LP Lung Transplant Case Presentation · Lung Transplant Case Presentation Errol L. Bush, MD...

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5/9/2015 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 2012 98% Class I, 74% Class II 2014 85% Class I, 63% Class II

Transcript of LP Lung Transplant Case Presentation · Lung Transplant Case Presentation Errol L. Bush, MD...

5/9/2015

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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

• 2012 98% Class I, 74% Class II

• 2014 85% Class I, 63% Class II

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LP

• 47y F never smoker w/ LAM at age 19– Bilateral pneumothorax

• 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

EM

• 24y F never smoker w/ worsening SOB

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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

• 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

EM

• 24y F never smoker w/ worsening SOB– 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

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

• 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

Next Steps?

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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 tx from CPMC on VA ECMO 6/8

– Concern: drug-induced DAD in setting of 3 drug therapy for mycobacterial skin infxn vscryptogenic 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

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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

– 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

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