Lung Transplant Case Presentation

Transcription

1 Lung Transplant Case Presentation Errol L. Bush, MD Assistant Professor of Surgery Heart and Lung Transplantation UCSF Medical Center Update in Advanced Lung Disease May 9, 2015 LP 47y F never smoker w/ LAM at age 19 Bilateral pneumothorax Left tetracycline pleurodesis 1986 R talc pleurodesis 2000 PRA % Class I, 74% Class II % Class I, 63% Class II 1

2 LP 47y F never smoker w/ LAM at age 19 Bilateral pneumothorax Left tetracycline pleurodesis 1986 R talc pleurodesis 2000 PRA % Class I, 74% Class II % Class I, 63% Class II Bilateral lung transplant w/o bypass 2 hours lysisof adhesions Extrapleural pneumonectomies 3U PRBC 2

3 Chest tube placed CT chest 3

4 Chest tube placed CT chest VATS lung BX LAM d/c home after 2 weeks, on home O2 2 weeks later Desaturations -> ER 4

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6 2 weeks later Desaturations -> ER Transferred to tertiary center Tachypnea->AMS w/ hypoxia and hypercarbia Intubated 12 minspea arrest L needle decompression with chest tube Improved hemodynamics R chest tube 2 weeks later Desaturations -> ER Transferred to tertiary center 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 2 weeks later Home: extreme SOB, intermittent hypoxia. Found on the sidewalk tachypneic, hypoxic, and tachycardicto 140s and brought straight to ER. 6

7 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 7

8 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 8

9 Thank you 9

10 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 10

11 CL continued 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 Now what? Admission CXR CL 48y M w/ DAD/AIP txfrom 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 Agitation w/ neuro checks -> flow disturbances 6/18 RIJ->PA VV ECMO 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 11

12 WJ 64y M with IPF and hypoxemic failure Planned outpatient appointment later in week ED Progressive dyspnea, multiple ED visits SpO290% on 8LPM and 70s with exertion ABG 7.46/36/51 on 8L high flow BiPAPand 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, SpO % 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, desaturatedwith 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 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 9/11 BOLT 12

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