Success in lung transplantation is highly dependent on appropriate candidate selection. At many centres, pre-transplantation dependence on mechanical ventilation has been considered a relative, if not an absolute, contraindication. The high nosocomial infection risk and weak respiratory musculature in ventilator-dependent patients can lead to prolonged post-transplantation mechanical ventilation and a more difficult postoperative recovery [1,2]. Acute respiratory failure is also a controversial indication for lung transplantation, and it is uncertain when transplantation might be of therapeutic value in acute adult respiratory distress syndrome (ARDS) [3,4]. We describe a double-lung sequential transplantation performed in a patient with ARDS caused by an occupational accident.
A 44-yr-old male, without previous medical history, was admitted to the intensive care unit after inhalation of ammonia and oil vapour. He required mechanical ventilation of the lungs and despite a negative fluid balance, positive end-expiratory pressure, inhaled nitric oxide and corticosteroid treatment his lung function progressively deteriorated. A lung biopsy showed obliterative bronchiolitis, extensive fibrosis and leucocyte infiltrates. Since the ventilatory support could not be discontinued, the patient was proposed as a candidate for lung transplantation after multidisciplinary assessment.
The patient was on ventilatory support through a tracheostomy (assisted spontaneous breathing with inspiratory pressure support) for 171 days, until an appropriate donor was obtained. Intensive respiratory and general physiotherapy was performed. Electromyography of the respiratory musculature was within normal range at the time of transplantation. A pre-transplantation echocardiography showed hypertrophy and slight dilatation of the right ventricle, and low-grade tricuspid regurgitation. The pulmonary artery systolic pressure was estimated at 58 mmHg. Computerized axial tomography scanning of the chest revealed bilateral bronchiectasis, mainly in the lower lobes. Pseudomonas aeruginosa and Acinetobacter were cultured in tracheal secretion and at bronchoalveolar lavage.
A sequential double-lung transplantation was performed. Anaesthesia was induced with etomidate and midazolam. Analgesia was achieved with fentanyl and neuromuscular relaxation with atracurium. After induction of anaesthesia, a left-sided double-lumen tube was inserted through the tracheostomy. The lungs were ventilated with 100% oxygen and nitric oxide 10 ppm. After the first lung bronchial blockade, the patient required extracorporeal circulation due to pulmonary hypertension and right ventricular failure. Weaning from cardiopulmonary bypass was supported with intravenous infusions of dopamine 7 μg kg−1 min−1, dobutamine 10 μg kg−1 min−1, prostaglandin E1 0.025 μg kg−1 min−1 and inhalation of nitric oxide 20 ppm. The cardiopulmonary bypass time was 190 min. The ischaemic time was 270 min for the first lung, and 360 min for the second lung.
The patient was admitted to the intensive care unit with strict aseptic precautions. In accordance with the preoperative cultures, the antibiotic treatment included ampicillin-sulbactam, ciprofloxacin and fluconazole. Immunosuppression consisted of prednisolone, cyclosporin and azathioprine. In the immediate postoperative period, the patient was haemodynamically unstable and developed predominantly right-sided reperfusion pulmonary oedema. Spontaneous breathing was achieved on the 18th postoperative day; the patient was discharged from the intensive care unit 20 days after operation. The tracheostomy was closed 32 days postoperatively and the patient was discharged from the hospital 72 days after transplantation. Fifteen months after the procedure, pulmonary function tests showed the following values: forced vital capacity (FVC) 4.2L; 1-s forced expiratory volume (FEV1) 3.87L. The patient is well, 4 yr after transplantation.
Indications for lung transplantation have broadened, and factors previously considered as definite contraindications are now regarded as relative contraindications, or high risk factors for the transplant. Pre-transplantation dependence on mechanical ventilation had traditionally been considered an absolute contraindication to lung transplantation at many centres. This is due to bacterial colonization of the airways and poor respiratory muscle strength, increasing the high risk of postoperative pneumonia and delayed recovery. Since transplantation is considered only for end-stage lung disease, it is not uncommon that patients develop respiratory insufficiency necessitating ventilatory support, while awaiting a suitable donor. Although pre-transplantation mechanical ventilation has been identified as a risk factor for early mortality , several groups have reported good results with lung transplantation in ventilator-dependent patients [1,2]. Survival, lung function and readmission rate were comparable with patients, who were not on ventilatory support preoperatively, but the duration of postoperative mechanical ventilation was longer, as were critical care unit and hospital stays.
Some centres have restricted lung transplantation to patients with short pre-transplantation ventilation times. However, Baz and colleagues  described a series of patients with pre-transplantation mechanical ventilation for more than 13 days and concluded that, although the postoperative intubation time was longer than in non-ventilated patients, the 1 yr survival rate was comparable. Baz and colleagues  found no correlation between the pre-transplantation '6 min walk test' and the postoperative intubation time or postoperative mortality in these patients.
Many transplant centres do not consider the possibility of lung transplantation in ventilator-dependent patients if they had not been evaluated and accepted for transplantation prior to the final respiratory failure . However, consistent with this case, there are a few previous reports of successful lung transplantation in patients, who were ventilator-dependent secondary to acute ARDS with terminal and irreversible respiratory failure [5-7]. The main controversial point is when to consider respiratory insufficiency truly irreversible in acute cases [3,4]. In our case, because of the lung biopsy result, and the failure of the therapeutic modalities applied, we considered the condition as terminal and bilateral lung transplantation as the only option.
In conclusion, we report a case of successful lung transplantation in a patient on a long-term ventilator support due to an acute lung lesion. The patient is in good condition with a follow-up time so far of more than 4 yr. This encourages us to consider long-term ventilator-dependent patients, with no other contraindication or high risk factors, as acceptable candidates for lung transplantation.
Department of Anaesthesiology; Hospital Universitario La Fe; Valencia, Spain
Department of Pneumology; Hospital Universitario La Fe; Valencia, Spain
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