The Kauvery Hospital Lung Transplant Program

Lung Transplant Hospital in Chennai – The Lung Transplant Team

Lung Transplant is a sophisticated procedure that requires a team of specialists to orchestrate the entire process right from the time the patient walks into our hospital, to the rehabilitation post-transplant and thereafter. Our Transplant team at Kauvery includes:

• Transplant Pulmonologist: He is the expert who specializes in lung disease and lung transplantation. He will conduct the various tests required, evaluate the results, review your past medical history, and then conclude if a transplant is the best option for you. Post-transplant, he will provide most of the follow-up care
• Transplant Surgeons: As the name implies, these are specialists who will actually perform the transplant surgery. Before the procedure, they will educate you on the procedure and the risks involved, to help you decide if a transplant is the best option for you.
• Transplant Coordinator: Acting as a single point of contact for you and your family, the Transplant coordinator is involved right from the evaluation process, educating you on the test results, the transplant schedule, the surgery and recovery processes. He will coordinate all care, before and after the transplant.
• Transplant Medical Secretary: She is required for seamless communication between you and transplant team. She will answer and prioritize phone calls from both parties and ensure lab results are shared with the concerned members of the team.
• Transplant Social Worker: The TSW will address the social impact of your transplant process. He will assess your current support system, which includes your family, social habits, relocation to Chennai for the transplant, financial constraints if any, managing recovery and rehabilitation post-transplant. He is also a resource for local social services and counselling.
• Medical Psychologist: As the name implies, this person specializes in human behavior. She will assess how well you understand the transplant process and its impact on your life, your past history of use/abuse of substances and all those factors that can affect a successful outcome. She will also suggest therapy before and after transplant if the need is felt.
• Transplant Physiotherapists: These specialists will assess your musculoskeletal system and your ability to exercise. This is crucial as an inability to perform rehabilitation prior to transplant will disqualify you from transplant unless we can make some progress. Their role post-transplant is to recover the loss of muscle and energy related to surgery and get you as strong as possible once your new lungs start working. They will also suggest structured, ambulatory in-hospital observed rehabilitation program and coordinate home-exercises for you that will increase your strength and endurance in order to prepare you for the transplant. Post-transplant, they will monitor your activity and make suggestions as needed.
• Transplant Dietitians: They will address your nutritional needs before and after transplant. This is important as a healthy weight at the time of transplant is crucial for a positive outcome. Low or high weight relative to your height can be reasons to decline a transplant till your goals are met.

The Transplant Team at Kauvery Hospital will work closely with you and your family to ensure a positive outcome. You are free to ask them any query at any time.

Why is a lung transplant required?

Oxygen is the life-force that supports us and is present in the air that we breathe-in. The lungs take in oxygen from the air and give up carbon di-oxide. Blood acts as a carrier transporting oxygen-rich blood from the lungs to the rest of the body. In people with lung disease, this gas-exchange begins to deteriorate. When medication cannot cure the condition causing lung disease, the lung(s) can fail, and this is usually life-threatening. The following conditions are common causes of irreversible lung failure in some patients:

• Chronic obstructive pulmonary disease (COPD)
• Idiopathic pulmonary fibrosis and Familial Lung fibrosis
• Progressive Pulmonary fibrosis caused by connective tissue disorders and hypersensitivity pneumonitis
• Bronchiectasis: Airways in the lungs get damaged, making it hard to empty mucous and is associated with repeated infections and blood in sputum
• Pulmonary hypertension, or high pressure in the lungs
• Sarcoidosis

There are also other less common conditions that can cause lung failure. As end-stage lung disease (ESLD) worsens, a lung transplant may be the only option. Unfortunately, as lung disease worsens, patients reduce their food intake due to breathlessness and poor appetite and they lose weight; they are unable to get up from bed and do their daily activities. This is called “frailty” and this reduces post-transplant survival. The team at Kauvery Hospital lung transplant hospital in Chennai, will evaluate if transplant is the best option for long-term health and also if there are any other conditions including frailty that can affect the outcome of transplantation. The team will conduct various tests and coordinate the results within the team, in order to arrive at a decision. The evaluation process will take 4 to 5 days and will be carried out at our hospital in Chennai. This is crucial to ensure the success of transplantation by identifying factors that need to be modified before lung transplantation. Before scheduling the same, we will check your overall health condition and ability to travel to Chennai.

Types of Lung Transplant

The Transplant team will evaluate which of the following is most suitable for you:

• Single lung: Generally, one healthy lung is enough to live a normal life. In some patients, we choose to transplant either one of your diseased lungs. This choice is often made for medical reasons
• Double lung / Bilateral: This is increasingly the choice in younger patients with end-stage lung disease
• Bilateral sequential: Bilateral lung transplantation (discussed above) is done one at a time. An ECMO which provides artificial lung-support may be used during the procedure to support oxygen in the blood while the lungs are being attached to your heart.
• Heart-Lung transplant: In this, both the lungs and the heart from the same donor are transplanted into the recipient. This is done for very specific medical reasons.

Based on Donor type

• Cadaveric: The lung(s) is/are donated from a person who is brain-dead and his/her family have altruistically offered his/her lungs for another’s second shot at life. The process of lung allocation is done by the government.
• Living: Healthy, non-smoking adults who are a good match can donate a part of one of their lungs, and still live a healthy life afterwards. Generally, two people are needed for one person and this is less commonly done.

Preparing for the Transplant Evaluation

By now, all preliminary discussions about the eligibility of transplant would have been discussed with the patient and the transplant team would have decided that there is no medical therapy available for your lung disease. Next the Transplant team will need to decide whether you have any conditions that can cause problems during transplantation and whether you need a single, bilateral or heart-lung transplantation.

This is accomplished during your transplant evaluation. At this stage, it is important to prepare logistics:

• Choosing a date for the Evaluation tests: The medical secretary and social worker will work with you and plan an admission for four working days
• How many and who among your family members to be involved
• Compiling and bringing all your medical records, including CT scan images
• Planning the Travel: You need to coordinate with our medical secretary to confirm availability of beds as per your desired date of travel and freeze the travel schedule accordingly
• Planning for Oxygen Needs: Oxygen supply must be adequate for your entire travel to our Hospital. If you are planning to stay locally after your evaluation till the transplant, the logistics of continuing oxygen supply and accommodation will be coordinated by the MSW
• How many and who among your family members to be involved

The last point is important. Kauvery Hospital will provide oxygen during your Hospital stay and also arrange for the supply in case you run short. Nevertheless, the plan must cover

• Confirming the need for an oxygen cylinder
• Duration taken to empty the cylinder at the rate at which you will be using it
• The need for medical personnel to travel along with you depending on your condition
• Need for an ambulance service or retrieval
• In case of air-travel, safety restrictions by the airline, or restriction on quantity of oxygen that can be carried
• Compiling paper-work necessary to facilitate travel
• The need to use oxygen while staying at a hotel in-between flights, where applicable
• The need for oxygen while flying back home after the evaluation

Tests and Evaluations for a Lung Transplant

The evaluation tests are important as they help us decide whether you are a good candidate for transplant and how successful the transplant will be. These tests will involve appointments with members of the Transplant team and various clinicians who will be involved in managing these tests. Please note, none of these personnel are authorized to share or interpret the test results with you. This will be done by the Transplant Pulmonologist and Transplant Coordinator.

They will summarize and explain all the test results to you. The battery of tests includes:

• Blood tests: This will identify blood type, reveal your kidney and liver function, health of the immune system, presence of viruses or infection of any kind that can complicate the transplant and help plan immunization
• Lung function test: This is done to assess your breathing capacity. You will be asked to breathe in and breathe out forcefully to assess the strength of your lungs.
• Echocardiogram (EKG): An ultrasound of the heart, which will reveal condition of the heart and its valves
• Angiogram: This is done to check for the presence of blockage(s) in major arteries of your heart, and measure internal heart pressures. A catheter is inserted into an artery through the skin after anesthesia without any incision, after which the catheter is threaded all the way to the heart. Once it reaches the heart, a mildly radio-active dye is released. A special X-ray machine creates an image of the heart and its arteries on a computer screen.
• Ventilation-perfusion lung scan: This will help us decide which of your lungs is more affected and help plan surgery
• Chest CT scan: Will help image your heart and lungs and reveal the connections between both. Any sign of infection or cancer can also become evident
• Arterial blood-gas analysis: A blood test that measures how well the lungs are pumping oxygen into the blood and removing carbon-dioxide from the blood.
• Pulmonary physical therapy assessment: You will be asked to do an exercise and a six-minute walk. A rehabilitation specialist will evaluate your endurance and any need for oxygen during activity. This will reveal how ready you are for a transplant.
• Colonoscopy and Upper GI Endoscopy: These look for any evidence of colon cancer, generally done for patients over 50 yrs of age
• Mammogram or ultrasound of the breasts: done for women, to rule out breast cancer
• Pap smear: done for women, to rule out cervical cancer
• Bone density test: to look for bone loss, due to the lung disease and/or medications being taken for the same
• Other tests: on a case-to-case basis

It is also important to prevent infections after the transplant. Towards this, you will receive vaccines and medicines that reduce the risk of infection. These include

• Vaccines for Pneumococcal disease, influenza and COVID-19
• Vaccines for Tetanus and meningococcal disease
• One or all doses of a 3-series vaccine for Hepatitis B
• MMR: Mumps, Measles and Rubella vaccine
• Ivermectin tablets to prevent worm-related infestations

Outcome of your transplant evaluation

After a thorough review of your medical history and the results of your evaluation, the lung transplant selection committee will decide the best way to move forward. The outcome of this discussion may be ONE of the below.

The committee may decide that lung transplantation is the best treatment option at this time, and you will be approved for listing in the TAMILNADU STATE (TRANSTAN) and NATIONAL lung transplant waiting list (NOTTO).

The committee may decide that lung transplantation is not the best treatment option for your lung disease. We will suggest what the other options are for your health and offer this to you.

The committee may decide that it is too early for transplant and we can offer other treatments while we continue to monitor your lung function closely. In this case, the team will continue to monitor you closely going forward to identify the best time for transplantation in the future.

The committee may decide that more information is necessary to determine the best course of action, so you will be asked to complete additional studies or accomplish specific goals to improve your candidacy for the lung transplant procedure.

You will be given an appointment at discharge from your evaluation tests when this will be discussed with you by the transplant team.

Transplant Listing and its Requirements

To maximize the success of the transplant, the Transplant team will insist you meet certain requirements before and after the transplant is done.

To match the right donor lungs with yours and initiate transplant

• You must attend all appointments regularly both before and after the transplant
• You must engage in an ongoing Pulmonary Rehabilitation (PR) Program before and after the transplant
• You must take all medications on time, as prescribed
• You must follow the transplant dietician’s guidelines/restrictions on food and beverage
• You must exercise regularly and maintain your weight
• You must monitor your fluid intake and blood pressure
• You must stop consuming any tobacco products, alcohol and quit smoking if you currently are using any of the above. You must attend programs to prevent any relapse, and undertake additional psychological counselling if needed.
• You must establish a plan for sound and long-term health
• You must relocate to Chennai for three months
• You must raise funds, if required, to meet all these expenses
• You must stay in contact, and communicate regularly and as needed, with the transplant team

How well you comply all the above regulations will determine the success of your transplant. Not doing so can invite a whole lot of negative outcomes for you such as

• Delay in placing you on the waiting list for transplant
• Getting removed from the waiting list
• The newly transplanted lungs being rejected by your body
• Poor physical health and low quality of life
• Death

Once your placement on this waiting list is confirmed, you will receive a verbal confirmation from the Transplant Coordinator as well as a Confirmation Letter

As a patient being considered for lung transplantation at Kauvery Hospital, the transplant team will ask you to meet certain requirements to maximize transplant success. This includes

Donor lungs are matched with recipients based on

• Attending clinic appointments regularly before and after your transplant
• Engaging in ongoing Pulmonary Rehabilitation Program before and after your transplant.
• Taking your medications on time and as prescribed.
• Following the transplant dietician’s nutritional guidelines/restrictions.
• Losing or gaining weight.
• Monitoring your fluid intake and blood pressure.
• Stopping the use of all tobacco products and alcohol and attending smoking cessation programs, relapse prevention, and/or additional psychological counseling where needed.
• Establishing a solid care plan.
• Relocating to the Chennai, typically for three months
• Fundraising to assist with expenses should this be necessary.
• Staying in contact, and communicating appropriately with the transplant team.

Your compliance with the transplant team’s requirements greatly influences the success of your transplant. If you do not follow the transplant team’s recommendations, it may result in negative consequences, such as

• Delays in transplant waiting list placement.
• Removal from the transplant waiting list.
• Rejection of your transplanted lungs.
• Poor physical health and quality of life.
• Death.

The day you are listed, you will be notified verbally by one of the Transplant team members. You will also receive a listing confirmation letter.

The Pulmonary Rehabilitation (PR) Program

Once you are listed in Kauvery Hospital’s waiting list for transplant, you must attend a Pulmonary Rehabilitation (PR) program that will educate you and condition you for the transplant. The program will improve your physical stamina and mental strength so that you go into the surgery under the best possible conditions. After the transplant, the program speeds up your recovery and rehabilitation so that you can be on your own at the earliest.

You must attend a minimum of 3 days a week, of this program, which will focus on

• Determining if you need oxygen while exercising, in order to maintain a minimum oxygen saturation level of 88%
• Teaching you various breathing exercises and techniques, including coordinated breathing, diaphragmatic breathing and pursed-lip breathing

Physical therapy sessions will focus on

• Strengthening your muscles using resistive weights or Thera-Bands®
• Flexibility or stretching exercises
• Building endurance through stationary bicycling for 20 minutes or walking for at least 20– 30 minutes
• Classroom sessions and written material to explain all about lung disease and how to cope with it, physically and mentally

The physical therapy requirements and goals that will ensure success of your transplant include

Walking

• To walk at least for 20 minutes
• To cover a distance of at least 800 meters in 20 minutes
• To cover at least 300 meters in 6 minutes.
• You can use a walker or cane while walking
• You can use as much oxygen as you want, as long as you have your own source of oxygen
• No stopping to rest

Bicycle

• You can use a standard stationary bicycle or a regular bicycle
• You must ride for at least 20 minutes, without stopping to rest
• You can use as much oxygen as you need
• The bike load should be at least 0.5 kp

Treadmill

• Walking for at least 30 minutes
• No stopping to rest
• You can use as much oxygen as you need
• Treadmill speed must be at least 2.0 mph

Strength Training and Flexibility

• Strengthening your upper and lower extremities and trunk, by using dumbbells, cuff weights, Thera-Bands®, or any other weight-training equipment
• Stretching exercises for all the major muscle groups in the trunk, upper and lower extremities

Education

• Performing paced breathing with exercise, along with diaphragmatic and pursed-lip breathing on your own
• A thorough understanding of the medications to be used before and after surgery

Preparing For Relocation

A lung transplant donation offer occurs unpredictably and at unusual hours. Each donation is a precious opportunity at a second life and our Unit tries to maximize the chance that each donation leads to a successful transplant. The transplant team has to travel to the city where the donation occurs, assess the suitability of the organ offered, retrieve the organs, travel back to Chennai and start the surgery for transplanting them to the patient. The donated Lungs have to be implanted at the earliest and ideally, within six hours of removal from the donor. This means that as a patient, you have to be available within an hour of information reaching you, at Kauvery Hospitals. This is the reason why you will need relocating to Chennai for your transplant procedure. Also, Tamil Nadu has the highest organ donation in the country and you will be eligible for registration at Kauvery for priority access to Tamil Nadu organ donations from TRANSTAN only if you relocate to Chennai. During this relocation, consider costs of Rent, Utilities, Food, Transportation, Parking, Medication and Other living expenses in addition to the transplant. The Transplant social worker and coordinator will provide you options for help with each of the above items.

Waiting for a Lung Transplant

Kauvery Hospital currently offers the shortest waiting time for lung transplants in India. It routinely undertakes measures to reduce lung transplant waiting times successfully. You must maintain excellent physical and mental health during the waiting time and meet the transplant team regularly as and when required to.

Having said that, it’s not always possible to estimate how long you may have to wait as that depends on when a matching donor will become available. If your chest cavity is too large or too small or you have some antibodies of concern, you may have to wait longer.

Organ availability and selection

Moving through the waiting list

All transplant candidates are listed in the state list (TRANSTAN) and the national list (NOTTO). Donor lungs from Tamil Nadu will be first priority, followed by those from other states. When the lungs are coming from other states, the availability of a quick connecting-flight, and the cost involved will be communicated to you so that you can take a call, and reduce the waiting time. Also, once a donor lung is available, the person with the longest wait time will get first priority.

Donor matching parameters

Donor lungs are matched with yours based on

• Blood type (O, A, B, or AB)
• Time on the waiting list

Donor screening

The donors’symptoms, family and social history will be checked thoroughly followed by an X-ray, bronchoscopy and visual-intraoperative examination of the donor’s lungs. The quality of the lungs is very important. We routinely test for all viral infections, blood cultures for bacterial infections, broncho-alveolar cultures for a variety of relevant infections, donor CMV and EBV status as well as the donor HLA type and its match with yours.

False call

Sometimes, a donor’s preliminary tests will pass OK and you will be called to prepare for the surgery. But the next set of tests may fail and the lung rejected. This can be disappointing to you and is called a False call. But it cannot be helped as there is a short window of time to initiate transplant. The Transplant Psychologist will counsel you in such a situation and teach you breathing techniques that can be relaxing.

The Lung Transplant Surgery

Admission for Transplant: Once you arrive at the hospital, you will be admitted and prepared for potential lung transplant surgery. A chest X-ray, Covid-PCR, ECG, and blood tests will be done, and you will be asked to sign the consent for surgery. At the same time, you are completing the admission workup, the organ procurement team is traveling to the donor’s location so the surgeon can exam the donor lungs. During this time, you will wait to hear if the donor lungs are good from the transplant coordinator.

The Surgery: Once the surgery is confirmed, you will be taken to the operating room. The surgery can take anywhere from eight to ten hours. Your family will be shown where to wait and will be kept informed through your surgery

Your surgery may be a single, double-lung or heart-lung depending on your medical condition. During the surgery

• An incision will be made across your chest for a double (bilateral) and heart-lung transplant or along both sides of your chest (bilateral) and on the side of your chest for a single transplant.
• A breathing tube will be inserted to help you breathe.
• A tube will be inserted through your nose and into your stomach to drain fluid.
• A tube will be inserted into your bladder to drain urine.
• Multiple tubes will be inserted into your chest to drain fluid.
• Intra-operative extra-corporeal support for oxygen supply may be instituted according to need
• You will receive IV medications.
• Your lung(s) will be removed and replaced with donor lung(s).
• If needed, a feeding tube will be placed into your stomach

After Surgery: Immediately following surgery, you will be brought to the Intensive Care Unit (ICU). Respiratory therapy will begin once you are stable and your new lungs are working with a goal of having you up and walking by day 2. Once your medical condition is stable, the breathing tube is removed and we will attempt to mobilize you. The monitoring tubes will be removed sequentially at this stage. Once you are stable, you will be transferred to the transplant ward and your medications are optimized. Typically, most people require 2-3 weeks in hospital for this

After discharge: Your post-transplant coordinator will establish a time to provide post-transplant teaching for you and your caregivers before you are discharged. You will have a teaching session with our transplant team to explain all your transplant medications. You will also have another for micro-spirometer teaching so that you can monitor your lung function daily at home. At the time of discharge, you will need to have

• Your own blood pressure cuff
• Pulse Oximeter
• Thermometer
• Weight scale
• Glucose monitor
• Micro spirometer

Post-discharge, you will be required to enroll in at least one month of pulmonary rehabilitation. During this time, you will also have regular clinic visits, pulmonary testing, lab draws and bronchoscopies to check for rejection and infection. Sometimes, patients need intravenous medications after discharge during the first month and we will arrange nurse providers so that these can be administered at home.

Challenges after Lung Transplantation

Post-Transplant Lung Care

You will require weekly blood tests and chest X-rays for the first 4-6 weeks following your transplant. Thereafter, blood tests are done second-weekly. Blood tests become less frequent after three months (monthly) and then every three-monthly after the first year. You will also require to do pulmonary function tests monthly for the first year and then three-monthly life-long. CT scans and bronchoscopies are done at 6 weeks, 3 months, 6 months, 9 months and 1- year period following your transplant.

You will be on tablets to prevent fungal infection and CMV (a virus) infection for three and six months following a transplant and will require blood tests once these are stopped to check for any infection until one year. The transplant team will be coordinating most of these tests at your hometown but you will be required to come for assessment at least 3-monthly for the first year and then six-monthly thereafter life-long. Together, we will strive to make your transplant a very long success story.