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Lung transplant
Definition
Lung transplant is surgery to replace one or both diseased lungs with healthy lungs from a human donor.
Alternative Names
Solid organ transplant - lung
Description
The new lung or lungs are usually donated by someone under age 65 who is brain-dead but is still on life-support. The donor tissue must be matched as closely as possible to your tissue type to reduce the odds that your body will reject the transplanted lung.
Lungs can also be given by living donors. Two or more people are needed. Each person donates a segment (lobe) of their lung to form an entire lung for the person who is receiving it.
During lung transplant surgery, you are asleep and pain-free (under general anesthesia). A surgical cut is made in the chest. Lung transplant surgery is done with the use of a heart-lung machine, which does the work of your heart while your heart is stopped for the surgery.
- For single lung transplants, the cut is made on the side of your chest where the lung will be transplanted. The operation takes 4 - 8 hours. In most cases, the lung with the worst function is removed.
- For double lung transplants, the cut is made below the breast and reaches to both sides of the chest. Surgery takes 6 - 12 hours. Tubes are used to send blood to a heart-lung bypass machine to provide oxygen and move blood through the body during the surgery.
After the cut is made, the major steps during lung transplant surgery include:
- One or both of your lungs are removed. For patients who are having a double lung transplant, most or all of the steps from the first transplant are completed before the second transplant is done.
- The main blood vessels and airway of the new lung are sewn to your blood vessels and airway. The donor lobe or lung is stitched (sutured) into place. Chest tubes are inserted to drain air, fluid, and blood out of the chest for several days to allow the lungs to fully re-expand.
Sometimes heart and lung transplants are done at the same time (heart-lung transplant) if the heart is also diseased.
Why the Procedure Is Performed
A lung transplant is usually the last-resort treatment for lung failure. Lung transplants may be recommended for patients under age 65 who have severe lung disease. Some examples of diseases that may require a lung transplant are:
- Cystic fibrosis
- Damage to the arteries of the lung because of a defect in the heart at birth (congenital defect)
- Destruction of the large airways and lung (bronchiectasis)
- Emphysema or chronic obstructive pulmonary disease (COPD)
- Lung conditions in which the lung tissues become swollen and scarred (interstitial lung disease)
- High blood pressure in the arteries of the lungs (pulmonary hypertension)
- Sarcoidosis
Lung transplant may NOT be done for patients who:
- Are too sick or badly nourished to go through the procedure
- Continue to smoke or abuse alcohol or other drugs
- Have active hepatitis B, hepatitis C, or HIV
- Have had cancer within the past 2 years
- Have lung disease that will likely affect the new lung
- Have severe disease of other organs
The doctor may recommend against a heart transplant if there is concern that you will not be able to keep up with the many hospital and doctor's visits, tests, and medications needed to keep the new heart healthy.
Risks
Risks from any anesthesia are:
- Breathing problems
- Reactions to the medications
Risks from any surgery are:
- Bleeding
- Infection
Other risks of transplant include:
- Blood clots (deep venous thrombosis)
- Diabetes, bone thinning, or high cholesterol levels from the medications given after a transplant
- Increased risk for infections due to anti-rejection (immunosuppression) medications
- Damage to your kidneys, liver, or other organs from anti-rejection medications
- Future risk of certain cancers
Risks of lung transplant include:
- Problems at the place where the new blood vessels and airways were attached
- Rejection of the new lung, which may happen right away, within the first 4 to 6 weeks, or over time
Before the Procedure
Before the procedure, your doctor will determine whether you are a good candidate by doing the following tests:
- Blood tests or skin tests to check for infections
- Blood typing
- Tests to evaluate your heart, such as EKG, echocardiogram, or cardiac catheterization
- Tests to evaluate your lungs
- Tests to look for early cancer (Pap smear, mammogram, colonoscopy)
- Tissue typing, to help make sure your body will not reject the donated lung
If your transplant team believes that you are a good candidate for lung transplantation, you will be put on a national waiting list. Your place on the waiting list is based on a number of factors, including:
- What type of lung problems you have
- The severity of your lung disease
- The likelihood that a transplant will be successful
The amount of time you spend on a waiting list usually does not determine how soon you get a lung, except possibly with children. Waiting time is often at least 2 - 3 years.
While you are waiting for a new lung, follow these guidelines:
- Follow any diet your lung transplant team recommends. Stop drinking alcohol, do not smoke, and keep your weight in the recommended range.
- Take all medicines as they were prescribed. Report changes in your medications and medical problems that are new or get worse to the transplant team.
- Follow any exercise program that you were taught during pulmonary rehabilitation.
- Keep any appointments that you have made with your regular doctor and transplant team.
- Let the transplant team know how to contact you right away if a lung becomes available. Make sure that, no matter where you go, you can be contacted quickly and easily.
- Be prepared in advance to go to the hospital.
Before the procedure, always tell your doctor or nurse:
- What drugs, vitamins, herbs, and other supplements you are taking, even ones you bought without a prescription.
- If you have been drinking a lot of alcohol (more than one or two drinks a day)
Do not eat or drink anything after midnight the night before your surgery. Take only the drugs that your doctor told you to take with a small sip of water.
After the Procedure
You should expect to stay in the hospital for 7 - 21 days after a lung transplant. You will likely spend time in the intensive care unit (ICU) right after surgery. Most centers that perform lung transplants have standard ways of treating and managing lung transplant patients.
During your hospital stay, you will:
- Be asked to sit on the side of the bed and then walk on the same day you have surgery
- Be asked to cough
- Have a tube coming out of the side of your chest to drain fluids
- Wear special stockings on your feet and legs to prevent blood clots
- Get shots to prevent blood clots
- Receive pain medicine through a tube that goes into your vein (IV) or by mouth with pills. You may have a special machine that gives you a dose of pain medicine when you push a button. This allows you to control how much pain medicine you receive.
- Be asked to do a lot of deep breathing to help prevent pneumonia and infection, and to inflate the lung that was transplanted. Your chest tube will stay in place until your lung has fully inflated.
- Receive many different medicines
- Have many chest x-rays
- Have bronchoscopy -- a flexible camera used to look at your airways and make sure that the new lung is healing
The recovery period is about 6 months. Often, your transplant team will ask you to stay close to the hospital for the first 3 months. You will need to have regular check-ups with blood tests and x-rays for many years.
Outlook (Prognosis)
A lung transplant is a major procedure that is performed for patients with life-threatening lung disease or damage.
Around four out of five people are still alive 1 year after the transplant. Around two out of five transplant recipients are alive at 5 years. Outcomes are similar for single and double lung transplants. The highest risk of death is during the first year, mainly from problems such as rejection.
Fighting rejection is an ongoing process. The body's immune system considers the transplanted organ as an invader (much like an infection) and may attack it.
To prevent rejection, organ transplant patients must take anti-rejection (immunosuppression) drugs (such as cyclosporine and corticosteroids). These drugs suppress the body's immune response and reduce the chance of rejection. As a result, however, these drugs also reduce the body's natural ability to fight off infections.
By 5 years after a lung transplant, at least one in five people develop cancers or have problems with the heart. These two conditions cause most deaths at 5 years.
For most people, the quality of life is improved after a lung transplant. They have better exercise endurance and are able to do more on a daily basis.
References
Smythe WR, Reznik Si, Putnam JB Jr. Lung (including pulmonary embolism and thoracic outlet syndrome). In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008: chap 59.
Solomon M, Grasemann H, Keshavjee S. Pediatric lung transplantation. Pediatr Clin North Am. 2010; 57(2):375-391.
Flume PA, Mogayzel PJ Jr, Robinson KA, Rosenblatt RL, Quittell L, Marshall BC; Clinical Practice Guidelines for Pulmonary Therapies Committee; Cystic Fibrosis Foundation Pulmonary Therapies Committee. Cystic fibrosis pulmonary guidelines: Pulmonary complications: hemoptysis and pneumothorax. Am J Respir Crit Care Med. 2010; 182(3):298-306.
Kotloff RM. Lung transplantation. In: Mason RJ, Broaddus CV, Martin TR, et al. Murray & Nadel's Textbook of Respiratory Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 95.
Reviewed By: Shabir Bhimji, MD, PhD, Specializing in General Surgery, Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
