lung transfer

In 1946, the famous Russian physiologist Rymviv began the animal experiment of lung transplantation, which pioneered the lung transplantation. Nowadays, lung transplantation technology has been perfected to solve the pain of many patients. Treating diseases: multiple lung infections Indication In principle, all kinds of advanced lung parenchyma or pulmonary vascular disease with pulmonary infection are double lung transplantation as long as the heart function is good, or the right heart function can be restored without serious coronary heart disease or heart disease. Indications. Contraindications The absolute contraindications for lung transplantation are: (1) Single lung transplant patients > 65 years old, double lung transplant patients > 55 years old. (2) The left heart function is not good. (3) Irreversible liver and kidney disease. (4) Significant extrapulmonary systemic diseases, such as collagen diseases. (5) Active extrapulmonary infection with malignant tumors. (6) The condition is critical and cannot tolerate surgery. (7) The patient does not cooperate with the family. Relative contraindications are: (1) Osteoporosis. (2) Application of hormones. (3) Smoking, alcohol hobbies or drug use. (4) Use a ventilator. (5) One side of the thoracotomy or sternal median incision. (6) Severe muscle and bone diseases such as hunchback. (7) Poor nutritional status, weight <70% of normal weight or >130%. (8) Tuberculosis. (9) There is mold and atypical mycobacterial sensation. Preoperative preparation Antibiotics are routinely used before surgery. Surgical procedure Step 1 Take out the donor lung. Step 2 Resection of the recipient lung. Step 3 lung implant anastomosis. complication 1. Infection: Infection is the most important complication in the early postoperative period and the most important cause of perioperative death. Bacterial infection is the most important cause of perioperative period, and common are Candida, mold, herpes simplex virus and cytomegalovirus. Broad-spectrum antibiotics are routinely used during the perioperative period, and the choice of antibiotics usually requires coverage of possible pathogens from donors and recipients. It is usually an empirical use of antibiotics before the susceptibility results come out, and adjustments should be made after the susceptibility results are available. If mold or Candida albicans is isolated from early secretion specimens, preventive medication should be considered even if there is no evidence of invasion or dissemination. Fluconazole 100-200mg is administered orally once a day or intravenously to prevent Candida infection. Itraconazole 200mg is administered orally twice a day or inhaled amphotericin 10-15mg to prevent Aspergillus infection. CMV virus infection is most likely to occur when the donor CMV antibody is positive and the receptor CMV antibody is negative. For RCMV-/DCMV+ patients, valganciclovir was used for 6 months to prevent viral infection, and for RCMV+, valganciclovir was used for 3-6 months. 2. Ischemia reperfusion injury: Ischemia-reperfusion injury is a type of acute lung injury accompanied by alveolar destruction and increased vascular permeability. The incidence of early post-transplantation is 10-15%. Moderate to severe ischemia-reperfusion injury is usually accompanied by impaired oxygenation, decreased lung compliance, increased pulmonary hypertension, and chest radiograph infiltration. Ischemia-reperfusion injury is the main cause of primary graft failure. The International Heart and Lung Transplant Association's recommendations for grading primary dysfunction are as follows: Grade 0- PaO2/FiO2 >300 and imaging is normal Grade 1- PaO2/FiO2 >300 and the chest radiograph is scattered in the shadow Grade 2- PaO2/FiO2 between 200-300 Grade 3- PaO2/FiO2 <200 It has been reported that Grade 3 grade graft dysfunction is associated with increased mortality within 90 days after surgery (17% vs 9%) compared with low graft dysfunction. The risk factors for Grade 3 graft dysfunction were donor age, donor smoking history of more than 200 years, recipient pulmonary hypertension, and primary disease. 3, airway complications: Complications of bronchial anastomosis include stenosis, rupture, and tracheal softening, and anastomotic stenosis is the most common complication. Airway complications are one of the major complications and causes of death after lung transplantation. Donor bronchial blood supply is one of the important causes of airway complications, but with current transplantation techniques, donor bronchial ischemia can be avoided without bronchial artery reconstruction. The blood supply to the donor bronchus depends on pulmonary blood supply within a few days after surgery. Shortening the length of the donor bronchus can reduce the possibility of postoperative bronchial ischemia. Usually we require the donor bronchial disconnection level at the upper leaf opening. The proximal bronchus of the cartilage ring, which effectively reduces the ischemic portion of the donor bronchus and greatly reduces the probability of airway complications. Airway complications can be diagnosed by a series of methods. Conventional application of anastomotic bronchoscopy can detect airway complications early. Occasionally, CT examination can also find airway stenosis and fracture for some other reasons. Such complications, in fact, in clinical work we found that CT is very useful for the diagnosis and assessment of airway complications. Airway stenosis is usually accompanied by dyspnea, wheezing, and a decrease in FEV1, and bronchoscopy can confirm the diagnosis. Normal bronchial anastomosis can be seen in the complete anastomotic suture as well as the intact epithelium, occasionally seeing epithelial flaky light necrosis, which generally does not cause any problems. Defects in the membrane are generally healed under conservative treatment, and defects in the cartilage usually cause a narrowing of the airway in the later stage. Severe bronchial rupture (greater than 50% of the circumference) generally requires some intervention to ensure the integrity and patency of the airway. Occasionally, severe rupture causes the bronchial cavity to communicate with the pleural cavity, resulting in pneumothorax and severe air leak. If the lung is fully dilated, the chest cavity will be fully drained, and the mouth will eventually heal and there will be no stenosis. There is also a bronchial rupture that directly communicates with the mediastinum resulting in severe mediastinal emphysema. If the lung is fully dilated, a mediastinal drainage tube can be placed through the mediastinoscope at the anastomosis, which usually results in a satisfactory healing of the cheek without leaving a stenosis. It has been reported in the literature that the incidence of anastomotic rupture in transplant patients with early application of rapamycin is high, so early application of rapamycin after transplantation requires caution. Due to bronchial anastomosis and other reasons after lung transplantation, the anastomosis is prone to fungal infection. Candida albicans and Aspergillus are potential pathogens that can cause fatal infections in the anastomosis. Nunley et al. counted 61 patients with bronchial anastomotic fungal infections and found that the majority of the infection was Aspergillus. The probability of complicated airway stenosis after anastomotic fungal infection was 46.7% significantly higher than that in the no fungal infection group. Specific anastomotic complications caused by fungal infection include bronchoconstriction, bronchial softening, and major bleeding. Endotracheal stents, balloon dilatation, electrocautery, laser, etc. have a role in the treatment of airway complications. If there is a pseudomembrane in the anastomosis of the bronchoscopy, biopsy should be performed immediately to eliminate the fungal infection. Once the diagnosis is usually performed, systemic and local aerosolized antifungal drugs are needed. The aerosolized antifungal drug can directly reach the lesion. 4, acute rejection: Acute rejection is a very important issue in the development of lung transplantation. It was a very difficult and often fatal problem in the 1960s and 1970s. Until the emergence of cyclosporine, the incidence of acute rejection after transplantation was greatly reduced, and this directly made the success of human lung transplantation in the 1980s possible. However, despite the continuous development of immunosuppressive drugs, acute rejection in clinical work still occurs from time to time. Acute rejection usually occurs most frequently in the first few months after lung transplantation, and the probability decreases slowly over time. Acute rejection is the inflammatory response around the blood vessels and airways that are dominated by lymphocytes. At present, acute rejection (especially recurrent acute rejection) is considered to be a risk factor for chronic obliterative bronchiolitis. The role of humoral immunity in acute rejection is still controversial. Some evidences suggest that capillary vasculitis is a humoral immune system. In addition, anti-HLA antibodies may play a very important role in the middle. Antibody-mediated rejection is ineffective for hormonal therapy and often requires additional treatments such as plasmapheresis, intravenous gamma globulin, and rituximab. The clinical manifestations of acute rejection are not specific. The main symptoms include hypothermia, shortness of breath, cough, hypoxia, leukocytosis, and decreased lung function. Imaging findings: Infiltration of the lungs, pulmonary interstitial edema, and thoracic exudation are all manifestations of early acute rejection, but they are not specific. It is very difficult to distinguish between acute rejection and pulmonary infection by clinical manifestations, but it is very important to make timely and accurate judgments because the treatment methods are quite different. The acute rejection occurred in the late stage of transplantation has no specific imaging findings. Many transplant centers recommend that patients be monitored for graft function after discharge from the hospital. Once the graft function is stable, the daily measurement data is 5%. Within, while FEV1 and FVC decreased by more than 10% for more than two days, suggesting the possibility of infection or rejection. The diagnosis of graft rejection after lung transplantation also requires a combination of bronchoscopy biopsy. We recommend that patients undergo routine bronchoscopy lung biopsy at 1 month, 3 months, 6 months, 12 months, 18 months, and 24 months. When the patient has symptoms of infection or rejection after transplantation, many clinical lung transplant centers use bronchoscopy for alveolar lavage or bronchoscopy lung biopsy to further distinguish and confirm that the specificity of this invasive test is about 69%. about. Biopsy generally requires 3-5 better tissue blocks. Generally, patients with double lung transplantation and cardiopulmonary transplantation only need to transplant lung on one side of the biopsy, but the site of biopsy usually chooses different lung and lung segments. . For the treatment of acute rejection, high-dose hormonal shock is usually used, and methylprednisolone is 500mg-1000mg/day for three days. Clinical symptoms are usually relieved after 24-48 hours of administration, and lung function returns to baseline levels after a few weeks. After that, prednisone was changed to 0.5 mg-1 mg/kg/day, and after several weeks, it was changed to a maintenance amount orally. There is still no standard treatment for persistent or repeated acute rejection, but there are also some reports such as: high dose of hormonal shock, cyclosporine to tacrolimus, azathioprine to Xiaoxue, Cyclosporine atomization, methotrexate treatment, anti-lymphocyte globulin (OKT3, ATGAM, etc.). 5. Chronic rejection: Chronic rejection is the most important factor affecting long-term survival after lung transplantation. Chronic rejection is mainly divided into chronic vascular rejection and chronic airway rejection. Chronic vascular rejection is a relatively rare form of chronic rejection, manifested as pulmonary vascular sclerosis. Chronic airway rejection is a relatively common condition, histologically manifested as occlusive bronchiolitis (OB). Obliterative bronchiolitis is very common after lung transplantation. Early pathology is characterized by submucosal lymphocytic inflammation and small airway epithelial rupture, followed by fibromyxoid granulation tissue hyperplasia and obstruction of the airway lumen.