Induction and maintenance immunosuppression in lung transplantation.

Immunosuppression for lung transplant recipients is a critical part of post-transplant care, to prevent acute and chronic rejection. Treatment protocols consist of induction and maintenance immunotherapy. Induction agents provide an immediate state of immunosuppression following transplantation and over time, and their use has become more commonplace. Several agents are available for clinical use, including anti-thymocyte globulin, alemtuzumab, and basiliximab, the latter being most commonly employed. Each induction agent has unique side effects and caveats to their use, of which we must be aware. Maintenance immunosuppression is initiated following transplant but requires multiple doses prior to reaching therapeutic levels. A calcineurin inhibitor, an anti-metabolite, and a corticosteroid are traditionally used, most commonly tacrolimus, mycophenolate mofetil, and prednisone. Dosing regimens and goal trough levels vary and are tailored to a patient's clinical status and duration post-transplant. Future clinical studies may be able to assist in determining the optimal induction and maintenance immunosuppression regimens. In the interim, we use cohort and registry data to guide our therapies.

Combination plate and band fixation for primary closure in bilateral lung transplantation.

BACKGROUND: Sternal complications are common following transverse thoracosternotomy in patients undergoing bilateral lung transplantation. We present a single-institution experience using a next generation rigid fixation system for primary sternal closure following transverse sternotomy for bilateral lung transplantation. METHODS: Retrospective review was performed on all patients who had bilateral sequential lung transplants utilizing a transverse thoracosternotomy from 2016 to 2020. Demographics, baseline characteristics, peri-operative data, and outcomes were collected, reviewed and summarized. Two groups of patients were identified: wire cerclage (Group A), combination plate-and-band rigid fixation (Group B). The primary outcome was sternal complications, which were divided into mechanical and non-mechanical. RESULTS: Twenty-two patients met inclusion criteria. Three patients (13.6%) were in Group A, nineteen patients (86.4%) in Group B. Two patients in each Group A (66.6%) and Group B (10.5%) experienced a sternal complication. Sternal complications included sternal dehiscence (2), sternal malunion (1), and surgical site infection (1). One patient with plate-and-band fixation (5.2%) had a mechanical sternal complication. Three patients required reoperation secondary to sternal complication. CONCLUSIONS: The utilization of a combination plate-and-band rigid fixation system for primary closure is safe and may be an effective method to reduce sternal complications following transverse thoracosternotomy for lung transplantation.

ATS Core Curriculum 2020. Adult Pulmonary Medicine.

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine in a 3- to 4-year recurring cycle of topics. The topics of the 2020 Pulmonary Core Curriculum include pulmonary vascular disease (submassive pulmonary embolism, chronic thromboembolic pulmonary hypertension, and pulmonary hypertension) and pulmonary infections (community-acquired pneumonia, pulmonary nontuberculous mycobacteria, opportunistic infections in immunocompromised hosts, and coronavirus disease [COVID-19]).

A Novel Diagnostic Algorithm for Heparin-Induced Thrombocytopenia in a Retrospective Cohort of Lung Transplant Recipients.

INTRODUCTION: Heparin-induced thrombocytopenia (HIT) is characterized by thrombocytopenia and potential for thromboembolism. Lung transplant recipients are at risk of developing HIT due to heparin exposure peritransplant. We describe the incidence and impact of HIT in lung transplant recipient index hospital length of stay and survival. DESIGN: A retrospective cohort was obtained from electronic medical records which were queried for all recipients treated with bivalirudin (institutional treatment of choice for HIT) between January 1, 2005, and February 16, 2017 (N = 1171). Patients who developed HIT >30 days after transplant or after their index transplant admission were excluded. A diagnostic algorithm was used retrospectively to determine clinical HIT with an intermediate or high pretest clinical suspicion ("4T" score ≥4) and either (1) positive anti-heparin-platelet-factor 4 (HPF4) assay and a positive functional platelet assay or (2) a positive HPF4 assay only, in patients who did not undergo cardiopulmonary bypass. RESULTS: Among all lung transplant recipients, 2.1% were found to develop HIT in the peritransplant period (N = 25, mean = 88%) with a mean lung allocation score of 50.8 and an incidence of venous thromboembolism of 72%, most upper extremity in location. When matched with historical controls, patients with HIT had a longer overall index hospital length of stay of 43 days (P = .008). There was no difference in short- or long-term survival posttransplant. CONCLUSION: Vigilance for the development of HIT in lung transplant recipients is necessary to prevent further morbidity from thromboembolic events. In our cohort, HIT increased hospital length of stay but did not appear to affect recipient survival.

Activity monitors in pulmonary disease.

Physical activity is reduced in patients with chronic pulmonary diseases. Activity monitors can measure physical activity objectively and accurately over prolonged periods of time. Research grade and commercially available devices, using accelerometer technology, are being increasingly used in clinical studies. Physical activity levels have been found to have a moderate to strong correlation with important measures such as pulmonary function, exercise capacity, quality of life, and mortality and hospitalizations in patients with COPD, interstitial lung disease, pulmonary arterial hypertension and cystic fibrosis. Their use as a clinical trial end-point and as a tool to augment rehabilitation efforts has also been explored in patients with COPD with variable results. Due to the ease of use, economic viability, widespread availability and good patient compliance, their use in adult and pediatric medicine is expanding. This narrative review summarizes the current evidence of use of activity monitors in COPD, interstitial lung disease, asthma, pulmonary arterial hypertension, cystic fibrosis and lung transplant patients for the purposes of prognostication, monitoring, outcome measures and intervention.

Development of a modified yoga program for pulmonary hypertension: a case series.

BACKGROUND: Pulmonary hypertension (PH) is a hemodynamic condition in which the pressure in the bed of the pulmonary arteries is elevated. Although medications have improved both symptoms and mortality, PH remains a debilitating and devastating disease. Little is known about the effects of nonpharmacologic approaches, such as yoga and meditative breathing, in treatment of the disease. OBJECTIVE: Given the unique hemodynamic concerns of PH patients, the research team intended to describe the development and subsequent initiation of a therapeutic treatment plan that uses modified yoga and to evaluate its benefits and safety. DESIGN: This study was a case series with 3 PH patients of varying functional abilities. Each patient was provided with a DVD, access to YouTube video segments, and a download of the Yoga for PH application. The patients were asked to document their use of the home exercise regimen and journal around their subjective observations. They were also administered the Health Promoting Lifestyle Profile II (HPLPII) at the beginning and end of the 8 wk. SETTING: The study took place in a tertiary care, academic hospital in a large urban setting. PARTICIPANTS: In this case series, 3 patients with group 1 pulmonary arterial hypertension, with varying functional abilities, are described. INTERVENTION: Three discreet yoga programs were designed with modifications specific to PH patients: chair yoga, intermediate yoga with a chair assist, and experienced yoga. Patients were provided with a video, Yoga for PH, in the form of a DVD, a video on YouTube, and a downloadable application and were instructed to log activity and subjective markers of well-being. OUTCOME MEASURES: Subjective and objective effects on clinical, physical function, and psychological outcomes were measured. Subjective effects were identified through journaling as well as the self-administered questionnaire HPLPII. When available, 6-min walk distance (6MWD) testing and oxygen saturation were also used. RESULTS: The modified yoga program proved feasible, safe, and effective in the 3 described cases. Patients described decreases in anxiety and joint pain, with improvements in health-promoting behaviors as measured by the HPLPII. Overall mean scores for health-promoting lifestyle increased in each patient, though due to the small sample size, statistical significance cannot be measured. No patient experienced an adverse event associated with the practice. CONCLUSIONS: The modified yoga program for PH patients can provide a standardized, accessible starting point for further study on the feasibility, efficacy, and safety of such a program on a larger scale.