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BACKGROUND: The development of severe primary graft dysfunction (PGD) is a risk factor for perioperative death following lung transplantation. Our goal is to improve the predictive value of the earliest Pao(2)/fraction of inspired oxygen (P/F) measurements that gauge PGD severity. METHODS: We identified 96 patients with severe PGD (P/F < 200) at ICU arrival through a retrospective review of 431 lung transplants performed at our institution from 1992 to 2005. The P/F trend, represented as quartiles of the 12-h percentage change in P/F, was analyzed using multivariate logistic regression. Study outcomes were 90-day death and long-term survival. RESULTS: The median percentage change in P/F over 12 h was + 52% (interquartile range, +20 to 90%). We observed the highest early mortality among those in the lowest quartile of the P/F trend (an increase in P/F

Objectives: To compare the detection of bronchiolitis obliterans syndrome (BOS) in lung transplant recipients by clinic pulmonary function laboratory measurement and home spirometry., Design: The subjects served as their own control group., Setting: A university-based thoracic transplant center., Subjects: Forty-five lung transplant recipients (26 women and 19 men; average +/- SD age, 47.7+/-11.4 years old at the time of transplantation). Lung function declined to at least BOS stage 1 in 17 of the 45 subjects., Measurements: All subjects were participants in a home monitoring program utilizing home spirometry measurements. Clinic spirometry and home spirometry measurements were collected concurrently. The determinations of BOS staging were based on home and clinic FEV1 values using retrospective analysis and development of the home-based BOS staging algorithm., Results: BOS stage 1 was detected an average of 341 to 276 days earlier with home spirometry than with clinic pulmonary function testing in the 17 subjects who had a pulmonary decline to BOS stage 1, depending on the persistence of the decline (1 day or 3 days, respectively). The difference in BOS detection time was statistically significant for both persistence requirements (p < 0.001)., Conclusions: Home spirometry detects pulmonary decline earlier than clinic spirometry; home spirometry can be a reliable and safe alternative to frequent pulmonary function testing in lung recipients.

Background: Invasive Aspergillus is an important cause of morbidity and mortality among lung transplant recipients. The diagnosis can be difficult and treatment is often unsuccessful so many centers preemptively treat all Aspergillus airway isolates to prevent invasive disease. This approach is untested as little is known about the relationship between Aspergillus airway colonization and invasive disease. This study was undertaken to evaluate the incidence of Aspergillus airway colonization after lung transplantation and the risk of invasive disease after colonization., Design: All cultures and histologic specimens obtained from a consecutive series of 151 lung transplant cases were reviewed for the presence of Aspergillus and compared with clinical data., Results: Aspergillus was isolated from the airway in 69 (46%) of 151 transplant recipients. Invasive disease occurred in five cases and was uniformly fatal, accounting for 13% of all posttransplant deaths. Results of cytologic examination of BAL fluid were normal in all cases of invasive disease and cultures were positive in only one of five patients prior to invasion. Invasive disease occurred exclusively in patients who died or were colonized with Aspergillus fumigatus within the first 6 months posttransplant. Patients growing A. fumigatus from the airway during the first 6 months were 11 times more likely to develop invasive disease relative to those not colonized., Conclusion: Aspergillus airway colonization after lung transplantation is common and in most cases, transient. In contrast, invasive Aspergillus disease is less common, but fatal. Bronchoscopy with cytologic examination and fungal culture are not sensitive or timely predictors of invasive disease. Invasive Aspergillus occurred only in patients initially colonized with A. fumigatus within the first 6 months posttransplant. A trial of empiric anti-Aspergillus therapy limited to the first 6 months posttransplant may be warranted.

Study Objectives: Obliterative bronchiolitis (OB) is a major factor limiting long-term survival after lung transplantation. The etiology of this disease process remains incompletely understood. Several risk factors have been identified previously, including acute rejection and cytomegalovirus pneumonitis. The purpose of this study was to evaluate primary pulmonary hypertension (PPH) as a potential risk factor for the development of OB after lung transplantation., Design and Patients: We retrospectively analyzed 107 lung allograft recipients (28 heart-lung, 18 bilateral sequential single-lung, 61 single-lung) who underwent transplantation between May 1, 1986, and April 30, 1994, and survived at least 3 months posttransplant. Mean follow-up posttransplant was 28.6 months (range, 3.5 to 99 months). Actuarial survival was estimated for patients with or without PPH and for those who did or did not develop OB., Results: In all, 25 patients (23.4%) developed OB, diagnosed by strict histologic criteria. Of 23 patients with PPH, 9 (39.1%) developed OB, compared with 16 (19.0%) of 84 patients without PPH (p = 0.044). Actuarial survival, sex, time on waiting list, and follow-up posttransplant were not significantly different between groups. PPH was the major determinant for the development of OB (p = 0.0468) when evaluating PPH and cytomegalovirus pneumonitis together as risk factors. Patients with PPH also developed OB significantly earlier posttransplant, compared with patients with other primary disease (p = 0.05)., Conclusions: Patients with PPH who undergo lung transplantation are at increased risk for the development of OB, which also occurs at a shorter time interval posttransplant. This subgroup needs aggressive monitoring for diagnosis and treatment of OB.

Study Objective: Health status and quality of life (QOL) in lung transplant candidates and recipients were compared to determine the impact of transplantation, and whether recipients experience continued improvements in the years after transplant surgery., Design: Two patient groups, adult lung transplant candidates (n = 44) and adult lung transplant recipients (n = 54), completed self-report QOL questionnaires. Eighteen of the 54 recipients completed QOL questionnaires on two occasions, about 18 months apart, after lung transplant. The questionnaire included the Medical Outcome Study Health Survey (MOS 20) that assesses six dimensions of health-related QOL: physical, role and social function, mental health, health perceptions and bodily pain, as well as a self-report Karnofsky Index and other indicators of QOL., Setting: University medical center transplant service., Results: Compared with candidates, recipients reported higher levels of happiness and more satisfaction with their life and their health. They also reported better function on the Karnofsky Index and in every MOS 20 dimension (p < 0.0001), except pain. No significant differences were found in comparisons among recipients, grouped by the time since their transplant. Eighteen recipients completed two QOL questionnaires after transplant. No significant differences were found between the earlier (median, 11 months) and later (median, 29 months) QOL responses for this group overall. However, recipients (n = 5) who developed obliterative bronchiolitis between assessments showed decrements in their health-related QOL. Dimensions particularly affected were physical and social functioning and bodily pain., Conclusions: Dramatic improvements in health status and QOL occur after successful lung transplant and remain stable over time. Obliterative bronchiolitis results in notable QOL reductions.

Congestive heart failure (CHF) has been associated with the development of restrictive ventilatory abnormalities and decreased pulmonary diffusing capacity. Whether these physiologic changes reflect permanent alterations of lung anatomy or result solely from potentially reversible alterations of lung water is not known. To examine this issue, we reviewed the pulmonary function tests (PFTs) and cardiac catheterization data from recipients of successful heart transplants prior to and 1 year after transplantation. Thirty-eight patients met the inclusion criteria (median age, 52 years). The median duration of symptomatic CHF prior to transplantation was 22 months (range, 3 to 72 months). After transplantation, spirometry revealed an improvement in FEV1 from 75.8 +/- 3.5 to 99.1 +/- 2.8 percent of predicted and FVC from 81.3 +/- 3.7 to 101.6 +/- 3.0 percent of predicted (p < 0.001). The FEV1/FVC ratio remained unchanged at 80 percent. Nonsmokers and former smokers had similar improvements in spirometry after transplantation. The TLC improved from 91.1 +/- 3.3 to 105.5 +/- 2.9 percent of predicted (p < 0.001); this improvement was due to an increase in inspiratory capacity. Diffusing capacity for carbon monoxide was decreased before transplantation and showed a small decline after transplantation from 82.3 +/- 3.2 to 76.8 +/- 2.6 percent of predicted (p < 0.05). After correction of severe CHF by cardiac transplantation, normalization of FEV1, FVC, and TLC can be anticipated. Diffusing capacity, however, may actually decline after transplantation.

Lung transplantation has resulted in dramatic functional improvement in patients with end-stage pulmonary diseases. Among the complications of lung transplantation are dehiscence and stenosis at the site of the bronchial or tracheal anastomosis. In this case report, we describe a single lung transplant recipient in whom partial bronchial dehiscence, followed by exuberant growth of granulation tissue, resulted in obstruction of the bronchial lumen. After mechanical dilation failed to produce lasting relief of bronchial obstruction, a novel approach to this problem was successfully employed: YAG laser phototherapy was used to remove obstructing granulation tissue, followed by application of a preparation derived from autologous blood platelets to promote epithelialization of the bronchial anastomosis. The bronchus remains patent and fully epithelialized six months after therapy.

Pulmonary emphysema results in hyperinflation of the lungs and concomitant changes in the configuration of the thoracic cavity. We describe a patient who underwent bilateral lung transplantation for emphysema due to alpha 1 antitrypsin deficiency. Dramatic changes in chest dimensions and configuration occurred following transplantation, demonstrating the dynamic and reversible nature of the thoracic cavity abnormalities of emphysema.