Adult bronchiolitis surgery: Difference between revisions

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==Overview==
==Overview==
Lung transplant is not the first-line treatment option for patients with adult bronchiolitis. Surgery is usually reserved for patients with untreatable and advanced stage lung disease.  
[[Lung transplantation|Lung transplant]] is not the first-line treatment option for patients with adult bronchiolitis. Surgery is usually reserved for patients with untreatable and advanced stage lung disease.  


==Indications==
==Indications==


*Lung transplant is not the first-line treatment option for patients with adult bronchiolitis. Surgery is usually reserved for patients with either:
*[[Lung transplantation|Lung transplant]] is not the first-line treatment option for patients with adult bronchiolitis. Surgery is usually reserved for patients with either:<ref name="pmid25085497">{{cite journal |vauthors=Weill D, Benden C, Corris PA, Dark JH, Davis RD, Keshavjee S, Lederer DJ, Mulligan MJ, Patterson GA, Singer LG, Snell GI, Verleden GM, Zamora MR, Glanville AR |title=A consensus document for the selection of lung transplant candidates: 2014--an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation |journal=J. Heart Lung Transplant. |volume=34 |issue=1 |pages=1–15 |date=January 2015 |pmid=25085497 |doi=10.1016/j.healun.2014.06.014 |url=}}</ref><ref name="pmid27381675">{{cite journal |vauthors=McKellar SH, Bowen ME, Baird BC, Raman S, Cahill BC, Selzman CH |title=Lung transplantation following coronary artery bypass surgery-improved outcomes following single-lung transplant |journal=J. Heart Lung Transplant. |volume=35 |issue=11 |pages=1289–1294 |date=November 2016 |pmid=27381675 |doi=10.1016/j.healun.2016.05.029 |url=}}</ref><ref name="pmid16399533">{{cite journal |vauthors=McAnally KJ, Valentine VG, LaPlace SG, McFadden PM, Seoane L, Taylor DE |title=Effect of pre-transplantation prednisone on survival after lung transplantation |journal=J. Heart Lung Transplant. |volume=25 |issue=1 |pages=67–74 |date=January 2006 |pmid=16399533 |doi=10.1016/j.healun.2005.07.012 |url=}}</ref>
**Clinically severe disease where medical therapy is ineffective The risk of death from lung disease without transplantation is >50 percent within two years
**Clinically severe disease where medical therapy is ineffective.
**The likelihood of surviving at least 90 days after lung transplantation is more than 80%
**The risk of death from lung disease without [[Organ transplant|transplantation]] is more than 50% within two years
**The likelihood of surviving at least 90 days after lung transplantation is more than 80%
**Absence of a non-respiratory comorbidity that would limit life expectancy in the first 5 years after transplant
**Absence of a non-respiratory comorbidity that would limit life expectancy in the first 5 years after transplant
**Acceptable social profile and support system
**Acceptable social profile and support system
Line 18: Line 19:
*Absolute contraindications include the following:
*Absolute contraindications include the following:
**Uncontrolled or untreatable pulmonary or extrapulmonary infection
**Uncontrolled or untreatable pulmonary or extrapulmonary infection
**Active TB infection
**Active [[Tuberculosis|TB]] infection
**Malignancy within previous 2 years
**Malignancy within previous 2 years
**Significant comorbidity of other vital organs  
**Significant comorbidity of other vital organs  
**Significant coronary heart disease not treated by revascularization  
**Significant [[coronary heart disease]] not treated by [[revascularization]]
**Untreatable bleeding diathesis
**Untreatable [[Hemorrhagic diathesis|bleeding diathesis]]
**Significant chest wall or spinal deformity expected to cause severe restriction after transplantation
**Significant chest wall or spinal deformity expected to cause severe restriction after [[Organ transplant|transplantation]]
**Grade II or III obesity with body mass index (BMI) ≥35 kg/m2  
**Grade II or III obesity with [[body mass index]] (BMI) ≥35 kg/m2  
**Smoker
**Smoker
**Drug or alcohol dependency
**Drug or alcohol dependency
**Unresolved psychosocial problems or noncompliance with medications
**Unresolved psychosocial problems or noncompliance with medications
*Relative contraindications include the following:
*Relative contraindications include the following:
**Age >65 years in association with low physiologic reserve or other relative contraindications  
**Age more than 65 years in association with low physiologic reserve or other relative contraindications  
**Grade I obesity with body mass index (BMI )30 to 34.9 kg/m2  
**Grade I obesity with [[body mass index]] (BMI) 30 to 34.9 kg/m2  
**Severe or progressive malnutrition
**Severe or progressive [[malnutrition]]
**Severe with clinical manifestations of osteoporosis  
**Severe with clinical manifestations of [[osteoporosis]]
**Previous cardiothoracic surgery
**Previous [[cardiothoracic surgery]]
**Colonization or infection with highly resistant or highly virulent agents
**Colonization or infection with highly resistant or highly virulent agents
**HIV positive patient
**[[Human Immunodeficiency Virus (HIV)|HIV]] positive patient
**Active hepatitis B or C infection  
**Active [[hepatitis B]] or [[Hepatitis C|C]] infection  
**Absence of a consistent social support system
**Absence of a consistent social support system


===Medical tests for potential transplant candidates===
===Medical tests for potential transplant candidates===
Patients who are being considered for placement on the organ transplant list must undergo an extensive series of medical tests in order to evaluate their overall health status and suitability for transplant surgery:<ref name="lung3">{{cite web |date=February 7 2003 |url=http://www.clevelandclinic.org/health/health-info/docs/2700/2720.asp?index=4491 |title=Lung Transplant Evaluation: Required Tests |publisher=Cleveland Clinic |accessdate=2006-09-29}}</ref>
Patients who are being considered for lung transplantation undergo the following tests to ensure lung transplant success and the patients' clinical status:<ref name="lung3">{{cite web |date=February 7 2003 |url=http://www.clevelandclinic.org/health/health-info/docs/2700/2720.asp?index=4491 |title=Lung Transplant Evaluation: Required Tests |publisher=Cleveland Clinic |accessdate=2006-09-29}}</ref>
*Blood typing:
*[[Blood typing]]:
**The blood type of the recipient must match that of the donor due to certain [[antigen]]s that are present on donated lungs.
**The [[blood type]] of the recipient must match that of the donor due to certain [[antigen]]s that are present on donated lungs.
**A mismatch of blood type can lead to a strong response by the [[immune system]] and subsequent [[transplant rejection|rejection of the transplanted organs]]
**A mismatch of blood type can lead to a strong response by the [[immune system]] and subsequent [[transplant rejection|rejection of the transplanted organs]]
*Tissue typing:
*Tissue typing:
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*Chest [[X-ray]]
*Chest [[X-ray]]
**To verify the size of the lungs and the chest cavity
**To verify the size of the lungs and the chest cavity
*Pulmonary function tests
*[[Spirometry|Pulmonary function tests]]
*Ventilation/perfusion (V/Q) scan
*[[Ventilation/perfusion scan|Ventilation/perfusion]] (V/Q) scan
*Electrocardiogram
*[[Electrocardiogram]]
*Cardiac catheterization
*[[Cardiac catheterization]]
*Echocardiogram
*[[Echocardiography|Echocardiogram]]


==Types of lung transplant==
==Types of lung transplant==
===Lobe===
===Lobe===
* A lobe transplant is a surgery in which part of a living donor's lung is removed and used to replace part of recipient's diseased lung.
A lobe transplant is a surgery where a lobe or the entire diseased lung is replaced by a healthy donor lung.
* This procedure usually involves the donation of lobes from two different people, thus replacing a single lung in the recipient.
* Donors who have been properly screened should be able to maintain a normal quality of life despite the reduction in lung volume.


===Single-lung===
===Single-lung===
Many patients can be helped by the transplantation of a single healthy lung. The donated lung typically comes from a donor who has been pronounced [[brain death|brain-dead]].
A single lung is transplanted and the donor has usually been pronounced brain dead.


===Double-lung===
===Double-lung===
* Certain patients may require both lungs to be replaced.
Certain patients may require both lungs to be replaced.
* This is especially the case for people with [[cystic fibrosis]], due to the bacterial colonization commonly found within such patients' lungs; if only one lung were transplanted, bacteria in the native lung could potentially infect the newly transplanted organ.


==Surgery==
==Surgery==
* While the precise details of surgery will depend on the exact type of transplant, there are many steps which are common to all of these procedures.
* Prior to operating on the recipient, the transplant surgeon inspects the donor lung(s) for signs of damage or disease.
* If the lung or lungs are approved, then the recipient is connected to an [[Intravenous therapy|IV]] line and various monitoring equipment, including [[pulse oximetry]].
* The patient will be given general [[anesthesia]], and a machine will breathe for him or her.<ref name="lung5">{{cite web |date=October 2005  |url=http://www.chestnet.org/patients/guides/lung_trans/p9.php |title=What Is the Surgical Procedure? |publisher=American College of Chest Physicians |accessdate=2006-09-29}}</ref>
* It takes about one hour for the pre-operative preparation of the patient.
* A single lung transplant takes about four to eight hours, while a double lung transplant takes about six to twelve hours to complete.
* A history of prior chest surgery may complicate the procedure and require additional time.
===Lobe===
===Single-lung===
===Single-lung===
[[Image:DoubleLungTransplantScar.jpg|right|thumb|Incision scarring from a double lung transplant.]]
*An incision is under the shoulder blade around the chest, ending near the sternum or an incision is made under the breastbone.  
* In single-lung transplants, the lung with the worse pulmonary function is chosen for replacement.
*The diseased lung is collapsed, the blood vessels are clamped and the lung is cut from the bronchus
* If both lungs function equally, then the right lung is usually favored for removal because it avoids having to maneuver around the heart, as would be required for excision of the left lung.<ref name="lung2">{{cite web |date=June 1 2006 |url=http://www.emedicine.com/med/topic2980.htm |title=Lung Transplant |publisher=eMedicine |accessdate=2006-09-29}}</ref>
*The donor lung is placed in the correct position and the blood vessels are reconnected.
 
*The lung is then reinflated.
* In a single-lung transplant the process starts out after the donor lung has been inspected and the decision to accept the donor lung for the patient has been made.
*A [[bronchoscopy]] is performed to remove blood or mucus in the new lung.  
* An incision is generally made from under the shoulder blade around the chest, ending near the sternum.
* An alternate method involves an incision under the breastbone.<ref name="lung1">{{cite web |date=January 30 2006 |url=http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/31212.html |title=Lung Transplant |publisher=Aetna intelihealth |accessdate=2006-09-29}}</ref>
* In the case of a singular lung transplant the lung is collapsed, the blood vessels in the lung tied off, and the lung removed at the [[Bronchus|bronchial]] tube.
* The donor lung is placed, the blood vessels reattached, and the lung reinflated.
* To make sure the lung is satisfactory and to clear any remaining blood and mucus in the new lung a [[bronchoscopy]] will be performed.
* When the surgeons are satisfied with the performance of the lung the chest incision will be closed.


===Double-lung===
===Double-lung===
* A double-lung transplant, also known as a bilateral transplant, can be executed either sequentially, en bloc, or simultaneously.
*The procedure is similar to the one described above, but the process occurs twice, once for each lung.
* Sequential is more common than en bloc.<ref name="lung2">{{cite web |date=June 1 2006 |url=http://www.emedicine.com/med/topic2980.htm |title=Lung Transplant |publisher=eMedicine |accessdate=2006-09-29}}</ref>
*A less common alternative is the transplantation of both lungs en bloc or simultaneously.
* This is effectively like having two separate single-lung transplants done.  
* A less common alternative is the transplantation of both lungs en bloc or simultaneously.
* The transplantation process starts after the donor lungs are inspected and the decision to transplant has been made.
* An incision is then made from under the patient's armpit, around to the sternum, and then back towards the other armpit, this is known as a clamshell incision.
* In the case of a sequential transplant the recipients lung with the poorest [[Spirometry|lung functions]] is collapsed, the blood vessels tied off, and cut at the corresponding [[Bronchus|bronchi]].
* The new lung is then placed and the blood vessels reattached.
* To make sure the lung is satisfactory before transplanting the other a [[bronchoscopy]] is performed.
* When the surgeons are satisfied with the performance of the new lung, surgery on the second lung will proceed.
* In 10% to 20% of double-lung transplants the patient is hooked up to a [[heart-lung machine]] which pumps blood for the body and supplies fresh oxygen.<ref name="dbl process">{{cite web |date=January 30, 2006 |url=http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/31212.html |title=Lung Transplant |publisher=Aetna intelihealth |accessdate=2006-11-02}}</ref>


==Risks==
==Risks==
*Signs of rejection:<ref name="lung1">{{cite web |date=January 30 2006 |url=http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/31212.html |title=Lung Transplant |publisher=Aetna intelihealth |accessdate=2006-09-29}}</ref>
*Signs of rejection:<ref name="lung1">{{cite web |date=January 30 2006 |url=http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/31212.html |title=Lung Transplant |publisher=Aetna intelihealth |accessdate=2006-09-29}}</ref>
**Fever
**[[Fever]]
**Flu-like symptoms, including [[chills]], [[dizziness]], [[nausea]], general feeling of illness
**Flu-like symptoms, including:
**Increased difficulty in breathing
***Chills
**Worsening pulmonary test results
***Dizziness
**Increased [[chest pain]] or [[tenderness]]
***Nausea
*In order to prevent transplant rejection and subsequent damage to the new lung or lungs, patients must take a regimen of [[immunosuppressive drug]]s.
***Lethargy
*Patients will normally have to take a combination of these medicines in order to combat the risk of rejection.
**[[Dyspnea]]
*The immunosuppressive regimen is begun just before or after surgery.
**Progressively worsening pulmonary function test
*Usually the regimen includes [[Ciclosporin|cyclosporine]], [[azathioprine]] and [[corticosteroid]]s, but as episodes of rejection may reoccur throughout a patient's life, the exact choices and dosages of immunosuppressants may have to be modified over time.  
**[[Chest pain]] or [[tenderness]]
*Sometimes [[tacrolimus]] is given instead of cyclosporine and [[Mycophenolic acid|mycophenolate mofetil]] instead of azathioprine.
*In order to prevent transplant rejection and subsequent damage to the new lung or lungs, patients must take [[immunosuppressive drug]]s  
*Chronic rejection, meaning repeated bouts of rejection symptoms beyond the first year after the transplant surgery, occurs in approximately 50% of patients.<ref name="Merck 18 p.1377">Merck Manual 18th ed. p. 1377</ref> Such chronic rejection presents itself as [[bronchiolitis obliterans]], or less frequently, [[atherosclerosis]].<ref name="Merck 18 p.1377" />
*Patients will normally have to take a combination
*The immunosuppressive regimen starts just before or after surgery, including:
**[[Ciclosporin|Cyclosporine]]
**[[Azathioprine]]  
**[[Corticosteroid]]s
*Chronic rejection, may occur after the first years with repeated episodes of rejection symptoms.
**Chronic rejection occurs in approximately 50% of transplant patients.


==Prognosis==
==Prognosis==
Transplanted lungs typically last three to five years before showing signs of failure.
Transplanted lungs on average last 3 to 5 years before showing signs of failure.


==References==
==References==

Latest revision as of 13:39, 5 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Overview

Lung transplant is not the first-line treatment option for patients with adult bronchiolitis. Surgery is usually reserved for patients with untreatable and advanced stage lung disease.

Indications

  • Lung transplant is not the first-line treatment option for patients with adult bronchiolitis. Surgery is usually reserved for patients with either:[1][2][3]
    • Clinically severe disease where medical therapy is ineffective.
    • The risk of death from lung disease without transplantation is more than 50% within two years
    • The likelihood of surviving at least 90 days after lung transplantation is more than 80%
    • Absence of a non-respiratory comorbidity that would limit life expectancy in the first 5 years after transplant
    • Acceptable social profile and support system

Contraindications

  • Absolute contraindications include the following:
    • Uncontrolled or untreatable pulmonary or extrapulmonary infection
    • Active TB infection
    • Malignancy within previous 2 years
    • Significant comorbidity of other vital organs
    • Significant coronary heart disease not treated by revascularization
    • Untreatable bleeding diathesis
    • Significant chest wall or spinal deformity expected to cause severe restriction after transplantation
    • Grade II or III obesity with body mass index (BMI) ≥35 kg/m2
    • Smoker
    • Drug or alcohol dependency
    • Unresolved psychosocial problems or noncompliance with medications
  • Relative contraindications include the following:
    • Age more than 65 years in association with low physiologic reserve or other relative contraindications
    • Grade I obesity with body mass index (BMI) 30 to 34.9 kg/m2
    • Severe or progressive malnutrition
    • Severe with clinical manifestations of osteoporosis
    • Previous cardiothoracic surgery
    • Colonization or infection with highly resistant or highly virulent agents
    • HIV positive patient
    • Active hepatitis B or C infection
    • Absence of a consistent social support system

Medical tests for potential transplant candidates

Patients who are being considered for lung transplantation undergo the following tests to ensure lung transplant success and the patients' clinical status:[4]

Types of lung transplant

Lobe

A lobe transplant is a surgery where a lobe or the entire diseased lung is replaced by a healthy donor lung.

Single-lung

A single lung is transplanted and the donor has usually been pronounced brain dead.

Double-lung

Certain patients may require both lungs to be replaced.

Surgery

Single-lung

  • An incision is under the shoulder blade around the chest, ending near the sternum or an incision is made under the breastbone.
  • The diseased lung is collapsed, the blood vessels are clamped and the lung is cut from the bronchus
  • The donor lung is placed in the correct position and the blood vessels are reconnected.
  • The lung is then reinflated.
  • A bronchoscopy is performed to remove blood or mucus in the new lung.

Double-lung

  • The procedure is similar to the one described above, but the process occurs twice, once for each lung.
  • A less common alternative is the transplantation of both lungs en bloc or simultaneously.

Risks

  • Signs of rejection:[5]
  • In order to prevent transplant rejection and subsequent damage to the new lung or lungs, patients must take immunosuppressive drugs
  • Patients will normally have to take a combination
  • The immunosuppressive regimen starts just before or after surgery, including:
  • Chronic rejection, may occur after the first years with repeated episodes of rejection symptoms.
    • Chronic rejection occurs in approximately 50% of transplant patients.

Prognosis

Transplanted lungs on average last 3 to 5 years before showing signs of failure.

References

  1. ↑ Weill D, Benden C, Corris PA, Dark JH, Davis RD, Keshavjee S, Lederer DJ, Mulligan MJ, Patterson GA, Singer LG, Snell GI, Verleden GM, Zamora MR, Glanville AR (January 2015). "A consensus document for the selection of lung transplant candidates: 2014--an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation". J. Heart Lung Transplant. 34 (1): 1–15. doi:10.1016/j.healun.2014.06.014. PMID 25085497.
  2. ↑ McKellar SH, Bowen ME, Baird BC, Raman S, Cahill BC, Selzman CH (November 2016). "Lung transplantation following coronary artery bypass surgery-improved outcomes following single-lung transplant". J. Heart Lung Transplant. 35 (11): 1289–1294. doi:10.1016/j.healun.2016.05.029. PMID 27381675.
  3. ↑ McAnally KJ, Valentine VG, LaPlace SG, McFadden PM, Seoane L, Taylor DE (January 2006). "Effect of pre-transplantation prednisone on survival after lung transplantation". J. Heart Lung Transplant. 25 (1): 67–74. doi:10.1016/j.healun.2005.07.012. PMID 16399533.
  4. ↑ "Lung Transplant Evaluation: Required Tests". Cleveland Clinic. February 7 2003. Retrieved 2006-09-29. Check date values in: |date= (help)
  5. ↑ "Lung Transplant". Aetna intelihealth. January 30 2006. Retrieved 2006-09-29. Check date values in: |date= (help)
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