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