Lung and Heart Lung Flashcards
The 4 most common indications for Lung transplant are…
- Obstructive Disease
- Restrictive Disease
- Septic Disease
- Vascular Disease
COPD/Emphysema is an example of what kind of lung disease
Obstructive Disease
A genetic disorder that leads to a build-up of abnormal AAT in the liver, that can cause liver disease and a decrease of AAT in the blood that can lead to lung disease is called…
Alpha-1 antitrypsin (ATT) deficiency
ATT deficiency is an example of what kind of lung disease
Obstructive Disease
Idiopathic pulmonary fibrosis is an example of what kind of lung disease
Restrictive Disease
Sarcoidosis-inflammatory disease is an example of what kind of lung disease
Restrictive Disease
Cystic Fibrosis is an example of what kind of lung disease
Septic Lung Disease
A double lung transplant will usually be required for which 2 kinds of lung diseases
- Restrictive Disease
- Septic Disease
The disease where bronchial tubes are permanently damaged, widened, and thickened, resulting in frequent infections and lockages of the airways is called
Bronchiectasis
Bronchiectasis is an example of what kind of lung disease
Septic Lung Disease
Primary pulmonary hypertension is an example of what kind of lung disease
Vascular Disease
Eisenmengers Syndrome is caused by…
a congenital heart defect which causes pulmonary hypertension
Chronic Pulmonary Thromboembolism is an example of what kind of lung disease
Vascular Disease
3 Indications for a heart-lung transplant include…
- Irreparable congenital cardiac defect with end-stage pulmonary hypertension
- End-stage lung disease with left heart failure
- End-stage lung disease with irreparable ischemic heart disease
5 COPD Guidelines for referral include…
- BODE score 5-6
- Frequent acute exacerbations
- Increase in BODE score >1 over 24 months
- FEV1 in the range of 20-25% predicted
- Pulmonary artery to aorta diameter >1 on CT scan
5 COPD Guidelines for listing for transplant include…
- BODE score 7-10
- FEV1 <20% predicted
- Moderate-severe pulmmonary hypertension
- Chronic hypercapnia
- History of severe exacerbations
Timing of Referral for Interstitial Lung Diseases includes these 5 guidelines…
- At the time of diagnosis of IPF/UIP based on a biopsy or CT scan findings
- Any form of fibrosis with FVC <80% predicted or DLCO <40% predicted
- Decline in FVC >/ 10% over the past 2 years
- Decline in DLCO >/15% over the past 2 years
- Need for supplemental oxygen at rest or with exertion
Timing for Listing for Interstitial Lung Disease includes these 6 guidelines…
- Absolute decline in FVC >10% in 6 months
- Absolute decline in DLCO >10% in 6 months
- Absolute decline in FVC >5% with radiographic progression
- Pulmonary hypertension
- Hospitalization because of respiratory decline, acute exacerbation, or pneumothorax
- Desaturation to SpO2 <88% during a 6 minute walk test or >50 meter decline in 6 minute walk test distance in 6 months
4 Referral guidelines for cystic fibrosis includes…
- FEV1 < 30% predicted
- FEV1 < 40% predicted and any of the following:
-6 minute walk distance < 400 meters
-PaCO2 > 50 mmHg
-Hypoxemia at rest or with exertion
-Pulmonary hypertension
-Worsening nutritional status
-2 exacerbations per year
-Massive hemoptysis, requiring embolization
-Pneumothorax
- FEV1 < 50% predicted and rapidly declining pulmonary function tests
- Any exacerbation requiring positive pressure ventilation
8 Guidelines for listing for transplant for cystic fibrosis includes…
- FEV1 < 25% predicted
- Rapid decline in lung function (> 30% decline in FEV1 over 12 months)
- Frequent hospitalizations for exacerbations
- Any exacerbation requiring mechanical ventilation
- Chronic respiratory failure with hypoxemia or hypercapnia
- Pulmonary hypertension
- Worsening nutritional status
- Recurrent massive hemoptysis despite embolization
7 Referral Guidelines for Pulmonary Arterial Hypertension (PAH) includes…
- ESC/ERS intermediate or high risk or REVEAL risk score 8 despite appropriate therapy
- Significant RV dysfunction despite appropriate PAH therapy
- Need for iv or sc prostacyclin therapy
- Progressive disease despite appropriate therapy or hospitalization for PAH symptoms
- Known or suspected high-risk variants such as PVOD, scleroderma
- Signs of secondary liver or kidney dysfunction due to PAH
- Recurrent hemoptysis
4 Listing for transplant guidelines for PAH includes…
- ESC/ERS high risk or REVEAL risk score > 10 on appropriate therapy
- Progressive hypoxemia
- Progressive liver or kidney dysfunction due to PAH
- Life-threatening hemoptysis
4 Absolute contraindications to transplant are:
- Active or recent malignancy
- HIV+, HepBsAg +, Hep C with abnormal biopsy
- Active or recent cigarette smoking
- Significant neurological, renal, hepatic, or cardiac impairment (at time of evaluation)
7 Transplant Evaluation tests specific to Lung includes:
- Pulmonary Function Test: PFTs (Know how to interpret)
- CXR (Know how to interpret)
- Exercise Studies
- Rehab (PT/RT Consult)
- V/Q Scan
- Barium swallow
- Cardiac Catheterization
On the Pulmonary Function Test, TLC is
Total lung capacity (TLC) or the total volume of gas contained in the lungs
On the Pulmonary Function Test, FRC is
Functional residual capacity (FRC) or the volume of gas left in the lungs with the individual relaxed at the end of expiration
On the Pulmonary Function Test, RV is
Residual volume (RV) or the volume of gas left in the lungs at the end of forced expiration
On the Pulmonary Function Test, VC is
Vital capacity (VC) - the difference between the largest (TLC) and the smallest (RV) lung volumes which can be obtained
The Pulmonary Function Test determines…
the type of lung disease (restrictive/obstructive)
FVC represents
the entire volume exhaled from the lungs in a forced breath
FEV1 represents
the volume of gas exhaled in the first one second of exhalation
FEV1/FVC determines what type of lung disease?
the lung disease is obstructive
TLC determines what type of lung disease?
the lung disease is restrictive
The severity of FEV1 >70% is
mild obstruction
The severity of FEV1 60-69 % is
moderate obstruction
The severity of FEV1 50-59% is
Moderately severe obstruction
the severity of FEV1 35-49% is
severe obstruction
The severity of FEV1 <35% is
Very severe obstruction
The severity of TLC 65-80% is
mild restriction
The severity of TLC 50-65% is
moderate restriction
The severity of TLC < 50% is
severe restriction
A Chest Xray is
a fast and painless imaging test that uses certain electromagnetic waves to create pictures of the structures in and around the chest.
A VQ Scan is
an imaging test that uses a ventilation (V) scan to measure air flow in the lungs and a perfusion (Q) scan to see where blood flows in the lungs
A VQ scan can help rule out…
a pulmonary embolism, or blood clots
The Composite Allocation Score is used to…
allocate donor lungs based on medical condition, urgency and survival >5 years
Candidates are ranked in order to promote…
a more fair and flexible allocation system
Points will be allocated for the following 9 factors…
- Candidate Medical Urgency
- Likely Survival >5 years
- Blood Type Match
- Immune System Match
- Height Match
- Listed younger than 18
- Prior living donor
- Travel efficiency
- Proximity efficiency
8 Factors that influence the medical urgency score include…
- Height and Weight
- FVC and FEV1
- 6 minute walk distance and oxygen needed at rest
- ABG
- Heart Cath ( PA pressures, CVP, Cardiac Index, Cardiac Output)
- Labs: Hgb, Hct, Bilirubin, Creatinine
- Diabetes
- Assisted ventilation (ventilator, CPAP, BiPAP)
Bilateral transplants are mandatory for _______________ lung disease
Septic Lung Disease
How will Single lung transplants affect cardiac output:
Subjects the allograft to high cardiac output
7 characteristics of the optimal donor will be:
- Age < 55 years
- Clear chest x-ray
- Manageable sputum gram stain
- PaO2 >300 mm Hg on FiO2 of 100%, 5 PEEP
- Less than 72 hours on ventilator
- No significant smoking history
- Maximum ischemic time 4-6 hours
Donor-Recipient matching is based on these 9 factors:
- ABO Compatibility
- Laterality
- Size
- Height
- Recipient pathology
- HLA considerations
- Prospective crossmatch
- HLA antigens to avoid
- Identifying a “back up recipient”
T/F: Swan-Ganz readings for the donor are required
F: encouraged, but not required.
T/F: During the surgical procedure, the native lung is removed
True
The ideal Ischemic time is…
- ideally less than 4 hours
- 4-6 hours
The most common surgical procedure for a double lung transplant is…
a sternotomy clamshell
6 Immediate Post-op concerns include:
- Immunosuppression
- Infection
- Re-perfusion injury
- Hemodynamic stability
(Tachycardia, Bradycardia, Blood loss through chest tubes) - Ability to wean from ventilator
(Wean from vent as soon as possible to oxygen mask) - Pain management/ Anxiety control for effective pulmonary toilet
5 Short Term Post-op considerations might include:
- Graft function
- Survival through hospitalization
- Medication tolerance
- Orientation to self care regimen
- Complications of transplantation
Normal Pulmonary Artery Pressure: Systolic (PASP)
15 - 25 mmHg
Normal Pulmonary Artery Pressure: Diastolic (PADP)
8 - 15 mmHg
Normal Mean Pulmonary Artery Pressure (MPAP)
10 - 20 mmHg
Normal Pulmonary Artery Wedge Pressure (PAWP)
6 - 12 mmHg
Normal Central Venous Pressure (CVP)
2-6 mmHg
Normal Cardiac Output (CO)
4.0 - 8.0 l/min
Normal Cardiac Index (CI)
2.5 - 4.0 l/min/m2
Normal Pulmonary Vascular Resistance (PVR)
<250 dynes · sec/cm5
Normal Pulmonary Vascular Resistance Index (PVRI)
255 - 285 dynes · sec/cm5/m2
2 Effects of a denervated heart in a heart-lung transplant include:
- HR post transplant may be higher at 100, versus 80 pre-transplant
- Takes longer for HR to increase with exercise after transplant
Immediate Post-op care requires monitoring of these 3 respiratory-related processes:
- Mechanical ventilation (wean from vent as soon as possible)
- Reperfusion edema/leaky capillary bed
- Pulmonary Hygiene
Goal is to achieve a negative fluid volume without causing…
nephrotoxic influences.
Clinical presentation of Acute Rejection can include these 8 characteristics:
- Dry, hacky cough
- Dyspnea
- Low grade fever, leukocytosis
- Crackles on exam
- Fall in PFTs (both FEV1 and FVC)
- Resting or exercise desaturation
- Normal oxygen saturations 95-100%, would allow >93% depending on underlying disease
- CXR: infiltrates, effusion (frequently normal beyond the first several months)
Biopsy Grading Scale: Grade 0
Normal parenchyma
Biopsy Grading Scale: Grade 1
scattered, infrequent perivascular mononuclear infiltrates
Biopsy Grading Scale: Grade 2
More frequent perivascular mononuclear infiltrates that are readily recognizable at low magnification; infiltrates may include lymphocytes, macrophages, and eosinophils
Biopsy Grading Scale: Grade 3
Dense perivascular mononuclear infiltrates commonly associated with endothelialitis; extension of inflammatory cell infiltrate into alveolar septa and airspaces;
Biopsy Grading Scale: Grade 4
Diffuse perivascular, interstitial, and air-space infiltrates of mononuclear cells; alveolar pneumocyte damage and endothelialitis
Treatment of Acute Rejection may be determined by these 4:
- grade of rejection
- # episodes of acute rejection
- presence of concurrent infection
- temporal relationship to transplant
2 potential treatments for Acute Rejection may include:
- Corticosteroids (IV or PO, +/- taper)
- Consideration of modifying maintenance immunosuppressive regimen
6 Anastomotic Complications may include:
- Dehiscence
- Stenosis
- Stricture
- Granulation tissue
- Malacia
- Fungal infection
5 Common infections Post-transplant include:
- Bacterial Infections
- Fungal Infections
- Viral Infections
- Opportunistic Infections
- Community Acquired Pneumonias
Chronic Lung Allograft Dysfunction manifests as…
bronchiolitis obliterans
CLAD Stage 0 spirometry value:
Current FEV1 >80% FEV1 baseline
CLAD Stage 1 Spirometry value:
Current FEV1 >65‒80% FEV1 baseline
CLAD 2 spirometry value:
Current FEV1 >50‒65% FEV1 baseline
CLAD 3 spirometry value:
Current FEV1 >35‒50% FEV1 baseline
CLAD 4 spirometry value:
Current FEV1 ≤35% FEV1 baseline
3 Clinical presentations of chronic rejection include:
- insidious onset of dyspnea, recurrent episodes of bronchitis or lingering
- productive cough, weight loss.
- It is identified as an early drop in FEF 25/75, and an irreversible drop in FEV1 of 20% from previous established baseline.
5 potential treatments of Chronic Rejection includes:
- Optimal immunosuppression
- Consider anti-proliferative agents
- Close surveillance of PFTs and CXR
- Prompt treatment of infection
- Advanced lung disease & end of life care
4 Post-transplant maintenance practices includes:
- Regular follow up visits
-Labs
-CXR
-PFTs - Surveillance biopsies per protocol
- Home microspirometry
- Vaccinations annual influenza shot
-H1N1
-Q5y Pneumovax
-DPT booster prn
