11/11/16 Kirstie Wallace/Hazel Muse Transplant Co-ordinators 5/1/2018 Lung Transplant Assessment 11/11/16 Kirstie Wallace/Hazel Muse Transplant Co-ordinators

Referring zones Northern region Northern Ireland Scotland - Lungs Eire - paediatrics only Adult congenital patients Paediatric patients Patient/Physician choice

Referral pathway Referral proforma Turn down Satellite clinic Inpatient assessment In-patient assessment Further investigation and review Too good Active list

Transplant Assessment Four day in-patient assessment Patient asked to bring carer Two way process for sharing information Medical assessment, and an opportunity for second or third opinion Patient learns outcome of assessment

Lung Transplant Assessment Is the patient sick enough? Full lung function including transfer factor ABG’s 6 MWT Perfusion scan CT scan - current Disease progression Microbiology

Aims of assessment To identify appropriate recipients and list them at the optimum time An opportunity to educate the patient and their family about their condition and future treatment options

Points of discussion Does the patient understand their condition? Does the patient understand the reason for referral? Does the patient understand their disease prognosis?

Transplant Assessment Four questions to answer 1. Does the patient require a transplant ? 2. Is the patient physiologically/physically strong enough to survive a transplant ? 3. Which operation and when? What degree of risk? 4. Does the patient want a transplant ? (informed consent)

Absolute contra -indications Other end organ failure Malignancy within 5yrs (usually) Active systemic infection Drug, alcohol, nicotine dependence

Relative contra-indications Other organ dysfunction Maintenance steroid > 20mg/day Osteoporosis with fracture history High/low BMI <17 or >30 Non compliance, non concordance Multiple antibiotic allergies Very resistant microbiology Surgical issues Frailty Index?

Transplant Team Patient Medical staff Nursing staff Social worker Co-ordinator Physiotherapist Clergy Dietician Psychology

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Is the patient fit enough? Cardiac function Liver function/ Renal function BMI Other co-morbidities – diabetes, osteoporosis, GORD General physical condition – frailty index? Surgical issues – anatomy, previous surgery Micro issues - sensitivities/allergies, cocktail

What does the patient want? Education Informed consent Risk/benefit Donor decisions

Window of opportunity Wellbeing COPD CF IPF Time

Outcome of assessment Not for transplant Too good for transplant (at present) Needs further investigation/management Accept for transplant

Accepted for active list Which operation? Heart lung Bilateral lung Single lung (which side?) Accepted for active list

Managing the waiting list

Active list considerations Organ waiting times are not predictable Organs are matched to recipient using blood group and size, usually related to recipient total lung capacity (TLC) HLA antibodies Unfortunately 25 - 30% of patients die before a transplant is possible

Challenges Working within limitations of resources Waiting times for clinic and in patient admission Managing patient/carer expectations Managing referring centres expectations Maintaining objectivity Managing waiting list Accepting we cannot save everyone

Alternative techniques Lobar transplant EVLP Novalung ECMO

References International society of Heart Lung Transplantation Annual Reports 2012, 2013 Selection of Candidates for Lung Transplantation Kreider and Kotloff Proc Am Thorac Soc vol 6 pp 20-27, 2009 Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates – 2006. J Heart Lung Transplant 2006;25:1024-42 Indication, patient selection and timing of referral for lung transplantation. Verlden , Fisher Eur Respir Mon 2009 NHSBT Activity report 2014-2015 Frailty: What does it mean for Clinical Care Provision? – Scottish Universities Medical Journal 2014 Vol3 (Issue1)