The evaluation process for lung transplantation includes three major areas: medical, surgical, and psychosocial. Candidates who are identified early on with no impediments to transplant may complete the evaluation process within one month. The Henry Ford Lung Transplant Program has pioneered the "FAST Track" process for evaluating lung transplant candidates. Qualifying lung transplant candidates may have their entire evaluation completed in two weeks or less. The majority of the extensive testing and evaluation process is done within a timeframe as short as two days, so this rigorous process is not appropriate for all candidates. The physician and transplant coordinator will determine the appropriate testing strategy with the patient. The coordinator will provide a complete testing schedule to the patient and will facilitate the patient's completion of this process.
The evaluation process usually begins with a referral by a physician to our program, followed by an evaluation by a pulmonologist member of the Lung Transplant Team. Other times it begins with a phone or internet inquiry by a patient or a patient's loved one. In that case, a Lung Transplant Coordinator or other member of the team will answer the initial questions, and if appropriate will schedule an appointment with a pulmonologist on the Lung Transplant Team.
At the initial appointment, the patient will meet the transplant physician and coordinator. A complete history and physical examination is done, and the patient and family will have an opportunity to ask questions. Subsequently, the patient and physician establish goals and a plan for follow-up is made. It may be decided at this point that lung transplant is not the best option for some people. In these cases, appropriate recommendations will be made to the patient and the referring physician. If so desired, referral to another of the advanced lung disease clinics at Henry Ford Hospital will be made. For patients admitted to the Lung Transplant Program, it will be time to meet many other members of the lung transplant team.
The Henry Ford Lung Transplant Team:
Transplant Physician, a pulmonologist specializing in lung disease and transplantation.
Transplant Nurse Coordinator, the patient's liaison to the medical community.
Transplant Surgeon, a cardiothoracic surgeon with special training in transplantation.
Transplant Infectious Disease Specialist, an Internal Medicine physician with specialized interest and training in infectious disease as it relates to the immunosuppressed transplant patient.
Pulmonary Rehabilitation Coordinator, a nurse who heads our pulmonary rehabilitation team.
Transplant Psychologist, who is part of the psychosocial evaluation and treatment team.
Transplant Social Worker, who with the patient identifies problems and solutions of social impact related to the transplant experience.
Transplant Financial Consultant, who helps determine if adequate resources are in place, and to provide information for those who need to seek additional financial solutions.
Transplant Registered Dietician, who helps develop nutritional solutions to solve problems related to body weights that are too high or too low.
Transplant Pastoral Care Person, one of a team who help us provide for the patient's spiritual and emotional needs.
The transplant patient will also meet other members of the team in the post-operative setting. These include a staff of dedicated, compassionate people on our surgical team, in our Surgical Intensive Care Unit, and on our step-down unit and pulmonary medicine hospital units.
The patient's initial medical examination and tests will include:
A history and physical examination to be performed by the transplant pulmonologist
Blood work and cultures:
Blood and HLA typing (determines the blood type and blood antigens present)
HIV testing (tests for the AIDS virus)
Hepatitis A, B, C titers (tests for viruses that infect the liver)
CMV, EBV, HSV and toxoplasmosis titers (tests for viruses that many people are infected with over a lifetime)
CBC, coagulation profile, and general biochemical profile (simple blood and biochemical screening tests)
Sputum for culture (tests for bacteria and fungi in the lungs)
PSA for male patients > 55 years of age (tests for prostate cancer)
Skin tests for TB with controls (tests for exposure to tuberculosis)
Colonoscopy (to check for cancer and to remove polyps)
Mammogram (to check for cancer)
PAP Smear (to check for dysplasia, cancer and cancer risks)
Urine sample (to check for protein and infections)
Chest x-ray
High-resolution computed tomography of the chest (a detailed picture of the lungs)
Electrocardiogram (a tracing of the electrical activity of the heart)
Echocardiogram (an ultrasound picture of the heart)
Pulmonary function and exercise testing including:
Spirometry (measurement of the ability to move air in and out of the lungs)
Lung volumes (measurement of the size of the lungs)
Diffusing capacity (measurement of the ability of oxygen to move or transfer between the air sacs and the blood vessels in the lungs)
Arterial blood gases (measurement of the oxygen and carbon dioxide levels in the blood)
Ventilation/perfusion scan (a measurement of blood and air flow to the right and left lungs)
Bone densitometry (measurement of the calcium in the bones)
Right and left cardiac catheterizations are the last tests scheduled. This provides direct measurement of the pressures generated by the heart and will also detect coronary artery disease. This test may be scheduled after the patient is accepted into the lung transplant program.
All of these tests are conducted to measure lung and other major organ function and to rule out any existing conditions that could hinder a successful surgery and recovery. Also, it is important to know that transplant patients must have their immune systems suppressed after surgery. This helps to eliminate the body's rejection of the new lungs, but also possess a higher risk of infection and cancer. For this reason, it is important to know if these disease states are present. During the initial history and physical or testing phase, certain findings may prevent rapid conclusion of testing, and additional consultations and testing and/or pulmonary rehabilitation may be indicated. In all cases, the Transplant Coordinator will guide each patient through the process, providing reassurance, direction and information.
A psychosocial evaluation is performed by a psychologist and social worker to explore existing support systems and identify any psychosocial concerns that could negatively impact the transplant process. All support candidates must have adequate psychosocial resources in place prior to transplantation. They will be asked to bring together their family members or loved ones who will be participating in the aftercare of the patient. At Henry Ford Hospital, we believe transplant is a "team activity."
Transplant candidates are tested for alcohol, nicotine, and illicit drug use. The use of these items can delay or eliminate a person's candidacy.
The results of the patient's examination and tests will be reviewed the Multidisciplinary Lung Transplant Committee which makes a collective decision regarding the candidacy for transplant. That committee is made up of the team members listed on the Lung Transplant Team. All voices are heard and all concerns are addressed to insure that the proposed therapy is appropriate for the transplant candidate. The decision is then shared with the patient, the family, and the referring physician.
The decision to accept or deny the option for lung transplantation ultimately resides with the well-informed patient. If a lung transplantation option is offered to the candidate, the patient will be provided with the most up-to-date survival statistics for Henry Ford and other transplant centers in the nation, be informed of the options for obtaining donor organs, and will be reminded of any stipulations or limitations that exist and of their option to be listed at another center instead of Henry Ford Hospital. The informed candidate is asked to sign agreements declaring their understanding of the information provided to them, and their intention to follow therapeutic and social directions as given by the Transplant Team.
Before the Transplant
Once a patient is accepted to the Henry Ford Lung Transplant Program, the process of acquiring a donor organ begins. All patients are added to the national United Network for Organ Sharing (UNOS) lung transplant wait list. This listing system uses various criteria to evaluate a person's risk of dying without transplant and likelihood of surviving with one. A score is devised and each person is prioritized on the list of those awaiting donor organs. The length of time a person will wait before a transplant organ is available cannot be known in advance. Depending on blood type, body size, a person's location and other factors, even a person with a high priority for a donor organ may not receive one. The average waiting time for lung transplantation at Henry Ford Hospital has been consistently far lower than the national wait time as reported by UNOS.
The Henry Ford Lung Transplant Team will closely follow the transplant patient throughout the entire waiting process. Patients may be instructed to begin or continue a pulmonary rehabilitation program to maintain the highest possible level of cardiovascular and body health. Additional education and support will be given, and will focus on the proper use of medication, disease management, and family issues. Every patient is given a pager and will be notified as soon as a donor organ becomes available. The patient's entrance into the Transplant Living Community of Henry Ford Hospital begins before transplant and continues for life. Transplant is a team effort and no one can "go it alone." The transplant nurse coordinator is available by pager 24 hours daily for medical emergencies and uncertainties related to lung health or transplantation.
During the Transplant Hospital Stay
Once a donor organ becomes available, the patient is notified by phone or pager by the Transplant Coordinator. Upon arrival to Henry Ford Hospital, the coordinator will help the patient undergo standard preoperative tests and prepare for surgery. The coordinator will be nearby throughout the pre-operative phase and the surgery, to assist the patient and loved ones as needed.
After the surgery, lung transplant patients remain in the hospital for about two weeks. During this time, patients will continue the pulmonary rehabilitation program which began during the pre-transplant phase.
All transplant patients are required to take powerful medications called immunosuppressants for the rest of their lives. These medications help to protect the new lung or lungs from being rejected by the body. It is important to know that almost every patient will experience some form of rejection of the new organ at one time or another. Acute cellular rejection is easily treated under the physician's direction with an increase in the dosage of the immunosuppressive corticosteroid medication. The side-effects of these medications can be prominent, but are usually manageable. Antiviral, antibacterial, and antifungal medications are also prescribed to protect the new organs.
Before leaving the hospital, each patient will have a series of follow-up appointments established by their Coordinator. All patients will have mastered their home medication program, be knowledgeable about the signs and symptoms of problems, know how to care for their incisions, and know how to contact the team for assistance 24 hours a day, 7 days a week. The transplant patient and their support persons will also have been taught additional lifestyle modifications that will further protect their new and precious organs.
Through the adoption of these lifestyle modifications and by following the transplant physician's recommendations, a patient has a very good probability of regaining the high quality of life they desire.
After the Transplant
Office Visits: All new lung transplant patients are closely monitored with weekly office visits for 4-6 weeks. Prior to seeing the physician, these visits may be preceded by chest x-rays, blood testing, and pulmonary function tests. About one month after transplant, a bronchoscopy will be done to assess for early rejection.
Rehabilitation: All patients with end-stage lung disease will have been de-conditioned by their pre-transplant illness and will need to continue the pulmonary rehabilitation program. Some patients will have become so debilitated by their lung disease that instead of being discharged from the hospital to their home, they are directed to a rehabilitation facility with the goal of providing a safer environment and a more rapid return to independence and mobility. Regardless of the location in which it is done, the physical and cardiovascular conditioning that continues after transplantation is done to maximize a person's recovery to be more able to accomplish the activities of daily living with no or minimal limitations. During pulmonary rehabilitation sessions, a patient will meet others who have experienced similar situations, and this will form another part of the psychosocial support system for the transplant patient.
Wound Care and Prevention of Infection: Lung transplantation is a major operation, and the immunosuppressant medications used are quite powerful and have many drug-to-drug interactions. To maximize the potential for recovery, patients are asked to follow a set of guidelines:
Do not drive a motor vehicle or lift anything heavier than 10 pounds for several weeks after returning home.
Patients should not take baths until directed to do so.
Digging in dirt or potted plants, swimming in non-chlorinated water (lakes, ponds, and oceans) or public pools, and being in crowds without a mask are highly discouraged.
Avoid people who are sick, and move away from people who are coughing or blowing their nose.
Take all medications exactly as directed by the transplant physician.
Never add any over-the-counter medication, herbal supplement, or vitamins without the express approval of the transplant physician.
Patients will continue to see their primary care physician for all non-transplant issues, but the patient or the primary care physician must contact the Transplant Team if any new medication is to be started.
Eat a healthy diet from the four food groups. Occasionally, some patients will need to monitor the amount of fluid they drink for a short time after transplant.
The recovery process takes about three months, after which many patients find they can return to work and other everyday activities. Though not a cure for the original lung disease, the lung transplant will allow most patients to live active, normal lives.
The evaluation process for lung transplantation includes three major areas: medical, surgical, and psychosocial. Candidates who are identified early on with no impediments to transplant may complete the evaluation process within one month. The Henry Ford Lung Transplant Program has pioneered the "FAST Track" process for evaluating lung transplant candidates. Qualifying lung transplant candidates may have their entire evaluation completed in two weeks or less. The majority of the extensive testing and evaluation process is done within a timeframe as short as two days, so this rigorous process is not appropriate for all candidates. The physician and transplant coordinator will determine the appropriate testing strategy with the patient. The coordinator will provide a complete testing schedule to the patient and will facilitate the patient's completion of this process.
