When a potential lung donor is identified, a Penn lung transplant surgeon is sent to evaluate the lungs and the recipient patient is called and asked to come to the hospital. Because time is of the essence, patients are called to the hospital before the surgeon has made the final determination as to whether the lung(s) are acceptable for transplant. If the donor lungs meet transplant criteria, the transplant surgery proceeds. But if for any reason the lungs are determined to be unsuitable, the surgery is cancelled. In this case, the transplant candidate retains his or her position on the waiting list and continues to await transplantation.
Every transplant involves two operations: the first operation involves a transplant surgeon from Penn who goes to the donor's hospital and recovers the lungs. The other operation transplants those lungs into the patient.
Lung transplant surgery typically takes up to six hours, though patients are usually in the OR much longer. Before the surgery begins, care is provided in the operating room by nurses and an anesthesiologist. They place intravenous lines and provide medication to help patients relax. The surgery does not begin until the surgeon recovering the donor lungs calls to report that the lungs are healthy and in good condition to transplant. Once the lungs have been accepted, patients are prepared for transplant surgery.
During the surgery, the new lung is placed in the chest and connected to the bronchus (airway), the pulmonary artery (the vessel that carries blood to the lungs) and two pulmonary veins (which carry blood from the lungs back to the heart) to each lung. The surgical incision is either in the middle of chest or on the side of the chest under the arm.
Surgical Intensive Care Unit (SICU)
Patients awaken from surgery in the surgical intensive care unit (SICU) at the Hospital of the University of Pennsylvania. They see many tubes attached to them and medical apparatus around the bed.
A breathing tube in the mouth and into the airway is connected to a ventilator. This assists patients with breathing during surgery and while waking up until they are able to do the work of breathing on their own. They are unable to talk while the tube is in place. The ICU staff and the transplant team are very good at communicating with patients and understanding their needs after surgery. Typically, the breathing tube is removed when patients are fully awake from the anesthesia, which can take from two to three days after the surgery.
Soft restraints are placed on the wrists to keep patients from accidentally pulling on the tubes as they wake up. The restraints are removed once patients are awake and able to follow instructions.
Patients receive several medications to support their new lung in the first few days following transplant. These medications are delivered through an intravenous (IV) line and will slowly be changed to pill form over the next several days.
Catheters (tubes) are placed in the neck, arms and wrist to assist with monitoring pressure and blood flow through the heart, lungs and rest of the body. All of the tubes and catheters are removed as patients recover.
Two chest tubes are placed in each transplanted lung. So, a single lung transplant patient has two tubes and a bilateral (double) lung transplant patient has four chest tubes. These tubes are placed during surgery and are intended to drain air and fluid from the area around the new lung(s) inside the chest, allowing the lung(s) to fully expand.
A bladder catheter is in place to drain urine. Early post-operatively, urine output is closely monitored to make sure that kidney function is intact. Once a patient is able to move independently, this tube is removed.
Patients who spend more than a couple hours a day in bed are at risk to develop blood clots in their legs. To prevent this, compression boots are applied to the lower legs. These devices gently inflate and deflate (like a blood pressure cuff) to promote good blood movement.
As soon as patients are able to participate in physical therapy, the pulmonary rehabilitation team begins to work with them. Typically, this work begins in the ICU and continues throughout the hospitalization and beyond.
Most people are in the intensive care unit for three to five days. A decision to advance a patient to the lung transplant floor is based on the individual's condition.
After SICU, Step Down
Transplant patients have a private room while in the hospital to protect them from infection. Although family and friends may visit, they are asked to avoid visiting if they have a cold, fever or feel sick. Anyone entering the room must first wash their hands.
Patients are encouraged to increase their physical activity after they move to the step-down unit. Their muscles may be weak and they need to begin exercising in small ways immediately following surgery. A physical therapist and respiratory therapist evaluate every patient’s exercise abilities and conduct physical therapy sessions daily. This is the beginning of the journey to recovery and the return to physical fitness.
Patients are assigned a primary nurse, who works with the lung transplant team to educate patients and their families about medications, lifestyle and activity. The patient’s primary care givers are asked to attend the teaching sessions with the lung transplant coordinator.
Before discharge, a bronchoscopy is performed to make sure the surgical connection of the air tubes (bronchus) are healing well and free of infection.
An average length of stay in the hospital after transplant is 10 to 14 days.