The lung transplant assessment is divided into four stages:
• Preliminary assessment at the outpatient clinic
• Secondary assessment at the centre
• Waiting List
At every stage, we encourage you to ask us any questions. This entire exercise is a combined effort between the medical team, the patient, caregiver, and the family. We hope the following information will offer you a start point to understanding the process better.
PRELIMINARY ASSESSMENT – AT THE OUTPATIENT CLINIC
The appointment for the preliminary assessment should be conducted within one week of referral unless the patient is unsuitable, and a physician or surgeon has made this decision. Before arriving at the clinic, the pertinent medical records will be obtained and reviewed by the transplant physician with a nurse coordinator. After reviewing these tests and a post a Skype or phone interview, the patient is scheduled for a preliminary assessment visit at the clinic.
The general principle of this assessment is to carefully review the medical history and data, perform a physical exam, begin education regarding lung transplantation, and perform a psychosocial screening. This initial visit saves the patient from more detailed tests and studies if they are unsuitable for transplantation.
Understanding the Preliminary Assessment
There are terms that physicians and team members use frequently that could sound unnerving, confusing, and overwhelming for patients and family. It is important that a general understanding of a few basic tests could make a patient and caregiver’s journey more educated and thus put them at ease. It could also serve as a platform for better understanding and cooperation between the medical team, and the patient and their family.
Pulmonary Function Test
Pulmonary function testing (PFT) is a diagnostic test or series of tests that provide an objective method for assessing the functional status or changes in a patient with known or suspected lung disease. When properly performed and interpreted, they help diagnose the cause of a symptom (such as shortness of breath), the extent of disease (how far advanced the condition is) and help determine the effectiveness of therapy. Usually, when a new patient is evaluated, a complete array of tests is performed. After the initial visit, smaller tests may be necessary to monitor a patient's status. Repeated testing helps to determine any improvement or deterioration. Also, a patient can track the rate their pulmonary function is declining by plotting the results on a line graph. This can be a useful tool in predicting when you should get listed for a lung transplant.
Arterial Blood Gas Analysis
Despite the extensive information that pulmonary function tests provide, they don't show the net effect of lung disease on gas exchange. This information is assessed by tests performed on arterial blood. To obtain a blood sample for arterial blood gas analysis (ABG), a needle is usually placed in the radial artery in the wrist. Three main measurements are obtained: arterial pH, paO2 and pac02.
Arterial pH measures the blood's acid-base equilibrium. This balance is controlled by several factors, primarily metabolism and oxygenation of the blood. Normal values run between 7.35 to 7.45. Values less than 7.35 are considered to be acidic, while those greater than 7.45 are more alkaline. A blood pH <7.35 or >7.45 is abnormal and is a sign of an acute, rather than chronic state, regardless of the oxygen and carbon dioxide levels.
Arterial paO2 measures the actual pressure of oxygen in the blood. A normal value is between 80 and 100 mm Hg (depending on age), but oxygen saturation is not seriously affected until it falls below 60 mm Hg. A low pa02 can damage other organ systems and oxygen therapy is usually given.
Arterial pa CO2 measures the body's ability to remove carbon dioxide. A normal paCO2 is between 35- and 45-mm Hg. An elevated is a sign of respiratory failure and may be associated with problems in blood oxygenation
A pulse oximeter is a photoelectric apparatus for determining the percent of red blood cells in the body that are saturated with oxygen. A small probe, in the form of a clip, that has both transmitting and receiving side, is placed on the finger. The receiving side measures the light that passes through the nail bed. This test is not as accurate as the values obtained from an ABG but can give a general measurement. A normal saO2 is 95% to 100%. Oxygen therapy is generally required when the saO2 is less than 86%.
The study of patients during exercise provides valuable information about their exercise limitations. Adding measurements of arterial blood gases during exercise provides an additional dimension and shows whether gas exchange problems contribute to the impairment.
During this test, the patient exercises on a treadmill or stationary bicycle while breathing through a mouthpiece or mask. Many measurements are made, but essentially how much oxygen the lungs and heart can supply to the leg muscles at anaerobic threshold (or the point when your body can no longer supply oxygen to the muscles) and peak exercise are the most significant. This is valuable in differentiating disability based on respiratory vs. cardiac vs. sedentary causes. This testing is a useful measurement when the patient is beginning a rehabilitation program.
Following the initial visit, patients will undergo secondary studies to evaluate the underlying, undiagnosed disease. If possible, these tests will be performed at the centre over three or four days. The following tests are performed based on a person’s primary disease, age, and individual needs. At all stages of the assessment, the patient and family are involved in discussions and encouraged to ask any questions.
Objectives of the Secondary Assessment Procedures
• To assess the patient's clinical, social, and psychological suitability as a transplant recipient.
• To impart factual information to the patient, caregiver, and family about all aspects of transplantation.
• To meet the medical team and other transplant patients.
• To provide an opportunity for the patient, caregiver, and family, to begin to come to terms with the prospect of transplantation, and to be informed about the procedure and its aftermath.
The importance of the multidisciplinary involvement in the assessment of the patient and the care received is paramount. The assessment involves a spectrum of healthcare professionals, including pulmonologists, surgeons, radiologists, nurses, transplant coordinators, pharmacists, occupational therapists, nutritionists, physiotherapists, social workers, psychologists (psychiatrists are also involved if needed), all of whom have a key role to play.
• Lung Condition
• Previous thoracic surgery
• Current therapy
• Marital status
• Substance/drug/alcohol abuse
• Unresolved pulmonary process
• Renal disease
• Liver disease
• Peripheral or cerebrovascular disease
• Peptic Ulceration, GI bleeding
• Diverticular disease, GI sepsis
• Unresolved sepsis in any site
• Herpes virus infection
• Previous blood transfusion
• Blood pressure and heart rate
• Height and weight
• Chest x-ray
• CT Scan of the Chest
• 6-minute exercise walk and/or metabolic exercise test (if capable of doing)
• Ejection fraction assessment
• Cardiac catheterization & Coronary angiogram if over the age of 40
• Pulmonary function tests
• 6-minute walk test with oximetry
• Arterial blood gases
• Sputum culture
• MSU and urine test
• Nose swab
• MRSA screen dental assessment
• Full dental examination
• Advice on dental hygiene
• Restorative work and extractions as necessary
Haematology Blood Tests
• Blood group
• Panel reactive antibody screen
• Complete blood count
• APTT, PT, INR, Fibrinogen
• Urea & electrolytes
• Uric acid
• Calcium phosphate
• Liver function tests
• Cardiac enzymes
• Thyroid function tests
• Fasting blood glucose
• Fasting blood lipids
Serology Blood Sample
• Hepatitis B/C
• Epstein Barr Virus
• Herpes simplex
Immunology Blood Tests
• Auto-immune (including ANF, DNA, SCAT/LATEX)
• HLA typing
• Lymphocytoxic antibody screen
• Letter from Treating primary physician confirming compliance with past therapy
• Interview with Social Worker
• SIPAT Assessment
• Creatinine Clearance or GFR
• Dietician (after discussion with transplant team)
• Physiotherapy assessment aggressive rehabilitation
The decision to place a patient on the waiting list is a multidisciplinary one. Following the completion of the testing, the patient is presented at the Lung Transplant Listing Meeting, which is held weekly. The patient and relatives will be informed of the outcome and a representative from the transplant team will discuss it with them.
The multidisciplinary transplant meeting comprises of a wide selection of healthcare professionals. The team includes:
• The Program Director
• Transplant Coordinators
• Transplant Nurses
• Financial Counselors
• Social Workers
If the team and the patient decide to go forward with transplantation, he or she is then registered with the local OPO (Jeevandan, Transtan, ZCCK, NOTTO) and placed on the waiting list. If the patient is not deemed suitable and/or declines the option of transplantation, the medical team explains the alternatives to the patient, caregiver, and family members. We also inform the referring clinicians of the outcome of the assessment.
THE WAITING LIST
Once placed on the waiting list, the patient receives a detailed explanation and information pertaining to the waiting period. This information is consistent with the Jeevandan/ TRANSTAN/ ZCCK/NOTTO guidelines.
Our medical team will discuss the following information with the patient, caregiver, and the family.
• Provision of a cell phone or a pager, and an explanation of its requirement.
• The patient's responsibility to make themselves available to be contacted by the transplant unit at any time. Our transplant coordinator will provide more details about this.
• Patients are requested to inform the transplant unit of any changes in their circumstances
• if they become unwell
• if they are admitted to hospital
• any changes in medication
• travel or vacation plans
We will provide you with an information booklet that will explain the following:
• Preparation for admission for surgery
• Maintenance of regular contact
• Reporting changes in circumstances
• What to do when called for surgery
• The surgery
• Accommodation for family
• Publicity and the media
• Wards and departments after the operation
During the waiting period, the Transplant Unit will maintain contact with you and your family to offer support, information, and guidance according to their needs. We will also schedule a clinical review for the patient on the waiting list.
Our surgeons use several factors to match donors with patients on the waiting list. Two of the most important factors are blood type and lung size. Because of this, there is no top spot on the waiting list.
While you are waiting for your lung transplant there are three main goals:
1. Maintain your health and improve your strength. Our physiotherapy program will help you achieve this goal. The physiotherapists will also work with the doctors to ensure your oxygen needs are met.
2. Identify and manage any new and existing problems that may arise. We will partner with your family to manage your health. You and your caregiver will attend frequent appointments at our hospital.
3. Continue to learn about life with a lung transplant through our support and education groups and by speaking to your transplant team.