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Panel Discussion: Lung Transplant

Jan 08 | 3:30 PM

Access, monitor, and treat form the basis of any transplant in the surgical world. However, a lung transplant does not begin with the surgery itself but rather when a physician makes a clinical decision to proceed with it. So, what are the criteria for a lung transplant? How does one go about it? What are the pre-and post-transplant workup procedures? Join India’s three most eminent chest physicians, responsible for forming the Mumbai Lung Transplant Program, as they discuss the right course of action to navigate the complexities of a lung transplant.

[Music] good evening everyone welcome to netflix and today's panel discussion is a lung transplant so the last 30 years we have seen development of lung transplant as a robust therapy for advanced lung diseases for which no other medical therapy is effective from what started as preliminary experiments on dogs by them and cough in russia in 1940s today with modern medicine lung transplant is advanced to a whole new level we all know that lung transplant is a major surgery with scarf resources including the shortage of tuna lungs so it is important to know what goes behind evaluating a patient who is recommended for lung transplant to understand this we have with us two eminent pulmonologists professor dr salil bendray and dr kumar doshi to enlighten us more about lung transplant and i am your moderator for tonight doctor yash kedya i am currently a md resident of pulmonary medicine at cyan hospital mumbai so let me introduce a panel for tonight we have dr professor dr salil bin ray who is a pulmonologist and a transplant physician currently attached at nanawati max hospital global hospital and massena hospital mumbai sir is the executive pulmonary medicine at cages for my hospital mumbai a second panelist for tonight dr kumar doshi is also a consumption pulmonologist and transplant physician at global hospital and messina hospital mumbai both our panelists have more than 20 years of experience practicing pulmonary medicine and have treated hundreds of patients using the expertise so without any further delay let us start a discussion for tonight so i would like to start with dr saleem sir so can you tell us about lung transplant in general what is the lung transplant are there any types of lung transplant and what is the whole theory behind it yeah first of all thank you yash for that modest introduction and i thanks rucha and her team of netflix for inviting myself and dr kumar doshi for this session on lung transplant i'm sure all of the doctors who are listening are presently busy managing and treating and doing online consults and treating themselves also for uh for infections and for kovaids and so many questions coming in so first of all heartiest wishes of mine for all those doctors who are working hard and uh thank you again matt flix for inviting us so coming to the topic of lung transplant today you know it's a very interesting thing we hear a lot of liver transplants we hear a lot of kidney transplants but even heart transplants for that matter but lung transplant is not something which is so often heard because the first question is can it be done will it be possible do people survive so let me tell you the first lung transplant was done in 1963 in mississippi in university of mississippi james hardy was a surgeon and the first heart lung transplant was done in 1981 so you know now as to why it is not so much rampant it's like 20 30 years first single lung transplant 1983 and first double lung transplant you see the successful one is 1986. so that just to tell the history and by the way in mumbai also lung transplants have been done as recent as last two to three weeks okay so for all those people who haven't heard of it we have been able to manage or at least get through with the lung transplant done so just as a background for that now i would like to tell here that when we say lung transfer it can be a single lung or it can be a double lung usually usually single lung transplants are from what we call as live donors okay it can be from a live donor two people giving one lobe from each and then we can do a transplant or of course the commonest one is the double lung transplant because we see more of diffused lung diseases which which need both the lungs to be transplanted or changed in simple words so what we are going to discuss more of today is a double lung transplant so that's how what is the overview of the history in mumbai what are we doing in india of course we have a good good number of patients who have been done especially after post coverage there is a lot of sudden awareness about a lung transplant coming so that's how it is and that's how it will move on so uh dr kumar sir uh what which patient should be recommended for lung transplant like we see many ilds and so uh ipf are so many patients so which ilds and which patients are recommended for lung transplant okay so thank you yes thank you rucha for having us on netflix uh so let's uh go straight to business it's only end-stage lung diseases period now if it's interstitial lung disease those ones who are even on supportive oxygen and on exertion the saturation is going to less than 88 or if a six minute walk distance is less than 250 meters these are the ones who are listed for transplant and if you see that there is a dramatic reduction in the lung functions which basically defined as more than 10 percent in their fpc over a period of six months or more than 50 meters in the six minute walk distance over the period of six months these are the guys who are to be picked up and transplanted you don't really have to wait till they get very sick and on ventilator because more sicker they get beyond this point the poorer are the outcomes so the timing is the key as you go to the copd's again those ones who are having the fev 1 in 15 to less than 15 or who are having a boar score you need to refer them when the board score is about five and you need to list them and the bold score is above seven again don't wait till they are very bad malnourished you know they are having a very poor bmi you wait beyond a particular window and the result starts going down so in summary all those interstitial lung diseases who are on oxygen whose six minute walk distance is less than 250 meters or desaturating less than 88 on or in copd so the fpv one is less than 20 are the ones who should be listed and worked up and transplanted at the appropriate chapter so uh i have specifically avoided [Music] those candidates of or pulmonary arterial hypertension or primary pulmonary hypertension or transplant because that's a different sub group all together and that really does not it's not a very large group the large group comes from the ilds and the cops so that was that is what i was trying to go to the next topic so what are the other diseases apart from copd and inds that we can recommend for them so yes there is a question i think we can see shilpa bhati is asking can you please tell us what is stage lung disease yes so what uh dr shilpa what we actually mean is all these progressive lung diseases where there is a problem with the oxygenation and the carbon dioxide being washed out so they are progressive illnesses where the patient as you must be seeing patients of ild patients of copd who have been on home oxygen okay they have you know you advise them to take home oxygen they are actually on home oxygen for five months six months their condition is such that even if they want to go to the washroom they get breathless they get tachypnea they feel i am like this for last one year but that doesn't mean that their quality of life is good they are in the end stage lung disease so these are people whom you should not wait as dr kumar was saying please don't wait that okay let us see when she gets more critical that's the time we should think about a lung transplant no it is not so in fact we can do it or at least list them as early as possible given the criteria so one would be oxygen at rest also the patient is stuck epic then all these end stage lung diseases also develop pulmonary hypertension so moderate to severe pulmonary hypertension as dr kumar said fev1 if the person is able to perform and there are multiple exacerbations you may have a patient who says so there are repeated exacerbations persistently on oxygen and every exacerbation is going to bring down their lung reserve so these are patients there are some patients of hours like copd which you may have treated who have bilateral or recurrent pneumothorax their lungs are mpc matters there are boule there are cysts they rupture we put icd in drains again put icd after three months what are we going to do for them you can't keep on saying okay take nebulization take oxygen that's not the treatment it's palliative so this is what is an end stage lung disease and apart from that yes what you are asking is abroad if you see cystic fibrosis was the primary indication of doing a lung transplant that's how it all started cystic fibrosis but we very well know now we have copd terminal copd stage 4 copd is ild but at the same time alpha one antitrypsin deficiency becomes one of the indications then primary pulmonary hypertension okay primary what is primary is there is no specific lung disease which is leading to a pulmonary hypertension and these are the best cases which can actually help and improve this life of these patients so primary pulmonary hypertension but more so to say what we will all be seeing will be bilateral bronchitis copd and terminal ile uh so so like we have seen the indications the uh patients who can be referred but are what are the contraindications like in a patient like you have said that we should not wait in the very end uh to refer the patient so apart from that what are the other contraindications what are the other actors which we should take into consideration before referring a patient for lung transplant okay so uh the contraindications are many may see when we when you ask me about contraindications we need to actually filter out our patients so if if today we have got say n number of doctors listening to us who are practicing they will think my patient of copd has been on oxygen he's a candidate for a transplant oh my patient of ild she's on anti-fibrotic she also takes oxygen she's also a candidate for lung transplant so there would be just by theoretical indications it would be many but we need to know that if the patient has an end staging disease it becomes a contraindication i mean you can't have doing a surgery like a lung transplant because these patients are bound to be going on immunosuppressants they are going to be on steroids patients who have got extensive osteoporosis so we have a bone mineral densitometer to be done before that active tuberculosis active infections these are not the candidates for a lung transplant patients who are having bleeding disorders which are not controlled we cannot push them on for a lung transplant even though if they may be candidates in terms of the indications if if i have a patient who is say interstitial lung disease she has been pumped with steroids and her weight is today 78 kg with a body mass index going to 45 she's obese she's overweight she's a diabetic she becomes a high risk almost like a contraindication for saying that okay you can do a lung transplant because we would be extending our risk of telling that there is a lung transplant to be done plus please remember that lung transfer doesn't end at the transplant itself it actually starts from there because there is extensive amount of care to be taken after the lung transplant which means similar suppressants you need to have a family support you need to have a psychosocial support patient should be ready and willing to take medical therapy regularly if he is having drug abuse substance abuse he is a frequent defaulter of the medical treatment prior he is not going to be a candidate who is going to be compliant with the treatment post the transplant so there are multi recently recently diagnosed malignancy for that matter becomes a contraindication for telling the patient that okay you should you know have a lung transplant to be done if the hiv patient is there what is cd4r well in control well good if he's on a good amount of h.a.r.t and he's been managed well he can be taken but uncontrolled hiv uncontrolled hepatitis b going into permanent level failure is not a candidate so there are many and that's the reason why we have a transparent pulmonology cell mumbai lung transplant so that we can actually come to understanding how to pick and choose from this basket of indications asking once we shortlist a patient what special investigation should we do to know if the patient is fit for transplant so are there any special investigation that is compulsory or some uh which is mandatory to do before selecting yeah so apart from all the baseline investigations respiratory and blood like lung functions and dlcs and six minute walk tests and blood of routine blood parameters and panel reactive antibodies the hla typing all the other standard investigations which we need to do including the echocardiogram you look for pulmonary artery pressure now individually you may have to do a coronary angiography if the patient can't have a significant triple vascular vessel disease and you post him for lung transplant you probably may have to do a right hard cat if your 2d echo is not very conclusive and see what is the end capillary which pressures and see the actual right-sided heart status we may have to do a vq scan to see whether he has any add-on thromboembolism we may have to do a pet scan especially in patients more than 50 years of age even tumor markers to see foreign malignancies to rule out we need to do bone mineral densitometries to see if they have any significant osteoporosis which actually is a relative contraindication for transplants so apart from the basic investigations these add-on investigations from case to case are extremely necessary to make sure that you don't pick up an inappropriate candidate on the table for a transplant when he may have some other ailments which is going to curtail his summit i hope dr meda's question is so a couple of uh doctors are asking that why osteoporosis is a contraindication so i was just reading through that dr danish is also asking that so remember now when we say osteoporosis the bones are fragile okay and bones when the surgery is done we need the bones the especially the ribcage and the spine because it's also in fact that brings to me one more contraindication is thoracic case deformities and spine deformities which may cause problems post-operative means the lungs are transplanted but if there is a scoliosis and you try to do that it's a contraindication but when we pulse this when we are doing a post-operative treatment they are in fact given a bolus dose of methylprednisolone right during the surgery there is immediately given pro postoperative and it is continued for almost a longer duration of time the higher dose of steroids so you imagine that there is a patient who has got osteoporosis risk of fractures risk of wound healing being affected and that coming in that the mobilization is not happening so we are going to deal with these problems if there is already an inherent osteoporosis which is significant so that comes into the relative contraindication okay so we have to take that into consideration as well so that's very important you want to add on that no no that's exactly that and so so we have seen about the recipient but how do we select the donor so how do we select the donor column transfer uh before that medha is asking if the patient is just osteoporotic and the rest of the parameters patient can be taken up for transplant after correcting osteoporosis the simple answer is yes it's a relative contraindication and not an absolute one the bottom line is don't take someone with a significant osteoporosis on the table unless you have corrected it uh adequately uh what was your question uh yeah uh donor selections how should we select the donors like we have seen the indications contraindication so first of all the blood typing has to be done and then the basically the donor selection has to be that he should not have any active tuberculosis in our country that is going to be the parameter he shouldn't be having any active tuberculosis and this usually then is the blood group and the panel reactive antibodies which you really don't have time for the pra of all but at least the blood group should be matched and then most important comes is a sizing of the donors is always going to be the size the size of the lung has to match the chest cavity then the simple solution to that is that we generally expect in a in an ild patient we will always want a lung which is lesser than the predicted total lung capacity of the patient and in the copd patient we will generally want a lung which is slightly more because it's a hyperinflated chest we want a lung capacity size which is slightly more than the total lung capacity in general the lung size should be in between the predicted of the patient and the donor it will take care of all your things and that is the easiest thing and of course you should not have any hiv you should not have possible you can do the run any active cm we try it as igm that we may not have time but active hiv active tb and sizing are the three major criterias so how do we uh dr asset is asking one question but before that and what i want to ask from my side so how do we so like you said uh we should select the proper size so how do we do that excising so is what is the procedure or what is it so it's a very funny anecdote which we i kumar likes to share every time so when we were in vienna austria for this training of lung transplant trust me on this but the transplant surgeons used to have an x-ray of the donor and the recipient and they were to actually put a span of their palm and they used to put this and on the recipient and they used to check whether it's going to fit or not going to be fitting and kumar had pointedly asked the topmost surgeon there but how can you just do like this to decide about the surgery as big as a lung transplant and they were saying we just do it this way i don't know how the others do it we have been doing this for years and years together and that's a typical surgical answer now but the bottom line is anthropometry height weight age you can predict your total lung capacity and the predicted total lung capacity and of the donor and the recipient it should be right somewhere in between that's the only way to assess you cannot do a ct scan volumetry to really see whether the lung is going to fit into that size or not and then there are surgical techniques if the lung is oversized how to make it fit inside the chest cavity they can do a resizing they can remove the middle lobe they can keep the clamshell incision open for a while till the rung accommodates into and then flows the incision there are surgical techniques to do that and that's why uh you know they have all weird ways to measure the lung uh instead of using a measure tape to measure the explanted lung they would use a stapler as a handle get the lung is of the size of the stapler man why can't you use a measure table or no that's not the way we do it so yeah yeah sure it's very interesting to know you know when whenever there is a call for an explant means the lung is available what we call as lung retrieval the the surgeon or the pulmonologist who goes there actually feels the lung we have to feel the donor's lung to know how buggy it is whether it is solidified how much is the we have to do a bronchoscopy actually to see whether there is any trauma whether there is bleeding inside where there is an infected material inside so there are factors which go even hands-on it will not be just on an x-ray or a ct scan to determine so i am assuming that bronchoscopy might play a big role because you'll have to out pre-explained bronchoscopy is a mandate unless the bronchoscopy is done uh they don't even explain the lung we we can't afford to have any purulent secretions coming out okay it has to be clean and neat few hemorrhagic areas here and there because you understand it's a donor it's generally it's going to be an accidental death or a sudden death or a vehicular accident so there's going to be some mechamotic patches here and there but we can't expect uh uh say somebody has a bronchial rupture or somebody has an infection that can't so a bronchoscopic view is a must without that there's no explanation there's the first step you know you know yes one more one more i mean just since we are talking of this one more anecdote i will tell you again it goes back to the time when we were in austria for this training so one of the delegates i don't know if it was kumar or some okay why don't we see the ct scans of the donor if the ct chest and then the surgeon's answer was ct will show something i mean we can't afford it and we don't want to see that because ct scan is take so many finer cuts that sometimes we actually don't need to really think about it but we may get biased you know there's a big problem and we may you know overlook taking the lung out so we have to have a very what we call as multi dimensional or multi speciality meeting to really think about should we take this lung or should we not take this in fact the recent transplant that we did was a vehicular accident and the lung had some patches on the on both sides which were appearing consolidating but when we did a bronchoscopy the lung was absolutely clean so those areas were probably confused areas because of the road traffic accident and if you are just gone by the ct scan we would have rejected the lung outside so it's basically a multi-dimensional approach oh yes so so dr asif das is asking who is the ideal donor can the cadaveric lung be used for transplantation yeah yes here you can continue no so yeah cadaveric means we have we need to have these lungs which are not diseased so most of them are going to be road traffic accidents so we are the patient is going to be the relatives the patient i mean the relatives are going to give a consent but most of them are going to be those who are uh root traffic accidents and they are not going to survive in any which ways so those are the people live live donor lungs it's still not approved in our country but but abroad yes i mean uh lobes of live donors there is a couple of places where the surgeries have been done but in in our country no and dr karishma is asking how long can an explanted lung be reserved before implanting there is nothing like reserved you have to whether as the cross clamp is put across the aorta and the cold ischemia time starts and the lung is to be uh anastomosed into the recipient bilateral and the perfusion starts it has to be eight hours so it has everything is extremely planned while the lung is being retrieved at xyz destination beat and or delhi the recipient is already on the table and they have already started uh taken the incision and started removing the lung and put them on the ecmo or a caterpillar bypass whatever the need may be so the two surgeries are happening actually parallel and it had the coldish time so if answer that lady's question is eight hours not more than that and so within how many hours of death can the lung can be used which death uh the do not transplant so uh so within how many hours of death can you drive this so the lung is two hours the liver is 20 minutes uh kidney is about an hour as long as two hours to us okay one and after two hours you need to get the lung out okay so uh uh so dr maida is again asking how is the donor lung brought is any special preservative used yeah so there is a preservative called as perfedex okay perfect that's like almost a global preservative now which has it's a mixture of dextron and chemicals so it it can maintain at and it's to be put in ice i mean there is a lung which is explanted put in perfect x ice and transferred wherever but as fast as possible because as dr kumar said the cold ischemia time has to be as less as possible lesser it is better it is better okay and so one more question that is being asked is in a lung transplant how much of the airways are included so apart from the lungs how much of the airway do we include in the right and the main they don't keep more than two or three cartilage rings that's the thing and the remainder of the right and the left main can you elaborate on the time of duration of stay in the hospital and so what is the procedure once the patient gets admitted so see what we are presently wanting to tell our friends here is that there is something called as referral first of all okay there is a referral referral means that the patient has to be assessed by the doctor who is seeing the primary consultant or the doctor who is going to see this patient and that patient is going to be referred to a transplant center where in takes a meeting of the palmologist of the surgeon the anaesthetist the intensivist the pulmonary rehab person and the microbiologist so there will be a meeting with at the radiologist of course to see whether this patient is fit for a transplant and there are multiple tests almost a day or two will go in getting the tests which will include many any any of you are interested in in contacting us we can pass on our email id to dr rucha and she can you know put it forth so there are those list it's a well printed list of tests which will be done including the lung functions or the blood gas and multiple blood tests there is a there is a thing called as counseling because we need to counsel the family it's not only the patient involved it's going to be the family counselling with the team and then the patient is going to be listed so there is a list referral and a listing today right now what we are telling talking is referral listing will happen when this multi-dimensional meeting happens and once the patient is listed with all the paraphernalia that she's or he is fit for surgery then it goes on a list of the transplant coordinators and then it can be a conventional listing like a regular listing or there can be a super urgent listing for that the patient need not wait in the hospital listing doesn't mean patient has to get admitted to the hospital listing means he may be called any moment the time the lung is available so that is one which is like you need to wait and there are other group of patients who are already admitted who are in the icu and who cannot be sent home and they are waiting for the lung to be there so they may be listed if the patient is a ventilator it goes into a super urgent place so that becomes the listed patients now if you are asking me how much is the time duration then if you are asking about the hospital stay of a lung transplant patient you should easily take in three weeks from the surgery onwards from the surgery three weeks okay it could be it could be say first week could be in the icu or first 10 days could be in the icu depending on how much hemodynamic stability is coming up and next two weeks could be in the ward just for rehabilitation physiotherapy and other things so that is how it is asking is the state listing statewide or country-wide yeah so we have a statewide listing which is a zonal transplant center and we have a country-wise listing and when we are offered a lung say for example if your patient is on a particular list say a routine list or a super urgent list there is a chronology where it is it is how it's followed like if i am doing the procedure in global hospital and there is a fatality in global hospital so that organ is offered to that in-house hospital first then it is offered to the zone that is maharashtra state and if there are no takers in maharashtra then it goes on to the country list so the listing happens is a central listing but at the same time it goes on to the maharastras the zonal list also in the country list also such that the chronology of preference is given as in-house state to country that somebody really asked that question well there are two ways to do the breathing lung uh one is a slightly old technology but there's only one place in india which has that is called xvo lung perfusion uh what they do is actually they attach the lung to an external ventilator so that they can keep it alive and actually perfuse the lung with the solution which can keep it alive and and it is not only to keep it alive but suspect lungs lungs which might not do well we are not sure what kind of lung it is they will put it on the xv that the evlp equipment and run the blood gases from the intravascular they will run the blood gases from the pulmonary artery they will run the blood gases from the pulmonary vein and see if the diffusion is absolutely fine there is other organ care system or thing also available where the lung is just put in that equipment and enough nutrients are given such that the lung is kept alive so it's quote unquote breathing lung a very expensive modality in india i found out that the ex vivo lung perfusion cost about four to six lakh rupees per session we need about two to four hours uh for the set of the lung um but uh abroad it's as good as the cost of lung transplantation because it is up absolutely about 50 000 so it it costs almost the cost of lung transplantation so it's very expensive thing but yes uh something which we can it's something like you start talking about it today and probably after a decade we might have it so it's an upcoming technique basically oh yes we we started talking about lung transplants so late that we are having cases later is asking sir from how many days after surgery can a patient undergo for chest physiotherapy so basically what is the post-operative management that uh post-separative care the patient needs so so firstly remember i mean it's very interesting to know that we are giving them normal lungs right so there are patients who have been extubated the next day surgery has been done and extubated the next day and the next day you move around then he says good morning sir you know that's that's that quick and that phenomenal response does happen so rehab or the physiotherapy is right from day two whatever it would be incentive parameters just breath holding because now patient doesn't need oxygen plus it doesn't need a ventilator because we have actually given them a normal lung so it is about the post-operative pain or the trauma and of course the lung inflating in a new thorax that but so we can start it right away from the next day onward not vigorous it would be of course graduated with monitoring what are the other post-operative care that we need to take post-operative management see remember now before we come to post-operative what is important for each of us to know is that we need to have a good amount of immunosuppression and the problems why many patients succumb would be also because of immunosuppression okay so we need to give them immunosuppressants now various institutes have different protocols methyl producilon remains the backbone of the immunosuppression but at some places it is tacrolimus at some places it is baxillium up so it would vary at different different centers but we need to start with an induction chemotherapy immediately and then continue with the steroids monitoring the level of if you are giving tacrolimus we need to monitor the levels and that is where we need to monitor the kidneys the sugars and their blood pressures so this is the basic idea of why we want to check frequently and how we monitor them frequently i think kumar you can tell them about the czech broncoscopies also like how many times we actually need to do that there are various different protocols but the one which is widely followed in our country is to do the first check bronchoscopy is one month and the next at three months uh there are centers in the west where they do first at 15 days then at one month two months and three months and they repeatedly look for uh rejection and uh so they keep doing the bronchoscopy and the transform kill biopsy to look for cellular rejection and even evidence of bronchitis obliterans which is very common in the transplant patients so uh in our country it's month one and month three in most of the centers the high volume centers in our country kumar there's a question which says put up and i think you are the best person to tell him can a transplant patient go to high altitude well uh i can i can just refer you to uh the university of vienna and you will be shocked to listen to this that they took 20 lung transplant patients to mount kilimanjaro at an altitude of 20 000 feet where the fio2 is only 12 so i suppose that answers your question and so what are the what is the prognosis post lung transplant survival rate and uh so so being very modest to us the question by that lady is very clear the results in survival rates as opposed to the rest of this we'll also be very realistic in answering yeah no what i want to tell dr shilpa is that your answer lies in which patient you are going to take and is that patient going to survive properly self-dependently for next five years think whether that is going to happen okay that is one so that's how your patient lands up into surgery now 75 to 80 percent is a five-year survival okay we are going to see to it that they are going to be persistent and they are going to live a life without an oxygen cylinder and without bipap and cpap and so on and so forth even in the indian patients as of what i have understood the rates have been almost comparable the patients though the number of volume is not as big as the west obviously we are talking of a smaller number of patients but yes their outcomes have been good the follow-ups have been good one year survival has been very nice so we are to look optimistically and i don't think we should compare at some point of time we have to start and have our own institute and experience that is very very important so saying that she herself is a lung transplantation so oh then then she is then please please tell her to tell her she would be telling us how's the experience yeah so dr mahadev is asking any research or studies on artificial lands and it refers to study spring it's all work in progress but there's this research in every practical field and artificial lungs are also being studied but we really don't have something which can be implanted inside a body and a person can walk independent not as yet but hope for that so what are the common complications post transplants that will comment so so the see that it's like when we talk of complication something going wrong in a patient what is the most dreaded problem in a patient post traumatic dropping oxygen suddenly patient desaturates second suddenly blood pressure drops third patients has a cardiac event and fourth patient starts getting fever these are the four logical things which create a remarkable shocking thing in the entire environment in the icu first will be dropping saturation so to put it in simple words we have an event called as a post graph this function okay post graph dysfunction where there is a sudden drop in the saturation almost as early as 24 hours 24 hours 24 hours the lungs may look white they may look like a rds or acute lung injury and in spite of a good pfio2 the po2 is less so the pf ratio goes down below 200 also so if you see white lungs host transplant sun and drop in saturation we consider this could be most likely a post transplant or post grafts dysfunction that is pgd that is the most rigid so the re perfusion which happens so that where we were talking of the cold ischemia that cold ischemia time can lead to more chances of a post graft dysfunction and we have to treat it like an ards almost 10 to 25 percent of our post transplant patient can go through a pgd which is definitely not good because it's like a no no for any transplant surgeon or transplant pulmonologist the other complications could be bleeding it could be related to a hemothorax it could be plural it could be a pneumothorax i mean related to the local things and of course later on there could be infections which come in where the patient you will get from the markers and the fever and the other localized patches of consolidation which come up where in what kumar was talking about bronchoscopy there that time your protocol may have to be tweaked that is different yeah we may have to tweak that and really go in earlier and so what is your experience about immunosuppression like what immunosuppressive therapy do you usually prefer in your patients basically over at our place we start with an anti-il2 inhibitor which is basilic's map methyl prednisolone is pulsed and its c ions we either give cyclosporine or tachylimus so these are the standard immunosuppressive protocols and whatever we use whether we use cyclosporine or whether you use uh acrylics we'll have to do frequent levels the trough levels have to be monitored so that it doesn't go below that and go on with that and so apart from me so actually my basic thought was do use do we start immunosuppression before we take the patient surgery or after uh is there any need to uh suppress the immunity before we start uh before they start this not a long time before there are patients where we may have to give them the anti-ill to inhibitors just about couple of hours before the surgery to induce them where we expect a pgd in a patient home and first of all somebody who's very sick who's on ventilator being bridged for an ecmo or has some potential complications like may have a sepsis so just this guy you'll have to give them uh the immune suppressant way before now if it's a stable patient who's not who is just waiting for a transplant and brought him from outside okay the donor has come so he comes in from home in an ambulance and gets transplant these are the ones who are not given any induction chemotherapy they are the ones who are just given methyl grams beforehand 500 milligrams broad spectrum antibiotics or gram positive cover should be yeah so so again see these are institute based protocols about what antibiotic cover to be given for a transplant i think each institute will have and by and large it would involve a gram negative cover very well either a pipracial intestine that's the commonest you know antibiotic which we use and of course we are going to do a lava center culture look take care of the biochemical markers the inflammatory markers and then gauge it so it's nothing like a fixed duration that we have to give for four days or five days but minimum we will have to continue definitely for at least uh two weeks of iv parenteral antibiotics we need to do that we need to keep a check because the patient is going to be in the hospital with a few of the tubes and wires inside we need to check that as well and one more thing is that we we have seen that you know our patients have got what we call epstein-barr virus or cmv and antibodies iggs which are positive so we need to also cover them with cyclovir as a profile actually so we have to take care of that this becomes important because you know when we say induction induction means there's a reperfusion happening on the table intra along which were bought and now they are being re-perfused after the anastomosis so just before the induction almost 500 milligrams of methyl prednisone one gram of methyl predispose has to be pulsed and then subsequently then you can make it at the end of say eight hours then 16 hours and 24 hours in the ic so we are going to pulse them with a good amount of steroids in fact the dosage which people get scared how can we give one gram and 125 and so so we need to keep a watch on these people definitely yeah and so like you mentioned that sometimes you might have to give anti uh fungus antivirus as well so doctor that's for sure not routinely unless you develop any secondary infection uh you know immediate postoperative period some fresh shadows or bronchoscopy showing you something or not as a matter of rooting please understand we have given a patient a new set of a potentially non-colonized lung so we really don't expect that these would have any other infections which will come up just suddenly so not routinely anti-fungus is asking would you pre-transplant physiotherapy or pulmonary rehabilitation improve outcomes post-transplant definitely definitely so in fact one of the questions which uh which was asked about osteoporosis you know why is it required why is it important same holds true for uh body mass and the nutrition the muscle building and the breathing technique so yes we have to teach them pre-operative also and i suppose all our patients whom we are talking today of end stage lung disease are already on pulmonary rehab it does it won't happen that they are going to be coming to us rather they are going to be used up all resources and now we are talking that okay you need to do is yes yes we have to do that we definitely need to do it because as as you're rightly pointing out it's a protocol because this is a post-transplant lung so we need to do a bronch we need to get the sample whenever we get the sample not only that a biopsy also because there could be a microbiologist may actually tell of detect earlier change and tell us that this this particular tissue is now undergoing some changes of a graft rejection so we need to have a good microbiologist so your answer is yes we need to do it is a protocol and that's why frequent bronchoscopies are going to be mandatory in some patients so how long do we continue the immune suppressor right now lifelong okay and uh so uh do we need to give uh like uh pcp profile access or something is there a special indication for that or only when we are suspecting respect only if you are suspected and so in your experience what is the five year survival in such patients post i think transplants has already answered that yeah yeah so so two things one is when we say you know the chemotherapy remember that or immunosuppressants what we are trying to see if we can use mycophenolate is one of the immunosuppressants it is a non-steroidal so after one year in fact we can keep keep the patients are microphenolic so the side effects which we are all worried about with steroids can be tried to be reduced okay so in case someone is worried about that then we can do that that is one second is the outcomes are definitely as i was talking about positive if you ask me what are the results in our patients no we have not yet crossed the five-year mark to answer your question of five-year survival individually yeah we are just uh what we call we have taken care that we have got a good team of surgeons who have got ample number of experience of 10 years 15 years and they have done n number of surgeries and the overall survival rate is found to be definitely somewhere between 70 to 75 percent by your survival so uh there's a question being asked that what are there any complications in maintaining negative pressure in transplants units are transparent units or transplant rooms i think what dr krishnan might be asking is about the keep the lung inflated or rejection and after how much time post-op can we be assured that the organ now won't be rejected oh you can you can get a rejection after a year that is why you need to do repeated bronchoscopies and even even on long term you need keep doing every three months or six months biopsies to look for delayed rejection so you have acute rejections you have delayed rejections and as in kidney by kidney transplant you get a rejection after two years chronic rejections can happen so and ultimately in all these patients the signs of rejections are going to be development of a new onset hypoxia or a nuanced shortness of breath or a new onset the development of chest shadows which in our setup will always have to rule out any infections and that is why when you do a bronchoscopy you do a lavash and you do a transfer biopsy and you run for infections and histopathology both to look for whether you are dealing with a infection or a rejection and one more addition to her answer to her question i'll tell you about the so there is a element called as a pulmonary edema because when we are re-perfusing we have to be careful that we don't overload with lot of fluids because it also presents with lot of fluffy shadows alveolar shadows and it's actually a pulmonary edema so acute yes post the post what we call as graph dysfunction pulmonary edema infections usually third day to sixth day these are the times and of course fever and things you need to go on throughout life we will have to keep a watch but let's be optimistic about this that the risk is going to be lesser because the lungs are going to be healthy uh so what are the chances that the transplanted lung might uh contact the same so for example if we if there's a patient of ind who we have done lung transplant so what are the chances that the transplanted lung might also develop an iod or if a patient of sarcoidosis or efficient of connective tissue disorder which have led to id such patient who's having transplant so uh i'll just take that uh question is that remember when we are talking here of ilds if you are talking of autoimmune what is the treatment for autoimmune dialysis it is immunosuppression isn't it so if you're talking about a systemic cause which can induce antibodies we are talking about too much of i would say a far-fetched thought first of all he has to be undergoing he is almost mortality is like 50 in the next two three years we are going to be uh he is going to be on immunosuppressant including steroids so we are going to take care of that as well of course there is a there are patients who undergo repeat or redo transplants okay it's not like one lung transplant means one lung so there are i i think we have seen a good number of series where there has been a re-transplant re-transplantation yeah so one of the very important and very big question is what about the cost of lung transplant is about 30 to 35 lakhs in most of the centers the lungs that are transplanted out with pleura without a fluoride no it's an armas it is it is explanted it's like a armas we don't strip off the pleura and put it separately it's an armas distraction and transplantation uh dr shilpa is asking so what are the long term complications apart from rejection and infection are there any other complications so there are basically three levels of complications one you have infection second you have rejection third you have bronchiolitis obliterans everything is going to revolve around these three so you can have an acute or a chronic rejection you can have early onset infections or late answer infections like tuberculosis because of long-term immunosuppression or fungal infections because of long-term immune suppression or you develop bronchiolitis obliterans which is going to be steroid responsive again so the complications revolve around these three uh so the best candidate for a lung transplant is those whose age is less than 55 years so the best best i can say we can of course have an extended criteria where up to 65 years also we can take in but we are here talking of a body which can sustain the amount of stress as well as the immunosuppression and the comorbid things which come along so there is there is definitely a partition about age so many of our ipf's patients and ilds are in the younger age group comparatively you talk about chp you talk of sarcoid sort of ctd ilds copd somewhat go a little age group wise higher around 60 to 64 also for that matter but you need to understand that lesser the age group with these diseases the outcome is better so dr shilpa is asking are there any other systemic complications uh apart from the lung uh that is what she is asking special kidneys or any chances of malignancies or any other systemic complications anything related to the immunosuppression so nothing specific related to transplant developing because of the transplant only because of the immunosuppression and so what is the role of a pulmonologist transplant like how like obviously the patient will need a lifelong consultation with this permanent that is for sure but it's like asking what is the role of a wife post-marriage there is apart from the pulmonologist there is no one else in the picture so uh okay so uh post surgery in the first couple of days or first in the first week what uh what parameters should a polymers be looking you see that patient and imagine or think about it that okay this patient is a candidate for electron right from that day and i'm not saying a pulmonologist see finally we we can't approach each and every patient in every state of the country neither the interiors of the maharashtra for that matter we are sitting in mumbai so it has to be awareness amongst all the doctors who are listening to us that they are the core group of extended transplant family if they get convinced then the patient is going to come back to them post transplant he's not going to stay at near just look at global all his life he's going to get discharged he's going to come and follow up with you and he's going to have a condo with the treatment physician the transplant physicians and the family so the role is extensive right from day of that then the interrupt evaluation post-operative immunosuppression checking whether there's an np infection or graft rejection and follow-ups so follow-ups if the physician who is seeing this patient is well-versed and capable enough he can have a video consult and just explain what is happening to the patient what is the outcome what is the scan that would be more than enough and we are all open to having more people come and meet us and interact so that each of them can become a transparent physician in their own respect so dr bridwe is asking any specific transplant criteria for younger patients in the age group 10 to 15 uh younger age what is asking any specific transplant criteria for younger patients younger yeah so there are no specific criteria for younger patients okay i think the only indications they would have is cystic fibrosis so that's what dr lina is asking is any experience in india of transplant and teenagers or younger population they have done it for primary pulmonary hypertension yes quite a few sure and so what is your experience through your journey of lung transplant so our journey has been really i would say overwhelming in terms of knowing people are interested in lung transplant all these years we were surprised how we were not in this and how people were not you know part of this journey but it's it's it's begun and it's taking off very well as i said in last two months we have been fortunate to be part of the team which did two lung transplants in mumbai and we have got a few patients who have been listed who have been referred to us from the different states and we are going very judiciously we are not in a rush in a patient our motto is that choose very carefully and i feel you know looking at the if i mean today i saw a patient of copd who was in the icu and he was on oxygen and i imagined him without oxygen without bipap walking to the washroom it's almost you feel it's a miracle happening you would never have expected that you go to a patient who is undergone a transplant post operative the next day and he is actually extubated in front of you the next day can you ever beat that for a ild patient or a copd patient coming off the ventilator the next day so it's it's almost you see some transformation which you never expected as a pulmonologist so so it is definitely fruitful i'm sure it's going to be good and i am optimistic that more and more patients will benefit from this so one more question by dr uh krishna uh uh as you said about retransplant are there any specific protocols yeah so retransplant has got definite protocol first of all we need to see why the patient needs a retransplant right if the normal lungs were affected like there are patients who have gone under i mean i'll tell you examples which i have seen not in india at this moment but patients were undergoing a lung transplant and got covered and then had developed post covered fibrosis and then underwent a second lung transplant okay so there have been instances and cases where we have seen not only in i mean of course this was in the elderly age group middle age to elderly as you so there are patients who develop this and we can always think in terms of that but not a very common entity it's not so common just given one example for that yeah and uh so can you tell us a little bit about the two recent lung transfers that you are saying so what were the cases and one of them i think kumar can say the other one i will talk yeah so uh one patient which we had was of interstitial lung disease who incidentally was on ventilator we had to put her on ecmo and uh it was done as a matter of last resort uh had we not done we had lost the patient uh the there was a call for a donor lung and fortunately we could get the patient on super urgent list and we could somehow manage the transplant the patient is running through currently a lot of complications and unfortunately uh the next day of transplant the patient had bleeding complication because the patient was on ecmo where they have to be apparent and that led to a preparatory bleed and we are still struggling through that so the transplant went off okay but we might have a negative outcome because of uh other bleeding complications which the patient had the other other patient was a case again it was extensive honeycombing cysts exchanges bronch cactuses fibrosis fibroblasts so usually we land up with these patients i mean these are the most common addresses we're seeing in mumbai or in any part of my you know yes the most important part i would like one question to be asking the the the people who are listening to us from where do we get the patients who are donate donors people i think the answer lies with all of you we need to have an awareness you know about donation and that's where we are lacking i think that's where i think we need to get more donors so that there is a better availability for the needy patients like the one case which dr kumar was saying she was on ecmo for a couple of days and family were very good understanding so we could also go ahead with that but not every person can survive those things they on more to avoid infections and hemodynamic instability is a task in itself we need a lot of donors yeah are there any other questions from the audience that you would like to ask i think you should be like you give some gift to dr shilpa bhatia she asked the most number of questions and dr knight who also asked a huge number of questions is there anything else you would like to cover or you would like to tell our audience no i i think what i it's yeah please go maria yeah so it's all about getting primed towards a very realistic possibility of getting a transplant done till this time and we've been equally guilty of that we always felt that lung transplant was something to be only talked of in movies or in a financial world not true it is very very realistic very very feasible and something which should be offered to deserving patients because everybody deserves a and uh unfortunately sitting in the commercial capital of the country we are lagging behind a very long way in this wonderful modality of but yes we need to put our best foot forward and you know i i always when patients come they have got three questions in their mind one kidnap that's the first question second is a patient these three questions so these three questions have to be you know in upfront we need to be confident have a conviction and explain to them that it's a major process it's a long term process and there are a good number of chances that the patient will actually live a good life and perhaps even trek to kilimanjaro so any other special electrode that you would like to share with the audience if kumar has any he can but but he he in fact he has got a lot of anecdotes he he he can actually take another one hour explaining how he flew from vienna to belgium on a jet like a mi6 in a small aircraft having only four seats and how he was taken through the green channel to get her explained done and how he came back i mean he can just go on it it was just an adrenaline rush and i i uh that was the day which was actually a life-changing moment that uh thank you i think we'll call it today thank you so much thank you so much for this amazing amazing session uh that was really very informative although i think the basics that one needs to know about lung transplant uh has been covered up very well uh this session and thank you both of you for this wonderful session i i just just one one thing i just just came as a after thought you know when that thing struck to me that how much would it cost and we had a package designed around 30 to 35 lakhs and when i told this patient of mine who underwent the transplant at masina their answer was sir you would have told me we would have agreed we are agreeing right now but you never told us all this time you know that was his answer it's not about we having and thought okay it will be too costly it's not possible you need to give as as kumar said rightly at least you offer whether to take it up whether to think it's still a step ahead there is a referral there is a listing there are discussions there are investigations and then sometimes out of 100 two patients three patients may actually be ready for it so let's start with that so i'm sorry again to interrupt but thank you so much thank you thank you so much thank you so much

BEING ATTENDED BY

Dr. Murtuza Zozwala & 880 others

SPEAKERS

dr. Salil Bendre

Dr. Salil Bendre

Pulmonologist & Transplant Physician, Nanavati Max Hospital, Global Hospital & Masina Hospital, Mumbai

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dr. Kumar Doshi

Dr. Kumar Doshi

Consultant Pulmonologist & Transplant Physician, Global Hospital & Masina Hospital, Mumbai

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. Salil Bendre

Dr. Salil Bendre

Pulmonologist & Transplant Physician, Nanavat...

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dr. Kumar Doshi

Dr. Kumar Doshi

Consultant Pulmonologist & Transplant Physici...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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