What Is It?

In lung transplant surgery, someone with life-threatening respiratory problems is given one or two healthy lungs taken from a person who has died. If one lung is transplanted, the procedure is called a single-lung transplant. If both lungs are transplanted, it is a bilateral or double-lung transplant.

Lungs for transplantation usually come from young, healthy people who have had severe brain damage because of trauma or cardiac arrest. Their lungs and other organs are maintained with life-support machinery. Under particular circumstances, two living people can donate small parts of their lungs to one person in desperate need of a transplant. Each person donates one lobe (section) of a lung. This rare use of living donors is done in some cases because of a great shortage of suitable lungs from donors who have died. Entire lungs are never transplanted from a healthy living donor because of the high risk of complications.

Most lung donors have been healthy nonsmokers younger than 55. An extensive medical evaluation is done to make sure that the lungs are healthy and free from serious damage and disease. In up to 80 percent of potential donors, the lungs are judged unsuitable for transplantation. Donors and recipients need to be about the same height, so the lungs will be the appropriate size. In addition, blood types are matched to reduce the risk that the recipient’s immune system will attack a transplanted lung as a foreign object. This process is called organ rejection.

About 3,900 people in the United States are on a national waiting list for a lung transplant. However, just over 1,000 lung transplants (half single-lung and half double-lung) are done in the United States each year. About another 30 people have combined heart-lung transplants. In comparison, each year surgeons perform 12,000 kidney transplants, 5,000 liver transplants, and 2,000 heart transplants. Relatively few lung transplants are done because of the general shortage of transplant donors and because so few donors meet the strict criteria for lung transplantation. The average wait for a lung transplant is just under two years. About 10 percent to 15 percent of those waiting die each year. Potential donor organs usually are found through an organization called the United Network for Organ Sharing (UNOS). After matching for body size and blood type, people are selected to receive new lungs based on how long they’ve been on the waiting list (seniority). People with more severe lung disease don’t get any special priority.

Lung transplantation is used to treat end-stage, life-threatening lung disease when other treatment options have failed. Because of the risks involved, transplants usually are reserved for people who are likely to die from their lung disease within one to two years. Receiving a lung transplant appears to improve a person’s quality of life. However, life expectancy does not always improve.

Lung transplants in the United States usually are performed for the following reasons:

• Chronic obstructive pulmonary disease (COPD), including emphysema (35 percent of all U.S. lung transplants in 1997)
• Cystic fibrosis (14 percent)
• Idiopathic pulmonary fibrosis (14 percent)
• Alpha1-antitrypsin deficiency (12 percent)
• Primary pulmonary hypertension (9 percent)
• A second transplant after a first lung transplant fails (4 percent)
• Other causes (14 percent), including bronchiectasis and sarcoidosis

Most lung transplants are done in adults between the ages of 18 and 65. A few transplants are performed each year in children, mostly teenagers, and in older adults.

Lung transplants are performed in fewer than 100 medical centers around the United States. To be considered for a lung transplant, you must apply to be added to the waiting list at one or more specific transplant centers. Each center has its own standards for admission. In general, a good candidate:

• Has severe, end-stage lung disease with limited life expectancy
• Has not been helped by all available alternative medical and surgical treatments
• Has good potential to complete a vigorous and complicated post-transplant recovery program
• Is mentally prepared to undergo the transplant process and has good support from family and friends
• Has medical insurance that will cover the costs of the transplant and follow-up care
• Is younger than age 65 for a single-lung transplant, or younger than age 60 for a double-lung transplant
• Is not ill (other than the lung disease), medically unstable, or malnourished
• Does not have uncontrolled or untreatable infections, recently treated or incurable cancers, or serious medical problems affecting the heart, liver, kidneys or brain
• Does not smoke, abuse alcohol, or use drugs
• Does not have HIV, or active hepatitis B or hepatitis C infection
• Has not had extensive previous chest surgery, which can make the transplant technically difficult

If you meet these standards, you will undergo an extensive pre-transplant medical evaluation. This focuses on making sure you truly need the transplant and are medically able to withstand the difficult procedure. The evaluation often includes blood tests, X-rays, measurements of lung and heart function, and psychological testing. Your blood and tissue types are determined so that a suitable donor can be found.

While waiting for a lung transplant, you will meet regularly with members of the transplant team. These specialists offer a wide range of support services during the long period before the transplant. You probably will wear a beeper so you can be contacted as soon as a suitable donor is found.

When a donor lung becomes available, a regional organ bank follows guidelines from the UNO. The candidate at the top of the list who is best suited to receive the transplant is selected. When you are selected and contacted, you will go to the transplant center immediately for surgery.

An intravenous line will be inserted into a vein in your arm to deliver fluids and drugs, and you will receive general anesthesia. The transplant surgeon will inspect the donor lung or lungs to make sure they look healthy and suitable for transplantation. The surgeon then will make a large incision in your chest. The incision may be horizontal, extending from below the shoulder blade, around the side to the front of the chest. It also may be made through the middle of the breastbone. For a double-lung transplant, a large “clamshell” incision may be used that exposes the entire front portion of the chest. A clamshell incision extends from one armpit to the other, under the rib cage, so that the chest opens like a clamshell.

For single-lung transplants, the surgeon first decides which lung to remove and replace. The failing lung is collapsed, its blood vessels are tied off, and its main airway (bronchus) is cut. The old lung is removed, and the donor lung is positioned in the chest. The airway is reconnected, and then the lung’s blood vessels are reattached. Once the new lung is in place, the surgeon looks inside it with a telescope (bronchoscopy). He or she will confirm that the lung looks pink and healthy inside and will remove any blood or excess mucus from the airway.

In most cases, a double-lung transplant is like a single-lung transplant done twice. One lung is transplanted first (usually the lung with the poorest function), followed by the remaining lung. In about 10 percent to 20 percent of these transplants, the patient is connected temporarily to a heart-lung bypass machine, which pumps blood and supplies it with fresh oxygen.

At the end of the transplant procedure, the chest incision will be closed. You will be taken to a surgical intensive care unit, where you will remain until you are stable. Often this takes two to five days or longer. The entire transplant team — including surgeons, transplant specialists, nurses and respiratory technicians — will monitor you closely. You will receive drugs to suppress your immune system and prevent your body from rejecting the transplanted lung. You also will receive drugs to improve lung function, treat infections, and reduce pain and discomfort. A mechanical ventilator will help you to breathe for most of this time. When you no longer need help breathing and your condition is stable, you will be transferred to a regular hospital unit for 10 to 14 days. Physical therapy and occupational therapy begin about two days after surgery. Frequent blood tests, chest X-rays, and tests of lung function will be done.

Before being discharged from the hospital, you will be given clear instructions:

• You will receive prescriptions for all necessary drugs, including those that prevent the body from rejecting the transplant.
• You may be instructed to use a device called a spirometer every day. This hand-held device measures lung function and can detect the earliest sign of rejection or other lung problems.
• You will be scheduled for regular appointments at the transplant center. During these appointments, you will have periodic pulmonary function tests, blood tests, and when necessary, bronchoscopy to inspect the transplanted lung.
• You may be enrolled in a pulmonary rehabilitation program.

You also will be told how to contact the transplant team any hour of the day or night, if you have questions, concerns or unexpected symptoms.

Although lung transplants were first performed in the 1960s, the procedure was not used widely until the 1990s. Survival statistics have improved over time. But lung transplants remain very risky, especially compared to kidney or heart transplants. According to the latest survival statistics from the UNOS registry:

• About 10 percent of transplant patients die within the first month of their surgery.
• Twenty-three percent die within the first year of their surgery.
• Forty-three percent die within the first three years of their surgery.

In addition, almost all patients develop at least some complications. Within the first three to four weeks after surgery, most patients have an episode of organ rejection. They receive drug treatment for a few days to suppress the immune system. Immediately after surgery, there are also risks of infection, bleeding, malfunction of the donor lung, or poor healing in which the donor lung’s airway attaches to the recipient’s airway. In up to 50 percent of patients, a form of chronic rejection called bronchiolitis obliterans attacks the new lungs. This causes slowly progressive breathlessness that usually cannot be reversed. Long-term use of immune-suppressing drugs also can cause diabetes, kidney damage, osteoporosis and increased susceptibility to life-threatening infections.

When you are discharged from the hospital, you will be told about potential problems and warning signs.

If you develop a problem, consult the information you received when you left the hospital. Contact your transplant doctor immediately if you develop:

• A fever
• A new cough or chest pain
• Shortness of breath, or a drop in your spirometry (lung capacity) readings
• Bleeding, pain or discharge from your surgical incision

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All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.