Adult bronchiolitis surgery: Difference between revisions

Jump to navigation Jump to search
No edit summary
Line 4: Line 4:


==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:
**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 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  
Line 24: Line 25:
**Untreatable bleeding diathesis
**Untreatable 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 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.

Revision as of 17:56, 3 March 2018

Adult bronchiolitis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Occupational lung disease from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Adult bronchiolitis surgery On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Adult bronchiolitis surgery

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Adult bronchiolitis surgery

CDC on Adult bronchiolitis surgery

Adult bronchiolitis surgery in the news

Blogs on Adult bronchiolitis surgery


Risk calculators and risk factors for Adult bronchiolitis surgery

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:
    • 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:[1]

  • Blood typing:
  • Tissue typing:
    • Ideally, the lung tissue would also match as closely as possible between the donor and the recipient, but the desire to find a highly compatible donor organ must be balanced against the patient's immediacy of need
  • Chest X-ray
    • To verify the size of the lungs and the chest cavity
  • Pulmonary function tests
  • Ventilation/perfusion (V/Q) scan
  • Electrocardiogram
  • Cardiac catheterization
  • Echocardiogram

Types of lung transplant

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.
  • 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

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-dead.

Double-lung

  • 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

  • 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 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.[2]
  • 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

Incision scarring from a double lung transplant.
  • In single-lung transplants, the lung with the worse pulmonary function is chosen for replacement.
  • 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.[3]
  • 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.
  • 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.[4]
  • 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 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

  • A double-lung transplant, also known as a bilateral transplant, can be executed either sequentially, en bloc, or simultaneously.
  • Sequential is more common than en bloc.[3]
  • 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 lung functions is collapsed, the blood vessels tied off, and cut at the corresponding 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.[5]

Risks

  • Signs of rejection:[4]
  • In order to prevent transplant rejection and subsequent damage to the new lung or lungs, patients must take a regimen of immunosuppressive drugs.
  • Patients will normally have to take a combination of these medicines in order to combat the risk of rejection.
  • The immunosuppressive regimen is begun just before or after surgery.
  • Usually the regimen includes cyclosporine, azathioprine and corticosteroids, 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.
  • Sometimes tacrolimus is given instead of cyclosporine and mycophenolate mofetil instead of azathioprine.
  • Chronic rejection, meaning repeated bouts of rejection symptoms beyond the first year after the transplant surgery, occurs in approximately 50% of patients.[6] Such chronic rejection presents itself as bronchiolitis obliterans, or less frequently, atherosclerosis.[6]

Prognosis

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

References

  1. "Lung Transplant Evaluation: Required Tests". Cleveland Clinic. February 7 2003. Retrieved 2006-09-29. Check date values in: |date= (help)
  2. "What Is the Surgical Procedure?". American College of Chest Physicians. October 2005. Retrieved 2006-09-29.
  3. 3.0 3.1 "Lung Transplant". eMedicine. June 1 2006. Retrieved 2006-09-29. Check date values in: |date= (help)
  4. 4.0 4.1 "Lung Transplant". Aetna intelihealth. January 30 2006. Retrieved 2006-09-29. Check date values in: |date= (help)
  5. "Lung Transplant". Aetna intelihealth. January 30, 2006. Retrieved 2006-11-02.
  6. 6.0 6.1 Merck Manual 18th ed. p. 1377