On June 12, 2021, MOHAN Foundation in association with Transplant Recipients of India and Organ failure patients - a Movement to Provide Hope (TRIOMPH) and The Network and Alliance of Transplant Coordinators (NATCO) organised a webinar on “Lung Transplants Post COVID-19 & Other Options” as part of the ongoing series “Synchrony Dialogues with MOHAN Foundation”. The webinar was supported by SBI Card and SBI Foundation.
The main objective of the webinar was to educate people on lung transplant post COVID and to receive expert opinions on other options available in the case of Acute Respiratory Distress Syndrome (ARDS) related to COVID-19. ARDS has posed an unprecedented challenge. In some patients, it can lead to irreversible and permanent lung damage, rendering them irrecoverable and leaving lung transplantation as the only lifesaving option. Many transplant coordinators of MOHAN Foundation, have been receiving queries from patients for the feasibility and opportunity for lung transplant post COVID. Hence, MOHAN Foundation decided to organize this webinar on what are the other options other than lung transplant, such as Extracorporeal membrane oxygenation (ECMO) and how can patient families go about this.
The webinar was moderated by Dr. Sandeep Attawar (Heart & Lung Transplant Surgeon & HOD, KIMS Hyderabad). Dr. Kumud Dhital (Cardiothoracic & Transplant Surgeon Chairman- Heart & Lung Committee, The Transplantation Society) and Dr. Unmil Shah (Transplant Pulmonologist, Institute of Heart & Lung Transplant-KIMS Secunderabad, Telangana, Gleneagles Global Hospital, Mumbai) were the experts. Two lung recipients were also invited to the panel discussion to share their experiences with the audience.
At the beginning of the session, Ms. Pallavi Kumar, Executive Director-MOHAN Foundation-Delhi NCR welcomed the audience and gave a brief introduction of esteemed panelists. She also informed about the objective of the webinar and invited Dr. Sandeep Attawar to begin the discussion.
Dr. Attawar began by with expressing his gratitude towards all the panelists to be a part of the webinar. He said issues like COVID requires human stories and therefore he was grateful to the two valiant fighters as lung recipients, who gave their consent to be on this panel discussion to share their thoughts on how they tackled the illness and period of insecurity that their families had gone through while these two fighters were on hospital bed, hoping to recover. He also thanked MOHAN Foundation for selecting this very important topic and to bring across scientific minds in the community to answer complex questions and to talk about the decisions that the family have to make at this time of crisis. Dr. Attawar asked each expert a question one by one, which was answered/discussed thoroughly.
Discussion with Dr. Kumud Dhital
Question 1: Many families have questions when they are told by local physicians that their loved one is in a terminal stage of COVID and his/her situation is critical so they need an immediate lung transplant and this is the only solution. How would you approach this situation?
- There are no proper guidelines for transplants that are written in India for local community. The healthcare units have been receiving guidelines from abroad. For Example, India received guidelines for lung transplants post COVID from Toronto Group.
- ECMO has a role in all phases of lung transplantation. It serves as a bridge to transplantation in appropriate patients awaiting lung transplantation.
- The treating doctors need to be realistic and should not give false hope to the families.
- ECMO is not meant for only lung transplants. It is also for transferring for continuity of care at a higher level center. It may not eventually lead to lung transplant because until the patient has been seen and examined thoroughly, a decision regarding transplant cannot be made.
- There should be simple sets of answers to queries related to lung transplant in hospitals/NGOs which should not contradict with each other.
- When faced with a decision about having a lung transplant, families/patients should know what to expect of the lung transplant process, the surgery itself, potential risks and follow-up care.
Question 2: What is ECMO and when would you make the decision to move someone from mechanical ventilation towards ECMO institution?
- Extracorporeal membrane oxygenation (ECMO) does the job of the lungs and/or heart, allowing the organs to rest and recover when patients are incredibly sick. The technology is used when all other forms of heart and lung support have failed for critically ill patients.
- ECMO works by temporarily drawing blood from the body to allow artificial oxygenation of the red blood cells and removal of carbon dioxide with a machine. Now, the treatment is being used to support critically ill patients with Covid-19 pneumonia for whom ventilation is insufficient to sustain blood oxygen levels.
- It is very difficult to get proper clinical summary of the patient as doctors/nurses have to rely on relatives for this information.
- Only after careful observation and receiving accurate clinical summary of the patient, the physicians should make a decision to transfer a patient from mechanical ventilation to ECMO institution.
Question 3: With all complexity of teams travelling in and out to be able to evacuate patients from remote locations, how would you secure the safety of medical staff who were not just involved in retrieval process? How would you motivate them? How would you take care of them not just during the surgery but in post-transplant set up in the ICU?
- We should limit the number of nurses in ICU and separate out the nurse team, doctor’s team and cleaning team as they are exposed to high potential areas of getting infected.
- There should be a separate team dedicated towards the post-transplant care of the patients.
- The team working in the ICUs/ operation theatres, who have been exposed to infected patients and having symptoms of COVID, should immediately isolate themselves.
- There should be adequate PPE kits available in the hospitals.
- The donors should be taken care of very well because they are at high risk of getting infected.
Discussion with Dr. Unmil Shah
Question 1: What would your approach be if a family member calls and says his younger brother, aged 23 is diagnosed COVID positive, his saturation is dropping and he is on high flow oxygen? He probably requires mechanical ventilation or might require an ECMO. How would you address this issue?
- First of all, it is very important to have a detailed clinical summary of the patient from the treating hospital and to discuss with treating doctor about what kind of treatment the patient has received? It is also important to discuss with the family to know about the course of disease.
- There is an assessment specially prepared for the patient to find out what is the general condition of the patient, whether a patient is really fit and needs ECMO? It is important to understand first the general candidacy of a patient.
- To follow the current guidelines for lung transplant post COVID 19, it is mandatory to receive the clinical summary of the patient.
- There are methods available to improve the P/F Ratio and reducing ventilator pressure. These methods should carefully be applied by the hospitals.
- It is a step by step approach to a query which comes. It should be a team work of family members, treating doctors, transplant/donor coordinators to decide the and come to a consensus.
Question 2: What are the challenges that very critically unwell patients have to face when they transit from a mechanical ventilation to a tertiary care center?
- Practically, there are two types of challenges-logistical and clinical challenge considering the pandemic situation.
- Inter facility transfer of patients with COVID 19 related acute respiratory failure is high risk because of the severity of respiratory failure and potential for crew exposure.
- Transport of a critically ill patient requires detailed coordination to ensure the safety of both the patient and the transport team.
- Smaller and critical access hospitals do not have the capacity or resources to manage critically ill patients, especially in large volumes.
- Cost of airlifting a patient to a tertiary care center is a major challenge that is faced by the healthcare units.
Sharing stories by lung transplant recipients
- Mr. Ravindra Babu Dasari from Hyderabad shared that he has been a seafarer for past 40 years retiring finally as Captain. He underwent a bilateral lung transplant at KIMS hospital, Secunderabad, Telangana in November, 2021. He shared his incredible experience of hope and healing from lung transplant.
- Mr. Pranav Munjal is an architect from Punjab. He underwent a lung transplant in April, 2021. While sharing his story, he gave powerful and heart-wrenching messages for the donors that affected the audience and experts emotionally:
“We make a living by what we get but we make a life by what we give. Organ donation is the greatest donation of mankind. Everyone should pledge for organ donation and MOHAN Foundation is doing a fantastic job.
If a donor could be a reason for me to live a new life then why can’t I be the reason for the same? Even though I do not know my donor but I would like to thank him for giving me a new life”.
The webinar was very exciting and impactful. The audience were thoroughly engaged in the discussion and asked many questions. Some of the questions that came from the audience are:
- Can a lung transplant recipient donate organs?
- Is partial lobectomy helpful for post COVID lung infection patients?
- How many days we can keep patients on ECMO?
- What are the chances to get recovered after post COVID fibrosis?
- How is the process of post COVID lung transplant care being addressed and treated by KIMS?
- After post COVID lung transplant, are there chances of antibody mediated rejection?
- Is there any lung transplant registry?
- What is the life expectancy after lung transplant in India and abroad?
- Can ECMO be hired? Where are ECMOs available in India?
The webinar was live on MOHAN Foundation’s social media platforms such as Facebook (1.3 K views) and YouTube (158 views).
Click here to watch the video.