Editorial by Todd Grazia, MD, Chief of Transplant Pulmonology, Baylor University Medical Center
When SARS Co-V2 arrived on U.S. shores in early 2020, physicians in all specialties faced an enormous learning curve. As many have said, we didn’t know what we didn’t know about the coronavirus. Some patients seemed to skate through the infection, while others were laid up with flu-like symptoms for a few weeks, and yet others developed severe respiratory failure from ARDS and died. Pulmonologists and intensivists were tasked with caring for and trying to treat a critical patient population whose lungs seemed to be systematically attacked, and often, permanently damaged by the virus. As the pandemic continued to rage and upend lives, transplant pulmonologists faced a daunting ethical dilemma: Should we or should we not consider lung transplantation for patients with irreversible lung damage from COVID-19?
In the early days, the answer to this question seemed relatively clear. A patient severely ill with COVID-19 who was non-ambulatory, on prolonged mechanical ventilation (or ECMO), was highly deconditioned, and often in renal failure, had many contraindications to transplant. While it is a difficult ethical decision to refuse a patient this potentially life-saving therapy, many centers will not perform lung transplants on patients who most assuredly will experience complications and have a high risk of a poor outcome and poor short-term survival. There were the rare, usually relatively young, patients with single organ dysfunction (lung) who were able to be successfully transplanted. But many, if not most, patients who were dying from acute COVID-19 were not candidates.
As above, very few patients will qualify for lung transplant listing in the acute phase of COVID-19 pneumonia. More specifically, to be considered patients should be under 60 years of age and preferably under 50 – as relative youth in a person who was in good shape before COVID-19 is a predictor that they may be able to get through the complexity of a transplant. Patients must have single organ failure with no significant co-morbidities. There should also be radiological evidence of fibrosis or irreversible damage to the lung. Patients who have been on a ventilator and haven’t walked for a prolonged period (weeks or more) must have the potential for physical rehabilitation. Patients who can make progress by beginning to stand and take steps even while on a ventilator (or ECMO) might be considered for listing for transplant.
According to International Society of Heart and Lung Transplant guidelines, patients should not be considered for listing until eight to 12 weeks have gone by from the onset of their acute respiratory failure (to be certain that their lung damage is not still reversible), and chest imaging should show evidence of irreversible lung damage. Our robust ECMO program at Baylor University Medical Center gives us the luxury of putting some patients on ECMO for a period of time to see if their lungs can indeed recover. Much to our surprise, a larger-than-expected number of patients thought to have irreversibly damaged lungs actually were able to be weaned off ECMO and discharged from the hospital. Nonetheless, in those not able to liberate from the ventilator or ECMO circuit, given these highly restrictive criteria, the number of patients who will be considered for transplant listing will be very small.
As our understanding of this disease has grown over the last 16 months, we have discovered that some patients who we thought could not survive severe acute COVID-19 pneumonia surprisingly did (as above), only then to progressively develop post-COVID pulmonary fibrosis. Unlike the acutely ill cases of severe life-threatening COVID-19, these patients with COVID-19- induced chronic lung disease are most often outpatients who are becoming progressively more short of breath and on escalating amounts of oxygen. A number of these patients may progress to the point where they require consideration of lung transplantation. These patients often have no previous history of lung disease but now have developed progressive hypoxia, pulmonary fibrosis and have a significantly diminished quality of life. We believe many of these patients have the potential for positive outcomes and should be considered for lung transplant evaluation in the same way we evaluate patients with other advanced lung diseases unrelated to the coronavirus.