icu care of the lung transplant recipient
TRANSCRIPT
11
2
ICU Care of the Lung
Transplant Recipient
4th Annual Topics in Pulmonary and
Critical Care Medicine
Ryan Hadley MDSpectrum Health and Richard DeVos Lung
Transplant Program
[Master name: Solid Color Background]
Conflicts of Interest
• None
• Off label medications discussed
• None
Learning Objectives
• Recognize indications and techniques for
peri-transplant application of ECMO
• Understand the salient features of primary
graft dysfunction
• Describe appropriate ventilatory and
hemodynamic support
Learning Objectives
• Clinical pearls for lung transplant patients
admitted to outlying hospitals (especially in
off hours)
Lung Transplant
• Often only treatment for end stage lung
disease
• 3973 adult lung transplant performed in
20141
• 94 centers perform transplants in North
America
1ISHLT registry
Lung Transplant Indication
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
Nu
mb
er
of
Tra
ns
pla
nts
Transplant Year
COPD A1ATD CF IIP ILD-not IIP Retransplant
JHLT. 2016 Oct; 35(10): 1149-1205
Lung Transplant Survival
1ISHLT registry
Median survival (years):
Double Lung = 7.3; Conditional = 9.8
Single Lung = 4.6; Conditional = 6.4
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Su
rviv
al
(%)
Years
Bilateral/Double Lung(N=31,075)Single Lung (N=18,049)
Recipient Selection
• Absolute contraindications=significant
untreatable
• Extra-pulmonary organ dysfunction
• psychiatric conditions
• substance abuse
• severe chronic infections
• BMI >35
1Weill JHLT. 2015 Jan; 34(1): 1-15
Recipient Selection
• Relative contraindications-Many
• Include “Mechanical ventilation and/or
extracorporeal life support (ECLS).
However, carefully selected candidates
without other acute or chronic organ
dysfunction may be successfully
transplanted”1
1Weill JHLT. 2015 Jan; 34(1): 1-15
Question
• I have a 55 yo patient with Idiopathic
Pulmonary Fibrosis (IPF) who was
intubated due to acute exacerbation,
should he be evaluated for transplant?
• Should he go on Extracorporeal
Mechanical Oxygenation (ECMO)?
Question
• I have a 55 yo patient with Idiopathic
Pulmonary Fibrosis (IPF) who was
intubated due to acute exacerbation,
should he be evaluated for transplant?
Maybe
• Should he go on Extracorporeal
Mechanical Oxygenation (ECMO)?
Ideal Pre-transplant ECMO
• Has already consented to transplant and
evaluation (is it truly informed consent on
ECMO)?
• Good Pre-ECMO functional status
• Without other relative contraindications (age,
obesity, AMS, social support, drug/tobacco)
• Evaluation complete (e.g. Heart cath,
colonoscopy, etc)
• Not Veno-arterial ECMO by femoral approach
When and Why to do ECMO
• End stage Lung failure not supported by
conventional support
• Patient cannot maintain muscular conditioning
due to dysfunctional gas exchange
• When ECMO and its complications are superior
to prolonged mechanical ventilation (e.g.
tracheostomy and feeding tube for cystic fibrosis)
• After evaluation complete or to allow
consent/evaluation
Proposed Criteria
Fuehner T
Chest. 2016;150(2):442-50
“Patient Listed or fully
evaluated” is in
contention
Trudzinski FC
Chest. 2017;151(5):1177-8
Hoopes et al. J.
Thoracic and Cardio Surg
145(3) 862-8. 2013
Veno-venous versus Veno-arterial
16
Gaffney AM. et al. BMJ 341:c5317. 2010
Single vs Double lumen VV ECMO
17
Brodie D and
Bacchetta M NEJM
365: 1905-1914. 2011
“Sport Model” VA ECMO
18
• IJ venous outflow
• Subclavian artery
inflow
• Allows ambulation
• Percutaneously
placed, no
anesthesia
• Used for cor
pulmonale
Biscotti M and
Bacchetta M Ann.
Thorac Surg. 8: 1487-
9. 2014
Carbon dioxide removal
• Respiratory Dialysis®
• ECCO2R
• Hemolung RAS
• Alung technologies,
inc
Death on ECMO while waiting
• Difficult to compare across countries/organ
allocation
• Germany 23% mortality1
• Italy 32% mortality2
• USA 13% mortality3
1) Fuehner T et al. AJRCCM 185(7). 763-8. 2012.
2) Crotti S et al. Chest 144(3): 1018-25. 2013
3) Hoopes et al. J. Thoracic and Cardio Surg 145(3) 862-8. 2013
Post transplant survival
Crotti S
et al.
Chest.
144(3):
1018-1025
Chest.
2013;144(3)
:1018-1025
Question
• I have a 55 yo patient with Idiopathic Pulmonary
Fibrosis (IPF) who was intubated due to acute
exacerbation, should he be evaluated for
transplant?
Maybe if good muscular strength and
no other precluding factors
• Should he go on Extracorporeal Mechanical
Oxygenation (ECMO)?
Only if a potential transplant candidate
ECMO for respiratory failure in ILD
• 21 patients placed
on ECMO for
respiratory failure in
ILD
• Only 1 survived
without transplant
• 5 received
transplant
• 4 listed “de novo”
Trudzinski FC AJRCCM
2016. 193(5) 527-33
Moral of the story
• Ideally, send us your patients early as outpatient
• Send us your inpatient transplant candidates
early (i.e. before intubation)
• If intubated, please send potential candidates
early to avoid critical care myopathy
• ARDS is not usually a transplant diagnosis, but
some have transplanted prolonged ARDS1
1) Hoopes et al. J. Thoracic and Cardio Surg 145(3) 862-8. 2013
Planned post-operative ECMO
• Used in pulmonary hypertension (de-
conditioned left ventricle)1,2
• Often employed when single lung
implanted in a patient with pre-operative or
intraoperative pulmonary hypertension
• Always Veno-arterial to prevent excess
flow to lung(s)
1) Tudorache I Transplatation 2015. 99(2): 451-8
2) Pereszlenyi A Eur J Cardiothoracic Surg 2002. 21(5): 858-63
Ventilation
• 6cc/kg ideal body weight (IBW) used
• Recipient vs. Donor Height for IBW
• Most wean FIO2 over PEEP
Diamond JM Ann Am Thorac Soc Vol 11, No 4, 598–9, May 2014
Hyperinflation of native lung
• Decrease
Minute
Volume
• ? Separate
lung
ventilation
Weill D et al. JHLT 18(11) 1080-1087. 1999
Ventilation of Donor
• Higher PEEP and Low tidal volume lead to
higher utilization of lungs in Brain Dead
Donors
• 6cc/kg likely best after transplant too
Mascia L et al. JAMA. 304(23):2620-2627. 2010.
Primary Graft Dysfunction
Suzuki Y et al. Semin Respir Crit Care Med 34(3): 305-19. 2013.
Primary Graft Dysfunction
Munshi L
et al
Lancet
Resp
Med
1: 318-28
2013.
Primary Graft Dysfunction (PGD)
Christie JD et al. JHLT 24(10). 1454-9. 2005
PGD criteria
• Edema pattern in allograft and it is NOT
• Cardiogenic “fluid overload”
• Pulmonary venous anastomotic problems
• Hyperacute rejection
• Pneumonia (viral, bacterial, fungal)
Christie JD et al. JHLT 24(10). 1454-9. 2005
Primary graft dysfunction
• Graded 0, 24, 48 and 72 hours
• Not graded different for single vs. double
lung
• Higher risk of chronic rejection1
• Worse immediate survival with 30 day
mortality for PGD 32, 3
1) Daud SA et al AJRCCM 175: 507-13. 2007.
2) Lee JC et al. PATS 6: 39-46. 2009.
3) Geube MA et al. Anest Analg. 122(4):1081-8. 2016
PGD Prevention and Tx in ICU
• Prevention
• Fluid restrictive maybe beneficial1,2,3
• Ex Vivo Lung Perfusion (EVLP) for
marginal lungs?
• Treatment
• Supportive (inhaled NO, ECMO)
• Avoid fluid accumulation1) Currey J. et. al. Cardiothoracic Trans. 139(1). 154-161. 2010.
2) Geube MA et al. Anest Analg. 122(4):1081-8. 2016
3) Pilcher DV et. al. J. Thorac Card Surg. 129: 912-8. 2005
Ex-Vivo Lung Perfusion
Munshi L et. Al. Lancet Resp Med1: 318-28 2013.
Ex-Vivo Lung Perfusion
Munshi L
et. al.
Lancet
Resp
Med1: 318-
28 2013.
Post operative antibiotics
• Other than small bowel, only non-sterile
organ transplant
• Cover for
• ventilator associated organisms
• Recipient colonized organisms (e.g.
cystic fibrosis)
• Fungal prophylaxis
.
Learning Objectives
Recognize indications and techniques for
peri-transplant application of ECMO
Used to maintain muscles, life until Tx
Understand the salient features of primary
graft dysfunction
Essentially like ARDS
Describe appropriate ventilatory and
hemodynamic support
Minimize fluids and LPV (like ARDS)
Lung Transplant in the Community
• Common ICU presentations
• Respiratory Failure
• Non-pulmonary surgical needs
• Shock, usually septic
• Acute renal failure
• Altered mental status
• Diverticulitis/Appendicitis
.
Lung Transplant in the Community• What do I do if I admit a lung transplant
patient at 2 am?
• Don’t worry too much about treating for
rejection, this requires biopsy and
exclusion of infection
• Ok to hold or continue cell cycle inhibitor
(Mycophenolate (MMF) or azathioprine
(AZA)
• Usually held if infection is suspected
• Not really a big deal either way for 1 dose
Lung Transplant in the Community• Start stress dose steroids if in shock
• If intubated, do a BAL for bacterial,
fungal, AFB, viral, galactomannen, PJP
• Presumptive antibiotics are OK
• Usually vancomycin/Zosyn/azithro
• If respiratory failure same abx plus
antifungal (Cancidis or voriconazole)
• Tamiflu if flu season
• If vori added, decreased CNI by 50%.
Lung Transplant in the Community
• In most patients, CMV DNA quant can be
sent, but prophylactic CMV treatment not
usually indicated
.
Lung Transplant in the Community
• Do not draw a random tacrolimus or
cyclosporine (CSA) level, these are not
helpful
• A level 10 hours after last dose (trough)
is helpful
• Do not draw mycophenolate levels…ever
.
Lung Transplant in the Community
• tacrolimus/cyclosporine and steroids
usually continued unless adverse Rxn
• If NPO
• Can hold prophy meds
• give CSA by feeding tube, if able
• do NOT give tacro by feeding tube
• Give tacro sublingual at ½ normal dose,
open capsule and pour under tongue.
• Prednisone Solumedrol
Lung Transplant in the Community
• Stop medication if adverse drug reaction is
suspected
• Tacro and CSAAMS, elevated K, Cr
• AZAleukopenia, elevated LFT’s
• MMFvomiting, diarrhea, leukopenia
• Bactrimleukopenia, elevated K, Cr
• ValgangcyclovirLow WBC, elevated
LFT
Lung Transplant with AMS
• Long differential
• Shorter differential
• Drugs (CNI)
• Posterior reversible encephalopathy
syndrome (PRES)
• Infection
PRES
• AMS
• Headache
• Vision changes
• Hypertension
• Seizure
• Tx=BP control and
withhold CNI
Bartynski WS. Am J Neuorad.
29(5) 924-30. 2008
Acutely elevated Cr
• Usually hypovolemia +/- supratheraputic
calcineurin inhibitor (tacro or cyclosporine)
• check 10 hour level, if more than 10 hours
since last dose OK to check “random
level”
• Hold CNI until level returns
• Gentle hydration
• Know baseline Cr if able, CKD is
common!
Lung Tx pt with abdominal pain
• Higher risk for diverticulitis or appendicitis
or perforation
• Low threshold for CT scan
Hoekstra HJ British J of Surg. 88(3). 433-38. 2001.
Lung Tx pt not right on the vent
• A variety of physiologies possible after
transplant
• Bronchiolitis Obliterans Syndrome (BOS)=
Obstructive physiology
• Restrictive allograft syndrome (RAS)=
restrictive physiology
• Single lung Tx may have 2 separate
physiologies
• Anastomotic issues
Bronchiolitis Obliterans (BOS)Williams KM
et al. JAMA
302(3) 306-
14. 2009
BOS and RAS
BOS
RAS
1) Krishnam et al Radiographics. 27(4).
957-74. 2007
2) Paraskeva et al AJRCCM. 187(12).
1360-8. 2013
Anastomotic Stricture
Murthy SC et al. Ann Thorac Surg 84(2) 401-409. 2007
Summary• Please send potential lung transplant
patients early
• Watch for ADR
• Minimal evidence for post-transplant
ventilatory or hemodynamic strategies
• LPV and avoidance of fluid excess
Questions• We are happy to take questions about
transplant patients or potential transplant
patients at any time.
• Office 616-391-2802
• c602-740-0609 or text (but no HIPPA PHI
by text please, only “general” questions)
56
Lung Transplant in the Community
• What do I do if I admit a lung transplant
patient at 2 am?
.