a person's eligibility for transplantation. This group includes pulmonary transplant physicians and surgeons and physicians specializing in cardiology, infectious diseases, psychiatry and other areas. Certified transplant coordinators and licensed social workers assist the transplant candidate and family during and after the evaluation.
Potential lung transplant candidates must undergo detailed physical, laboratory and psychological testing to ensure proper selection and therapy. The typical evaluation takes a few days and includes assessing the respiratory, cardiac, kidney, liver and immune systems. Tests typically include:
The transplant team evaluates test results and screening assessments for each patient to determine the likelihood of a successful transplant. Patients who can be expected to undergo a transplant with a reasonable margin of safety will be added to a waiting list. Patients return for a visit with the transplant physicians to discuss the outcome of their evaluation and their suitability for a transplant. Patients who are not considered candidates for transplantation will be offered alternative medical or surgical care if there are any available.
Individuals approved for transplant are placed on the active list and are given a pager to notify them when a donor organ becomes available. Transplant recipients usually have two to three hours to reach the hospital to prepare for surgery. Therefore, transplant candidates must live close enough to arrive at the hospital in that time frame.
Transplant candidates are evaluated every three months or sooner if necessary. Regular communication between the transplant team and the referring physician is essential for successful shared care.
Mayo Clinic helps transplant candidates coordinate any necessary air transportation to ensure rapid travel to Mayo Clinic when a donor organ becomes available.
After a transplant recipient receives notice that a compatible donor organ is available, he or she will be admitted to the hospital. The transplant physician will do a final evaluation to ensure the patient is still in appropriate condition for transplantation.
Coordination between the team of surgeons retrieving the organ and the team caring for the patient is vital. Before making the final decision to proceed with a transplant, the surgeon retrieving the lungs carefully examines them and their function to make sure they are viable. Surgery on the transplant recipient is not begun until the surgeon retrieving the organ approves it for transplant. Therefore, a lung transplant candidate could be admitted to the hospital and could even be in the operating room when the procedure is canceled because the donor lungs did not remain viable. This process is called a "dry run," and it is important that the lung transplant candidate be emotionally prepared to deal with this situation. Doing a last-minute check on donor organ viability improves the likelihood of a successful transplant.
Once the surgeon retrieving the organ determines that the donor lung is viable, the team will begin surgery. Meanwhile, the retrieval surgeon preserves the lung, transports it to the hospital and joins the transplant surgery in progress.
Because each individual's situation is unique, we will address this important issue in the broadest terms. Patients are given many opportunities to discuss their needs and concerns with experienced physicians and caregivers during visits to the transplant center. The following general information usually applies.
Lung transplant recipients usually stay in the hospital for three to four weeks. Education and physical rehabilitation begin soon after surgery and continue in the outpatient pulmonary transplant rehabilitation program after the patient leaves the hospital.
In the early post-hospital phase, Mayo's transplant team sees patients several times a week. Eventually these visits decrease to one per month. Transplant recipients will be asked to remain in the Mayo Clinic area for two to three months following transplantation to allow Mayo's transplant team to closely monitor their status. Transplant recipients and their families participate in educational activities to help them feel comfortable with taking medications, monitoring blood pressure and measuring lung function.
Daily and lifelong immunosuppressive medication is required to prevent rejection of the transplanted lung. The threat of acute rejection is highest in the first six months after surgery. To screen for signs of rejection, transplant patients undergo routine chest X-rays and lung function measurements such as spirometry and pulse oxymetry.
If organ rejection is suspected, samples of lung tissue are tested to determine whether rejection has begun or another problem, such as an infection, is developing. This procedure is called a bronchoscopy with trans-bronchial biopsies. Lung transplant patients undergo screening bronchoscopies and biopsies at one, three, six and 12 months after transplantation and when necessary if signs of rejection are present. These procedures are done under sedation to avoid discomfort.
Most patients are treated with three immunosuppressive drugs to prevent rejection. These medications usually require frequent adjustments, especially soon after transplant. These medications must be given in doses high enough to avoid acute rejection but not so high that the patient becomes vulnerable to infections. Because the likelihood of developing infections soon after transplant is high, patients also are given protective antibiotics to prevent the most common infections that occur after transplant. After a few months, as the body becomes more tolerant of the newly implanted lung, doses of immunosuppressive drugs are progressively lowered, and that makes it possible to slowly discontinue protective antibiotics.
Once transplant recipients' health is stable and they have returned home, they should see their primary care physician regularly. They should test their lung volume with a portable spirometry device every day. Each transplant patient is given the necessary equipment and is instructed in its correct use. These measurements provide important and objective information about how well the lungs are working. A decline in the measurements is a signal that patients should be evaluated.
The lung transplant team continues to care for transplant patients in coordination with their primary care physicians.
Because transplant patients must take medications that suppress their immune system, they are vulnerable to developing complications from infections. Therefore, patients and their primary care physicians must be on the lookout for signs of potentially serious infections that should be treated early and aggressively.
Additional complications of lung transplantation, usually caused by side effects of immunosuppressive therapy, include high blood pressure, poor kidney function, weak bones (osteoporosis), weight gain and diabetes. Medications are available to help manage these problems, but a healthy lifestyle, proper diet and exercise are equally important prescriptions for transplant patients.
Lung function is also monitored to identify and treat possible chronic rejection, also called bronchiolits obliterans, which is characterized by slowly progressive breathlessness.
Immunosuppressive therapy also makes transplant recipients more prone to developing tumors and cancer. Therefore, a healthy lifestyle, proper diet, strict avoidance of tobacco products and regular checkups to screen for common preventable cancers, such as breast, cervix, colon, and prostate, are important.
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