ICU Care of the Lung Transplant Recipient.

1. 11

2. 2
ICU Care of the Lung
Transplant Recipient
4th Annual Topics in Pulmonary and
Critical Care Medicine
Ryan Hadley MD
Spectrum Health and Richard DeVos Lung
Transplant Program
[Master name: Solid Color Background]

3. Conflicts of Interest
• None
• Off label medications discussed
• None

4. 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

5. Learning Objectives
• Clinical pearls for lung transplant patients
admitted to outlying hospitals (especially in
off hours)

6. 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

7. Lung Transplant Indication
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
NumberofTransplants
Transplant Year
COPD A1ATD CF IIP ILD-not IIP Retransplant
JHLT. 2016 Oct; 35(10): 1149-1205

8. 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
Survival(%)
Years
Bilateral/Double Lung
(N=31,075)
Single Lung (N=18,049)

9. 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

10. 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

11. 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)?

12. 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)?

13. 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

14. 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

15. 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

16. Veno-venous versus Veno-arterial
16
Gaffney AM. et al. BMJ 341:c5317. 2010

17. Single vs Double lumen VV ECMO
17
Brodie D and
Bacchetta M NEJM
365: 1905-1914. 2011

18. “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

19. Carbon dioxide removal
• Respiratory Dialysis®
• ECCO2R
• Hemolung RAS
• Alung technologies,
inc

20. 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

21. Post transplant survival
Crotti S
et al.
Chest.
144(3):
1018-1025
Chest.
2013;144(3)
:1018-1025

22. 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

23. 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

24. 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

25. 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

26. 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

27. Hyperinflation of native lung
• Decrease
Minute
Volume
• ? Separate
lung
ventilation
Weill D et al. JHLT 18(11) 1080-1087. 1999

28. 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.

29. Primary Graft Dysfunction
Suzuki Y et al. Semin Respir Crit Care Med 34(3): 305-19. 2013.

30. Primary Graft Dysfunction
Munshi L
et al
Lancet
Resp
Med
1: 318-28
2013.

31. Primary Graft Dysfunction (PGD)
Christie JD et al. JHLT 24(10). 1454-9. 2005

32. 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

33. 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

34. 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 accumulation
1) 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

35. Ex-Vivo Lung Perfusion
Munshi L et. Al. Lancet Resp Med1: 318-28 2013.

36. Ex-Vivo Lung Perfusion
Munshi L
et. al.
Lancet
Resp
Med1: 318-
28 2013.

37. 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
.

38. 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)

39. 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
.

40. 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

41. 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%.

42. Lung Transplant in the Community
• In most patients, CMV DNA quant can be
sent, but prophylactic CMV treatment not
usually indicated
.

43. 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
.

44. 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

45. Lung Transplant in the Community
• Stop medication if adverse drug reaction is
suspected
• Tacro and CSAAMS, elevated K, Cr
• AZAleukopenia, elevated LFT’s
• MMFvomiting, diarrhea, leukopenia
• Bactrimleukopenia, elevated K, Cr
• ValgangcyclovirLow WBC, elevated
LFT

46. Lung Transplant with AMS
• Long differential
• Shorter differential
• Drugs (CNI)
• Posterior reversible encephalopathy
syndrome (PRES)
• Infection

47. PRES
• AMS
• Headache
• Vision changes
• Hypertension
• Seizure
• Tx=BP control and
withhold CNI
Bartynski WS. Am J Neuorad.
29(5) 924-30. 2008

48. 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!

49. 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.

50. 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

51. Bronchiolitis Obliterans (BOS)
Williams KM
et al. JAMA
302(3) 306-
14. 2009

52. 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

53. Anastomotic Stricture
Murthy SC et al. Ann Thorac Surg 84(2) 401-409. 2007

54. 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

55. Questions
• We are happy to take questions about
transplant patients or potential transplant
patients at any time.
• ryan.hadley@spectrumhealth.org
• Office 616-391-2802
• c602-740-0609 or text (but no HIPPA PHI
by text please, only “general” questions)

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57. Lung Transplant in the Community
• What do I do if I admit a lung transplant
patient at 2 am?
.