Lung transplantation

[shane246]

Just wondering if anyone out there is aware of any clinical practice guidelines or evidence/literature on the physiotherapy management of the donor lung prior to transplantation?

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[Physiobase]

Not sure you get any treatment time with the donor lung before it is transplanted? Unless you are referring to Steve Martin's concept of the man with 2 brains?, and perhaps you can row it about on a boat and sing to it. Please take no offense by my jest.

Do you mean the recipient of the new lung prior to transplant? 8o

[shane246]

Thanks for the laugh and jesting - no offense taken.
What I am interested in is how best to manage, from a physio perspective, the deceased patient who is consented for transplantation but is awaiting theatre for organ procurement. Logistics in our situation mean that in some instances we may have a deceased donor patient ventilated in ICU for up to 8-12 hours awaiting the retrieval of their lungs prior to subsequent transplanting, either at our facility or St Elsewhere. It is the role of physio in the deceased patient during this 'waiting' period that is of interest; can we influence/optimise the lungs before they are transplanted from the donor into the recipient?

[Physiobase]

Great!, and a most unusual question. I will put this one out on this weeks eNews to all the members. Here's hoping we can elicit an educated response or two

[Martin345]

i'm pretty doubtful as to the presence of any literature out there.

i've been asked to "treat" a donor in this situation before, where there was some concern about excess secretions and the medical staff involved declared they wanted the lungs in as good condition as possible. they and i both believed that physiotherapy would aid in this.
there is potential risk for introduction of infection into 'clean' lungs. i guess it depends on what the donor's past medical history is and the reason why they are now 'dead'.

[Fiona Schreuder]

I feel that this is a topic that all physios working on ITU should be aware of. I am not sure of any evidence, but I would presume that just because a patient is brain dead they are not immune to the development of nosocomial pneumonia and all the other complications associated with ventilation. I feel it is therefore prudent to continue to treat the patient as you would do if they were not brain dead in the chance that they may become an organ donor. Obviously if they have pre- existing lung disease or damage to the lungs as a result of trauma this would probably exclude use of the lungs for transplant. We have such a small number of organ donors, and even less with suitable lungs that we need to maximise the chance of using lungs for transplant.

[Martin345]

good point fiona
i think it would be reasonable to extrapolate what we already know about ventilator-associated pneumonia and the benefits of chest physiotherapy in the icu setting to this population. studies by ntoumenopoulos etc (sorry, no reference list with me here) would suggest benefit in treating these people.

[shane246]

Thanks Marty and Fi.
So I guess that if we treat the deceased patient awaiting retreival of theirs lungs for subsequent transplant, then the question is what indications do we use to commence the treatment (?CXR findings, PF ratio, sputum quantity, CPIS), how often to treat, what outcome measures (again ?CXR findings, PF ratio, sputum quantity, CPIS). In my experiences often these patients have not had physio in the day or two leading up to officially being declared deceased (as neurologically unstable or no clear indication for resp PT- isolated ABI with clear CXR, low FiO2, little sputum, no resp PMH, etc)
Do you think the issue of VAP and the benefits of physio may be evident in the short term between diagnosis of brain death, initiation (or re-initiation) of resp PT, and the patient going to theatre for organ procurement?

[Fiona Schreuder]

I agree that these patients often have not had physio as they often have a raised ICP. Once declared brain dead I would in this situation carry out a "routine" chest treatment. Depending upon sputum production etc would then plan my treatments accordingly. I have never had donor hanging around ITU more than 24 hours. Sometimes we are lucky to get one treatment in. If these patients are suitable lung donors they usually have no pre- existing lung pathology (I think this includes asthma) and I think they have to have been non- smokers.

[Martin345]

i like your idea fiona, but don't feel it is quite complete. i think one treatment is probably all we could hope to do given the time constraints you speak of, but it's important to consider that sputum characteristics are not the be all and end all. that said, is anything better? as shane said, is there sufficient time to say that there will be a significant benefit from treating them, especially if only once?

i like the idea of using the cpis. evidence of aspiration would be another factor, but isn't always clear. how many times do you read "? aspirated" in the medical notes? if they did aspirate, the amount aspirated and the effects are so variable, that this is perhaps only of limited value.

[Fiona Schreuder]

I don't know if we are getting too technical here. If the deceased patient has any potential to donate lungs then I believe we should routinely treat them using usual precautions to minimise any damage to the lungs during treatment. Surely it won't cause any harm to prophylactically treat the lungs in a careful manner whether or not there are any strong clinical indicators? I have seen so many people die waiting for lung transplants that I feel we have to preserve lungs no matter how remote the possibility may be that they are suitable for transplant. What does everyone else think?

[sdkashif]

Have a look over this topic for more information

Lung Transplantation


Requirements before transplantation