16 - Medical management

Summary

Introduction and general considerations

No procedure in medicine depends as much as lung transplantation does on a team approach from various disciplines including surgeons, respiratory physicians, microbiologists, physiotherapists and nurses if success is to be achieved. To minimize any confusion and optimize patient care it is essential to develop standard treatment protocols and to organize regular multidisciplinary ward rounds on a daily basis.

Although occasionally patients are extubated in the operating theatre, the majority of patients are extubated between 12 and 24 hours after surgery. They arrive in the intensive care unit mechanically ventilated and the approach to ventilation is to minimize the risk of trauma whilst ensuring adequate oxygenation on as low a fraction of inspired oxygen as possible. A low positive end-expiratory pressure of 5 cm H₂O is usually employed. A degree of lung vascular injury resulting from factors in the donor lung, method of lung preservation and ischaemia–reperfusion injury occurs in all lungs but the severity varies considerably. Brain death itself induces systemic and local cytokine responses in the donor lungs. A severe injury is manifest by parenchymal infiltrates and significant hypoxaemia. This may require careful ventilatory management, diuresis and the use of inhaled nitric oxide. When diuretics are used it is important to ensure that the circulating blood volume is not reduced to a degree that impairs tissue perfusion. It is also important to avoid electrolyte abnormalities and uraemia. Chest drains are monitored for evidence of mediastinal or pleural haemorrhage and if this is persistent or massive, re-exploration is required. The frequency of surgical re-exploration for bleeding has decreased markedly over the years.