Improving Patient Outcomes After Lung Transplantation

Innovations in Pulmonology, Critical Care & Sleep Medicine | Summer 2024

As with most transplantable organs, the number of lung transplants is on the rise nationwide. According to the United Network for Organ Sharing (UNOS), 197 people underwent lung transplants in Ohio between April 2023 and April 2024. New protocols and technologies for lung transplant patients at University Hospitals Cleveland Medical Center places the hospital on par with much larger transplant centers.

Silpa Kilaru, MD

Silpa Kilaru, MD, pulmonologist in the Division of Pulmonary, Critical Care and Sleep Medicine at University Hospitals Cleveland Medical Center, and Medical Director of Lung Transplantation at University Hospitals Transplant Institute, highlights the program’s latest enhancements.

Diaphragm pacing. One or both diaphragms may not work immediately after transplantation, although they usually recover over time with aggressive rehabilitation. By placing wires at the time of transplantation, clinicians can externally pace the diaphragms so patients will have better diaphragmatic functionality down the road and recover sooner after their transplant. University Hospitals Cleveland Medical Center pioneered this technology and has more clinical experience with it than any hospital in the country.

Less invasive surgical techniques. Traditional lung transplant surgery requires a large clamshell incision, putting patients at higher risk of post-operative infections and wound dehiscence. “We are implementing surgical techniques such as median sternotomies and bilateral thoracotomies which use smaller incisions under the breastbone,” Dr. Kilaru says. “While it is still a major surgery, these techniques help patients heal faster and need fewer pain medications during recovery.”

Simultaneous cardiac surgery. “Many of our lung transplant patients are quite sick at the time of evaluation and have cardiac comorbidities, such as coronary artery disease or valvular abnormalities,” she says. “We offer concomitant cardiac bypass or valve repair at the time of transplantation. This allows patients to be listed for transplant in a timelier fashion and have their cardiac issues addressed at time of transplant, instead of being on Plavix for three to six months after a cardiac stent placement, which lengthens their time to transplant.”

Ex Vivo Lung Perfusion. Some donated lungs are marginal at harvest, but Ex Vivo Lung Perfusion, an alternative to cold storage, maintains the organ’s physiologic state, significantly improving the condition of donor lungs before transplantation, Dr. Kilaru says. “UH approved this procedure in July 2023. This will hopefully make it possible to perform more life-saving transplants in the future with comparable survival rates.”

New lung transplant monitoring. Bronchoscopy has long been the gold standard for monitoring lung transplant patients to investigate for signs of rejection or infection. Patients undergo bronchoscopy every two months for the first two years after transplant. AlloSure is a new FDA approved dd-cfDNA test for lung transplant recipients. It provides a noninvasive way to test for injury in the allograft, such as infection or rejection, and helps reduce the need for surveillance bronchoscopies.

Induction. “Post-operative induction reduces the risk of future organ rejection and is used regularly at larger transplant centers,” says Dr. Kilaru. “UH Cleveland Medical Center has revised its protocol, so patients receive their first medication dose of Simulect in the OR after surgery, and the second dose four days post-op.”

Early mobilization and updated immunosuppression guidelines. Lung transplant patients are at much higher risk of blood clots than other patients, says Dr. Kilaru. Doppler ultrasound of patients’ upper and lower extremities conducted two weeks postoperatively and physical therapy started immediately after surgery lowers this risk significantly. UH standard guidelines have also been revised to provide improved prophylaxis for potential fungal, viral and bacterial infections post-transplant.

Aspiration precautions. Aspiration risk is extremely high immediately after lung transplantation and is often not recognized. It ultimately may lead to allograft failure and is a significant cause of post-transplant morbidity and mortality. “We place feeding tubes while patients are still on a ventilator in the ICU to mitigate this risk,” Dr. Kilaru says. “After seven to 10 days, we conduct a swallow study. If the patient can safely pass the test without evidence of aspiration, we then slowly start them on a diet. We continue to closely monitor patients for signs of aspiration and quickly investigate further if needed. This is standard at UH and overall we have seen better outcomes with our patients.”

“UH Cleveland Medical Center has made significant advances in the lung transplant program over the last year,” Dr. Kilaru says. “We’re continually incorporating new technologies into our clinical practice and updating our protocols to help ensure excellent patient outcomes and, ultimately, patient satisfaction. Our team is continually growing, and we offer a truly multidisciplinary approach to patient care. Our goal is for all our patients to have happy and healthy lives post-transplant.”

For more information about post-transplant lung care or for referrals, call Dr. Kilaru at 216-844-2707.

Contributing Expert:
Silpa Kilaru, MD
Medical Director of Lung Transplantation
University Hospitals Transplant Institute
Clinical Associate Professor
Case Western Reserve University School of Medicine