A lung transplant is an operation to remove and replace a diseased lung with a healthy human lung from a donor. A donor is usually a person who has died, but in some cases a living donor may be used (see box, below left).
Why a lung transplant is needed
Lung transplants are normally offered to people in the last stages of lung disease due to conditions such as:
- cystic fibrosis (where the lungs become clogged with thick, sticky mucus)
- emphysema (damage to the tiny air sacs in the lungs)
- pulmonary fibrosis
- lung cancer
Other less common conditions include:
- pulmonary vascular lung disease (disease of the blood vessels in the lungs)
- congenital lung disease (lung disease present from birth)
- inoperable cardiac-related lung disease (also known as Eisenmenger's syndrome)
If one or both of your lungs can no longer work efficiently and you are severely breathless when doing little or no exercise, with a reduced quality of life, you may need a lung transplant.
How common are lung transplants?
Around 5 lung transplants are carried out in Ireland each year, mainly on people in the final stages of lung disease caused by conditions such as cystic fibrosis and emphysema.
Very few children and teenagers have lung transplants, mainly because treatment for cystic fibrosis has improved over the years and lung transplants are not needed as often.
Around 70% of transplants are bilateral, which means both lungs are replaced. All patients with infection in their lungs, for example from cystic fibrosis, will need to have a bilateral lung transplant.
Most other transplants are single transplants.
A lung transplant is a challenging operation and, as with all surgery, there is a risk of complications. However, most transplant patients go on have a good quality of life. Failure of the new organ occurs in approximately one in five cases.
Having a lung transplant from living donors instead of from someone who has just died (a cadaveric donor) is sometimes possible. Transplants from living donors may be an option for:
- patients who cannot get one from someone who has died
- patients who are getting worse so quickly that they are likely to become too ill to have a transplant while they wait for a cadaveric donor
- critically ill children, for whom there is a particular shortage of suitable donors
Two living donors are usually required for one recipient. The lower lobe of the right lung is removed from one donor and the lower lobe of the left lung is removed from the other donor. Both lungs are then removed from the recipient and are replaced by the lung implants from the donors in a single operation.
Most people who receive lung transplants from living donors have cystic fibrosis. Most of the lung donors are parents, sisters, brothers or children of the recipients. The donors and the recipient need to be compatible in size and have matching blood groups.
If a lung transplant is thought to be an option for you, you will be referred for a transplant assessment, where tests will be carried out to find out whether a lung transplant is really your best option.
You will need to stay in hospital for a few days for a lung transplant assessment.
Tests are carried out to make sure your other major organs (heart, kidneys and liver) will function properly after the transplant. These may include blood tests and any of the following investigations:
- chest X-ray
- echocardiogram, which checks how well your heart is pumping
- electrocardiogram (ECG), which records the electrical activity of your heart
- angiogram, an X-ray that takes pictures of the blood flow in the vessels of your lungs
During the assessment, you will have the chance to meet members of the transplant team and ask any questions. The transplant co-ordinator (your main point of contact) will talk to you and your family about what happens, and the risks involved in a lung transplant.
When the assessment is complete, it will be decided whether a lung transplant is suitable for you and if it is the best option.
It may be decided that:
- You should go on the active waiting list (which means you could be called for a transplant at any time).
- A transplant is suitable for you, but your condition is not severe enough. You will be put on a provisional waiting list, and if your condition worsens, you will then be put on the active waiting list.
- You need more investigations or treatment before a decision can be reached.
- A transplant is not suitable for you. In this case, the assessment team will explain why and offer you other options, such as drug therapy or alternative surgery.
- You need a second opinion from a different transplant centre.
Why you might be unsuitable for a lung transplant
The supply of donor lungs is limited, which means there are more people who would benefit from a transplant than there are donor lungs. You may be considered unsuitable if:
- You have not complied with previous advice or been reliable, for example you have not given up smoking despite advice to do so, you have a poor history of taking prescribed medication or you have missed hospital appointments.
- Your other organs, such as your liver or kidneys, do not function well and, therefore, may fail after the stresses of the transplant operation.
- Your lung disease is too advanced, so it is thought that you are too weak to survive surgery.
The waiting list
Once you are on the active waiting list, the transplant centre may give you a pager so you can be contacted at short notice.
The length of time you will have to wait will depend on your blood group, donor availability and how many other patients are on the list (and how urgent their cases are).
While you wait, you will be cared for by the doctor who referred you to the transplant centre. Your doctor will keep the transplant team updated with changes to your condition. Sometimes, another assessment is necessary to make sure you are still suitable for transplant.
Generally, your transplant team will be given relatively short notice of donor organs, so will have to move swiftly. When a suitable donor is found, you will normally be in hospital ready for your transplant within six to eight hours (see box, top right). If you live a long way from a transplant centre, you will be flown to the centre or taken by ambulance.
Your transplant team
Your transplant team will include:
- intensive care specialists
- a transplant nurse
- a transplant co-ordinator
Getting the call
When a suitable donor lung is found, the transplant centre will contact you and ask you to go to the centre.
When you hear from the transplant centre:
- do not eat or drink anything
- take all current medicines with you
- take a bag of clothes and essentials for your stay in hospital
At the transplant centre, you will be reassessed quickly to make sure that no new medical conditions have developed. At the same time, a second medical team will examine the donor lungs.
When the medical team have confirmed that the lungs are suitable, you will be given a general anaesthetic (put to sleep) in preparation for the transplant. The procedure must be carried out as quickly as possible for the transplant to have the best chance of success.
A lung transplant normally takes six to eight hours. After you have had your general anaesthetic, a breathing tube will be placed down your throat so your lungs can be ventilated.
When you are fully asleep, you will be laid on your back on the operating table with your arms at your sides. Your chest is opened and preparations are made to remove the diseased lung or lungs.
If your circulation looks like it will need help, a cardiopulmonary bypass machine (heart and lung machine) may be used to keep your blood circulating during the operation.
The old lung or lungs are removed and the new lung is sewn into place. When the transplant team are confident that the new lung is working efficiently, the chest is closed and you will be taken off the bypass machine.
Tubes are left in the chest to drain any build-up of blood and fluid, and these will stay in place for several days.
You will be taken to the intensive care unit, where further tubes will be attached to supply your body with fluids and drugs and drain urine from your bladder.
The risks of a lung transplant include:
- early failure of the new lungs
- rejection of the donor organ (see box, right)
- side effects of the immunosuppressant drugs (medicines taken to lower the chance of rejection), including a significant decrease of kidney function
- narrowing of the air passages of the new lung (a form of long-term rejection)
Also, taking immunosuppressant medication can make certain types of cancer more likely.
What is rejection?
Rejection is a normal reaction of the body. When a new organ is transplanted, your body’s immune system sees it as a threat and produces antibodies against it, which can stop it from working properly.
Immunosuppressant drugs (which weaken your immune system) are given during and after your transplant and must be taken for life, so your body will not reject your new lung.
After surgery, you will remain in the intensive care unit for around four to seven days. You will have an epidural (a type of local anaesthetic) for pain relief and will be connected to a ventilator to help your breathing.
You will be carefully monitored so the transplant team can check that your body is accepting the new organ. This monitoring will include regular lung X-rays and lung biopsies (where tissue samples are taken).
The transplant team can determine whether your body is rejecting the lung from the biopsy results. If it is, additional treatment will be given to reverse the process.
When your condition is stable, you will be moved to a high-dependency ward, where you will stay for one or two weeks.
You will probably be discharged from hospital two to three weeks after surgery and asked to stay near the transplant centre for one month.
For the second month, you will need to visit every week or four weeks. After that, for the rest of your life, you will have a blood test every six weeks and will be seen at the transplant centre every three months.
Getting back to normal
It normally takes three to six months to fully recover from transplant surgery. In some cases, it may take longer.
For the first six weeks after surgery, you need to avoid pushing, pulling or lifting anything heavy. You will be encouraged to take part in a rehabilitation programme involving exercises to build up your strength.
You should be able to drive again four to six weeks after your transplant, once your chest wound has healed and you feel well enough.
Depending on the type of job you do, you will be able to return to work around three months after surgery.
You will need to take immunosuppressant drugs, which weaken your immune system so your body does not try to reject the new organ. However, these drugs also reduce your ability to fight infections and can affect the functioning of your kidneys.
You will have your first dose of immunosuppressants during your operation, and then immediately after surgery. For the next few months, you will need to take high doses of immunosuppressant drugs. You will need to take these for the rest of your life (although the high dosage may be gradually reduced).
If you do not take immunosuppressants, your transplant will fail.