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Miscellaneous ITU Chest Conditions


Lung Transplantation

Lung Transplantation

Definition

Single lung transplantation

This is indicated for non-suppurative lung disease: emphysema ▸ idiopathic pulmonary fibrosis ▸ sarcoidosis ▸ lymphangioleiomyomatosis

Bilateral sequential lung transplantation

This is indicated for suppurative lung disease: cystic fibrosis ▸ bronchiectasis

Preoperative Imaging

  • Typical imaging procedures that are performed: PA and lateral CXR ▸ CT chest ▸ quantitative ventilation–perfusion scintigraphy

  • This can determine the optimum side for a single lung transplant procedure, screen for potential cancer and assess for donor–recipient size matching

Perioperative Imaging

Reperfusion oedema (reimplantation syndrome)

Definition

This is caused by increased capillary permeability and is nearly universally seen ▸ causes include interruption of the donor lung lymphatic drainage, underlying donor lung injury, surfactant deficiency and pulmonary capillary ischaemic damage

CXR/HRCT

These are non-specific but will most commonly demonstrate airspace opacities (within the mid and lower zones) ▸ linear or reticular shadowing is also common ▸ peak shadowing is seen at day 4 and has usually cleared by day 10 post-op

  • There is a poor correlation between the radiographic appearances and physiological measurements

Early Graft Dysfunction

Definition

A general term describing a range of early injuries (e.g. reperfusion oedema, ARDS or graft failure) with diffuse alveolar damage or an organizing pneumonia

CXR/HRCT

The appearances range from mild airspace opacification (associated with reperfusion oedema) to complete lung opacification

Postoperative Imaging

Infection

Definition

The lung transplant patient is vulnerable to infection due to a variety of causes: associated immunosuppressive therapy ▸ a lost cough reflex ▸ impaired mucociliary function (as the transplanted lung is denervated)

  • The most common infecting organisms: Cytomegalovirus ▸ Pseudomonas ▸ Aspergillus

CT

Consolidation ▸ ground-glass opacification ▸ septal thickening ▸ multiple or single nodules ▸ pleural effusions

  • Imaging does not allow a specific organism to be identified

Acute rejection

Definition

This occurs in virtually all transplanted lungs (usually within the first 3 months)

  • The diagnosis is confirmed with a transbronchial biopsy (demonstrating perivascular and interstitial mononuclear infiltrates) ▸ the majority respond to IV methylprednisolone

CXR

Non-specific appearances ▸ it can demonstrate new or persisting airspace opacities 5–10 days following transplantation ▸ there may be pleural effusions and interstitial lines without other signs of heart failure

HRCT

This is similarly non-specific ▸ ground-glass opacification or septal lines may be the predominant finding

Bronchial anastomotic complications

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