5/9/2015
Lung Transplant Case Presentation
LP • 47y F never smoker w/ LAM at age 19 – Bilateral pneumothorax • Left tetracycline pleurodesis 1986 • R talc pleurodesis 2000
Errol L. Bush, MD Assistant Professor of Surgery Heart and Lung Transplantation UCSF Medical Center
– PRA • 2012 98% Class I, 74% Class II • 2014 85% Class I, 63% Class II
Update in Advanced Lung Disease May 9, 2015
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LP • 47y F never smoker w/ LAM at age 19 – Bilateral pneumothorax
EM • 24y F never smoker w/ worsening SOB
• Left tetracycline pleurodesis 1986 • R talc pleurodesis 2000
– PRA • 2012 98% Class I, 74% Class II • 2014 85% Class I, 63% Class II
• Bilateral lung transplant w/o bypass – 2 hours lysis of adhesions – Extrapleural pneumonectomies – 3U PRBC
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EM • 24y F never smoker w/ worsening SOB – Chest tube placed – CT chest
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EM • 24y F never smoker w/ worsening SOB – Chest tube placed – CT chest – VATS lung BX • LAM
– d/c home after 2 weeks, on home O2
EM • 24y F never smoker w/ worsening SOB – 2 weeks later • Desaturations -> ER
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EM • 24y F never smoker w/ worsening SOB – 2 weeks later
EM • 24y F never smoker w/ worsening SOB – 2 weeks later • Desaturations -> ER
• Desaturations -> ER • Transferred to tertiary center
• Transferred to tertiary center – Tachypnea->AMS w/ hypoxia and hypercarbia – Intubated • 12 mins PEA arrest • L needle decompression with chest tube – Improved hemodynamics
– Tachypnea->AMS w/ hypoxia and hypercarbia – Intubated • 12 mins PEA arrest • L needle decompression with chest tube – Improved hemodynamics
• R chest tube
• D/c Home after 3 week hospitalization and heimlech valve – Oxygen 4L at rest, 6L for ambulation – Expedited transplant evaluation mostly complete
• R chest tube
EM • 24y F never smoker w/ worsening SOB – 2 weeks later – Home: extreme SOB, intermittent hypoxia. • Found on the sidewalk tachypneic, hypoxic, and tachycardic to 140s and brought straight to ER.
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Secondary Spontaneous Pneumothorax • Pneumothorax that occurs as a complication of underlying lung disease • Most commonly – Chronic obstructive pulmonary disease, cystic fibrosis, primary or metastatic lung malignancy, and necrotizing pneumonia – 70% COPD • 50 percent likelihood of recurrent SSP over three years among patients with a SSP due to COPD
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Treatment • Hospitalization – Underlying lung disease increases the risk for an adverse outcome
• Supplemental Oxygen • Stabilization with pleural drainage • Referral to Lung transplant center – Further therapy?
• 18y F with cystic fibrosis and SSPx – 10d air leak – EBV placed • Tube removed in 5 days • d/c home
– 3 days later, recurrent PTx – Lung transplant 1 month following EBV
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Thank you
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CL 48y M Peruvian immigrant aquarium cleaner with acute hypoxic respiratory failure – Recently hospitalized for mycobacterial facial cellulitis and left lower lobe pneumonia • Six months earlier had facial cellulitis – Soft tissue only by MRI, despite abx
• T-4m noted cough and SOB – CXR w/ LLL pneumonia, Moxifloxacin » Only facial improvement, added minocycline
• T-2m daily fevers, pulmonary process worsens • T-1m hospitalized, VATS bx – Organizing pneumonia w/ acute lung injury and fibrosis » Steroids, Abs
CL
Next Steps?
• 48y M Peruvian immigrant aquarium cleaner with acute hypoxic respiratory failure – Recently hospitalized for mycobacterial facial cellulitis and left lower lobe pneumonia • Six months earlier had facial cellulitis – Soft tissue only by MRI, despite abx
• T-4m noted cough and SOB – CXR w/ LLL pneumonia, Moxifloxacin » Only facial improvement, added minocycline
• T-2m daily fevers, pulmonary process worsens • T-1m hospitalized, VATS bx – Organizing pneumonia w/ acute lung injury and fibrosis » Steroids, Abs
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CL continued
Now what?
• 48y M Peruvian immigrant aquarium cleaner with acute hypoxic respiratory failure – F/u pulmonologist: hypoxic, SOB, significant weight loss • 2 week hospitalization – 2L NC -> NRB – Failed high dose steroids, cellcept » Intubation – Oscillator » Oxygen saturations only in 80s
Admission CXR
CL •
48y M w/ DAD/AIP tx from CPMC on VA ECMO 6/8 – Concern: drug-induced DAD in setting of 3 drug therapy for mycobacterial skin infxn vs cryptogenic organizing PNA. • •
RIJ->R CFA VA ECMO 6/14/10 RIJ->LCFV VV ECMO
•
6/18 RIJ->PA VV ECMO
– –
• • • • • • • • • • •
Agitation w/ neuro checks -> flow disturbances Chest left open
6/20 RA->PA tunneled VV ECMO w/ chest closure ?6/22 RIJ/RCFV to RCFA VA ECMO 6/25 weight bearing; listed for lung transplant 7/5 BOLT on CPB 7/12 Washout for R empyema 7/22 dysphagia, continue TF 8/2 tx floor 8/12 tracheostomy closure 8/17 perc GJ and passed swallow, but no motivation 8/20 d/c home 9/30 L groin seroma evacuation
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WJ • 64y M with IPF and hypoxemic failure – Planned outpatient appointment later in week – ED • Progressive dyspnea, multiple ED visits – SpO2 90% on 8LPM and 70s with exertion – ABG 7.46/36/51 on 8L high flow
• BiPAP and HFNC 15 L/min • No infections or heart failure • Solumedrol, levaquin, spiriva, budesonide, nebs, PPI
– admitted 8/27
• SpO2 low 80's on HFNC 15L ->supplemental NRB • Exam – BP 118/79, HR 107, T 36.4, SpO2 90-94% on 25L HFNC and NRB 100% – A&OX3 – Spoke four to five word sentences – Moderate distress, rapid and abdominal breathing to the mid 30’s, desaturated with any movement or talking. – ABG 7.47/39/158 on high flow 25L and NRB
• Transferred to ICU • Intubated/Paralyzed 9/5
Course • 9/6
Perc Trach
• 9/11 BOLT
– Awakened from sedation and paralytics were weaned off. – Minimal exertion caused desaturations to the 60s with poor recovery – PA pressure 61/21 (34) on swan – NO did not reduce the PA pressure on swan – Hypoxemia and respiratory instability requiring urgent ECMO
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