Pneumonia in Heart-Lung Transplant

OVERVIEW

• pulmonary infections = most frequent complication with high mortality
• requires aggressive, early, broad spectrum antimicrobial therapy
• close consultation and even transport to transplant unit may be indicated

PATIENT

• severity of pneumonia
• co-morbidities: ischaemic heart disease, pacemaker, hypertension, DM, renal function, graft vs host disease
• severity of immunosuppression
• medications: discussion with transplantation team about how to manage
• smoking history

TRANSPLANT

Cardiac

• heart is denervated -> only responsive to direct acting drugs/hormones in circulation
• requires careful titration of intravascular volume
• requires invasive monitoring
• altered ECG and rhythm strips
• premature obliterative coronary atherosclerosis -> LV dysfunction
• arrhythmia management

Respiratory

• exercise capacity
• premorbid lung function
• impaired cough and clearance of secretions
• impaired function from obliterative bronchiolitis (chronic rejection)
• bronchial or tracheal stenosis relating to original anastomotic site

PNEUMONIA

Opportunistic Infections

• requires early aggressive investigation (CXR, bronchoscopy, CT chest, open lung biopsy)
• early aggressive broad spectrum anti-microbial cover
• community acquired bacterial organisms (cefuroxime + erythromycin -> imipenem)
• Aspergillus and Candida (caspofungin)
• CMV (foscarnet, ganciclovir)
• Pneumocystis jiroveci (co-trimoxazole)
• Cryptococcus neoformans (amphotericin B)
• consider steroids early

Adrenal Issues

• secondary to steroid use
• requires increased steroids to cover illness

DISPOSITION

• isolation
• early referral and possible retrieval
• early discussion with patient and family about risk
• may need advanced oxygenation techniques:
  -> nitric oxide
  -> prostacycline
  -> prone ventilation
  -> high frequency oscillation
  -> ECMO

CONCLUSION

• requires decisive, aggressive management
• involvement of quaternary level services