Lung Transplantation and Endoscopic Issues

Abstract

In the last 20 years lung transplantation has become a therapeutic reality for many end-stage parenchymal and vascular lung diseases; despite the difficulty in finding donors, the results are currently satisfactory [1][2][3].Infections, lung rejection and airway complications are the major causes of morbidity and mortality in patients who undergo lung or heartlung transplantation (LT) [4,5]. The usefulness of transbronchial lung biopsy (TLB) was reported for the first time in 1988 [6]. Since then TLB has become a routine practice in the management of patients who have undergone LT and still remains the "gold standard" for the diagnosis of rejection of a transplanted lung [7][8][9][10][11] Bronchoscopy with a flexible fibre-optic bronchoscope (FB), together with bronchoalveolar lavage (BAL) and TLB, have contributed significantly to the success of LT, being able to identify rejection and infections (bacterial, fungal, viral, protozoan)

International Society for Heart and Lung Transplantation consensus statement for the standardization of bronchoalveolar lavage in lung transplantation

“… 97 , 98 Fiberoptic bronchoscopy of donors may maximize organ utilization through airway clearance, anatomical assessment, and identification of infectious organisms. 99 , 100 , 101 The ISHLT BAL survey showed that most (72.4%) perform bronchoscopy for culture analysis. Bronchoscopy and sample collection in donor assessment is uniformly done before procurement and varies from several days before to intraoperatively during the procurement 98 , 102 (Association of Organ Procurement Organizations policy and Organ Procurement and Transplantation Network/United Network of Organ Sharing policy).…”

“…Reports on airway sampling for microbiological assessment of potential organ donors have included tracheal aspirates, BW, and BAL. 97 , 99 , 100 , 103 , 104 , 105 , 106 Precise explanation of the sampling methodology is rarely available, making evidence-based practice recommendations problematic. The ISHLT BAL survey demonstrated significant variation in donor airway sampling methodology and technique; however, bronchoscopic aspiration of secretions (35.2%) and large airway BW (28.6%) were by far the most common practices.…”

“…Complicating this observation is the limited evidence to support these practices 104 , 105 and the general support for BAL by many experienced groups as the preferred sampling technique. 97 , 99 , 100 , 102 , 103 Although there is evidence for low-volume BAL in diagnosing infections, 107 , 108 based on Section 1 explanations, a low-volume airway sample does not necessarily reach the alveoli and should be called BW rather than BAL. Additionally, evidence to support location or side for donor lung assessment is lacking.…”

“…Based on the ISHLT BAL survey, clinical donor assessment of airway samples most commonly includes bacterial Gram stain and culture (75.2%), fungal stain and culture (59%), and acid-fast bacilli stain and culture (49.5%). Practices cited in the literature agree that microbiological assessment is necessary, 28 , 97 , 99 , 100 , 101 , 103 , 104 , 106 , 118 but unambiguous description of the specific clinical assessment is sometimes lacking. In general, most suggest that bacterial Gram stain and culture and fungal stain and culture should be performed.…”