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Review
. 2024 Jul 20:6:100124.
doi: 10.1016/j.jhlto.2024.100124. eCollection 2024 Nov.

Applied physiological principles in the management of a lung allograft to thoracic cavity size mismatch in severe emphysema

Michael Eberlein  1 , John C Keech  2 , Robert M Reed  1
Affiliations
Review

Applied physiological principles in the management of a lung allograft to thoracic cavity size mismatch in severe emphysema

Michael Eberlein et al. JHLT Open. .

Abstract

In this review, we discuss physiological principles that guided the management of a lung transplant for emphysema related to alpha-1-antitrypsin deficiency, where a lung allograft to thoracic cavity size mismatch occurred (donor-to-recipient predicted total lung capacity [pTLC] ratio was 0.89, donor pTLC-to-recipient actual-TLC ratio 0.62). In emphysema, the loss of lung elastic recoil and airway obstruction leads to air trapping and lung hyperinflation. Remodeling of the thoracic cavity ("barrel chest") develops, which has implications for donor-to-recipient sizing and postoperative management of lung transplantation. We discuss the physiology of a relatively undersized allograft and the impact on chest tube, mechanical ventilation, and respiratory system mechanics management. This case also illustrates how chronic adaptations of the ventilatory pattern to advanced lung diseases are reversible and the chest cavity size can remodel back to normal after lung transplantation.

Keywords: chest tube; collateral ventilation; emphysema; lung transplant; size mismatch.

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Conflict of interest statement

All authors have no relevant conflicts of interest to disclose. Funding: None.

Figures

Figure 1
Figure 1
(A, B) Pretransplant computed tomography of the chest. (A) Coronal view showing lower lobe predominant emphysematous changes. (B) Sagittal view showing intact major fissure and lower lobe predominant emphysematous changes. (C) Intraoperative situs following clamshell incision. (D) Left explanted native recipient lung. The explant remained hyperinflated following pneumonectomy and did not fit into a 3.5-liters specimen container. (E) The pleura of the left lower lobe is punctured and immediately following the pleural puncture (F) the explant fully deflated.
Figure 2
Figure 2
(A) Intraoperative situs following right allograft implantation. The hyperinflated left native lung is filling the entire left hemithorax, while the right allograft is not fully reaching the apex in the right hemithorax. (B) Intraoperative situs following bilateral allograft implantations. Bilateral allografts are not fully reaching the apex of the hemithoraces and a size mismatch is apparent. (C) Post-transplant computed tomography of the chest. Residual pleural space from a significant size mismatch between a smaller allograft and a larger recipient's chest cavity is shown in axial view (C), sagittal view (D), and coronal view (E).
Figure 3
Figure 3
(A) Pretransplant FVL and (B) first post-transplant FVL. (C) Follow-up chest CT at 11 months post-transplant shows normal lung parenchyma and resolution of previous pneumothorax. (D) Axial and (E) sagittal views. CT, computed tomography; FVL, flow volume loop.
See this image and copyright information in PMC

References

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