Lung Transplant Program | About Us | What to Expect | Frequently Asked Questions | Transplant Team | Support Group | Patient Success Stories
The University of Maryland Medical Center's Lung Transplant Program is committed to provide the best possible care to today's patient with end stage lung failure in a compassionate, supportive environment. In addition, we are uniquely positioned to contribute to scientific progress in the field which will improve care for tomorrow's patients.
Entering the Transplant Program
Most candidates for transplantation are referred to the program by their primary physician or specialist. Others come to be evaluated at their own initiative. The process begins with a call to the Lung Transplant Office (410-706-6625). The patient will be asked to provide some basic medical information by telephone, and to give us written permission to obtain medical records from other health care providers.
Evaluation
The common causes of lung failure that result in pulmonary transplantation are
cystic fibrosis, emphysema (acquired, usually related to smoking; or caused
by an inherited protein abnormality: alpha-1 anti-trypsin deficiency), idiopathic
(otherwise unexplained) pulmonary fibrosis, and "primary" (otherwise
unexplained) pulmonary hypertension. Together, these diagnoses account for about
9 of 10 lung transplant patients. A small percentage of patients who undergo
pulmonary transplantation have venous vascular lung disease (disease of the
blood vessels in the lungs), congenital lung disease (present from birth), or
inoperable cardiac-related lung disease ("Eisenmenger's syndrome"),
as the underlying condition.
Which Procedure for Which Patient?
For some patients, a single lung (one side, "single-lung transplant") is all that is needed. For others, both lungs ("double-lung transplant") or a heart as well as both lungs ("heart-lung transplant") are the best option. Occasionally, the decision about whether a given patient needs one lung or two will be influenced at the time of surgery, by the function of the donor, availability of organs, or the severity illness of the recipient.
Who Needs a Lung Transplant?
In general, patients with advanced lung failure who continue to have severe symptoms (breathlessness with little or no exercise) on maximal medical therapy should be considered for transplant evaluation. In general, patients with increasing medication requirements, frequent hospitalizations, or overall deterioration of clinical status should be considered relatively urgently.
All candidates for transplantation begin the program with a comprehensive series of tests conducted by our multidisciplinary team of specialists. Some of these tests are required for any operative procedure (history and physical, chest X-ray, EKG, etc.) while others (such as special blood tests to learn about prior infection exposure) are required to optimize the recipient's care after the transplant.
During the evaluation the lung transplant candidate will meet many members of the transplant team. Each member of the team will want to get to know the individual needing the transplant as well as all family members and friends who make up the candidate's health care and social support network. There are so many of us because a successful transplant program requires a combination of many people with different areas of expertise. While some aspects of transplantation have become routine, other aspects require innovation. This is where the experience of the team can make the difference between success and failure for an individual patient, particularly if the problem is unusual or serious. The various members of the team play different roles in each patient's care. During the evaluation phase the candidate's primary contact person will be the transplant nurse practitioner.
Once the evaluation is complete, the transplant team will decide if lung transplant is the best option. The risks and benefits will be discussed with each patient. If the patient and the transplant team agree that transplantation is the best available choice, the patient is then placed on the transplant waiting list at the University of Maryland.
This lung transplant waiting list is organized through the United Network for Organ Sharing (UNOS), which is the national list. Waiting time for a new lung varies by blood type, recipient size and weight, with minor adjustment by diagnosis for patients with a higher chance of dying before a lung becomes available (idiopathic pulmonary fibrosis). At the time of this publication, lung candidates are not assigned a "status", but national policy groups are considering a system to reflect the severity of lung failure symptoms, and divert lungs to those at greatest risk of dying. Ranking candidates by status was instituted for heart candidates in hopes of assuring that the sickest patients receive organs first, and particularly those most likely to die while awaiting a transplant. The average waiting time for a new lung in Maryland is currently about 18 months.
What to Expect While Waiting
The time may be shorter or longer depending on the donor supply and the patient waiting list. While waiting, the patient is seen in clinic periodically to assist with any medical issues that may arise. In addition to transplantation, patients with lung disease can be treated with various innovative and investigational modalities at the University of Maryland. The problem of acute lung failure and the role of artificial lung support (also known as "ECMO", or extracorporeal membrane oxygenation) as a bridge to recovery or transplant is also being studied. Please remember that it is VERY IMPORTANT for the candidate and their physician to let us know promptly if there is any change in medication (especially steroid dose) or in the candidate's medical condition. When in doubt, CALL.
During the wait for transplant, the primary contact person for medical problems will usually be the transplant pulmonologist. The transplant nurse practitioner or transplant secretary is always happy to field questions regarding transplantation.
When a compatible organ becomes available, the transplant patient is immediately contacted by a nurse coordinator and admitted to the hospital. At this time, a history is taken of any medical events which may have occurred since the initial transplant evaluation. Appropriate testing is also done to ensure the patient's readiness for surgery.
One surgeon will lead the team that travels to the hospital where the donor is located to remove the lung from the donor and to "put it to sleep" in a way that is likely to protect ("preserve") its function. This is done by interrupting blood flow to the donor lung while flushing a special cold "preservation" solution through the donor lung's pulmonary arteries. The preservation solution greatly slows the lung's metabolic activity (and thus reduces its need for food and oxygen). The lung is then carefully but swiftly removed. The organ is protected by wrapping it in sterile plastic bags inside a picnic cooler (yes, really!) and brought to UMMC for implantation. Meanwhile another team of surgeons will prepare the recipient to receive the new lung (or lungs).
Careful coordination is required between the donor and recipient surgical teams in order to minimize the amount of time that the new lung is "asleep". As soon as we are confident that the donor lung is in good condition and is suitable for the recipient, the patient is taken to the operating room. There, special IV lines are placed and the recipient is carefully put to sleep by the anesthesia team. The chest is opened, and preparations are made to remove the old lung. If the patient has had prior lung surgery or infections, this is one of the more difficult and dangerous parts of the procedure. Preparations may be made for supporting the recipient's circulation with a heart-lung ("cardiopulmonary bypass") machine if it appears that the circulation will not be adequate without this assistance.
Once the new lung has arrived safely, the old lung is removed, and the new lung stitched in place. This is done by sewing together the ends of the airway (bronchus) and main blood vessels (pulmonary artery and left atrium) leading in and out of the lung. After assuring that the new lung is working well, the chest is closed, leaving "chest tubes" to drain any blood or fluid that might otherwise accumulate around the new lung.
The surgery lasts approximately six to eight hours. When the surgery is completed, the patient is taken to the intensive care unit. Over the subsequent days as the patient recovers from surgery, the breathing tube and various drainage tubes and intravenous lines are gradually removed, and the process of rehabilitation is begun.
Occasionally the new lung may function poorly, due to unrecognized infection in the donor, or more commonly because of "ischemia/reperfusion injury". When this occurs, prolonged machine support using evolving lung ventilation strategies or even a temporary artificial lung support (ECMO) may be required.
Careful, comprehensive post-surgical monitoring allows the transplant team to constantly evaluate whether the body is accepting the new organ. This includes regular lung X-rays, bronchoscopies, and periodic biopsies. Biopsies are performed through a bronchoscope inserted into the airway, and passing a delicate scissor device through the airway branches and into the lung under X-ray (fluoroscopy) guidance. Several small pieces of the lung are removed for microscopic examination. This usually causes some bleeding; occasionally the bleeding is severe or even life-threatening.
Despite these risks the biopsy is important: if we see evidence of immune injury to the lung (infiltration of cells called "lymphocytes"), then additional therapy may be prescribed to reverse this "acute rejection" process. In almost every instance this therapy is successful at reversing the rejection.
The average length of stay in the intensive care unit is 3-7 days, followed by 1-2 weeks in the hospital.
The Outpatient Clinic
Follow-up care initially involves returning to the Outpatient Clinic once a week for the first month after leaving the hospital. At this time a series of tests, including blood tests, are conducted to closely monitor the patient's progress. This is a period when medications are precisely adjusted. After this initial period of relatively intensive follow-up, patients are seen periodically as determined by their condition.
The Patient's Responsibility
While transplantation can greatly improve the quality of life of the recipients, it also demands much of them. They must become active participants in preserving their health.
Immunosuppressive Medication
Transplantation has become so successful in recent years in large part through the development of new, more effective drugs which prevent rejection by the body of donated organs. These drugs inhibit the body's immune system from identifying the new organ as foreign. It is necessary for all patients to take immunosuppressive medication for the rest of their lives following transplant. A successful transplant can be undermined very quickly by the failure of patients to take their medications appropriately and responsibly.
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Typical Medicines to Prevent or Treat Infection:
Typical Complications That May be Prevented by Other Medicines, as Appropriate:
The Lung Biopsy Regimen
Lung biopsies are a necessary part of careful, comprehensive monitoring to evaluate whether the body is accepting the new organ. Biopsies are performed through a bronchoscope inserted into the airway, and passing a delicate scissor device through the airway branches and into the lung under X-ray (fluoroscopy) guidance. Several small pieces of the lung are removed for microscopic examination. This usually causes some bleeding; occasionally the bleeding is severe or even life-threatening. Despite these risks the biopsy is important: if we see evidence of immune injury to the lung (infiltration of cells called "lymphocytes"), then additional therapy may be prescribed to reverse this "acute rejection" process. In almost every instance this therapy is successful at reversing the rejection.
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