Lung transplantation as therapeutic option in acute respiratory distress syndrome for coronavirus disease 2019-related pulmonary fibrosis

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Lung transplantation as therapeutic option in acute respiratory distress syndrome for coronavirus disease 2019-related pulmonary fibrosis

Jing-Yu Chen¹, Kun Qiao², Feng Liu¹, Bo Wu¹, Xin Xu³, Guo-Qing Jiao⁴, Rong-Guo Lu¹, Hui-Xing Li¹, Jin Zhao¹, Jian Huang¹, Yi Yang⁵, Xiao-Jie Lu⁶, Jia-Shu Li⁷, Shu-Yun Jiang⁸, Da-Peng Wang⁸, Chun-Xiao Hu⁹, Gui-Long Wang⁹, Dong-Xiao Huang⁹, Guo-Hui Jiao¹, Dong Wei¹, Shu-Gao Ye¹, Jian-An Huang¹⁰, Li Zhou¹, Xiao-Qin Zhang¹, Jian-Xing He³
¹Wuxi Lung Transplant Center, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, China; ²Department of Thoracic Surgery, Shenzhen Third People’s Hospital, Shenzhen, Guangdong 518100, China; ³Department of Thoracic Surgery/Oncology, State Key Laboratory and National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510120, China; ⁴Department of Cardiothoracic Surgery, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, China; ⁵Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, China; ⁶Wuxi Fifth Hospital, Wuxi, Jiangsu 214000, China; ⁷Department of Respiratory Medicine and Critical Care Medicine, The First People’s Hospital of Lianyungang City, Lianyungang, Jiangsu 222061, China; ⁸Department of Critical Care Medicine, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, China; ⁹Department of Anesthesiology, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu 214023, China; ¹⁰Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China

During the COVID-19 pandemic, some patients beat the virus—only to face a new, fatal threat: irreversible lung fibrosis caused by acute respiratory distress syndrome (ARDS). Even with life support like mechanical ventilation (MV) or extracorporeal membrane oxygenation (ECMO, a machine that takes over heart/lung function), their lungs could no longer deliver oxygen. For these patients, lung transplantation (LT) emerged as a last hope. A 2020 study by a team of Chinese transplant surgeons, published in the Chinese Medical Journal, offers the first real-world evidence of how LT can save lives in this worst-case scenario.

Who Were These Patients?

Between February and March 2020, three men (ages 58–73) with COVID-19-related end-stage lung failure were rushed to transplant. All had:

  • Negative COVID tests (confirmed via multiple samples—nasopharynx, sputum, blood—to rule out active infection).
  • Severe organ damage: Extremely high Sequential Organ Failure Assessment (SOFA) scores (14–18, indicating multiple failing organs) and sky-high D-dimer levels (a marker of blood clots).
  • Life support dependence: All were on MV and ECMO for weeks. Two had uncontrolled lung bleeding that conventional treatments couldn’t stop.
  • Pre-existing conditions: Hypertension, diabetes, or chronic kidney disease—common in severe COVID cases.

Their lungs were beyond repair: Chest scans showed thickened, scarred tissue (pulmonary fibrosis) that made breathing impossible. Waiting longer meant certain death.

The Transplant Process: Prep, Protection, and Precision

LT for COVID patients isn’t routine. The team faced two big challenges: ensuring the virus was gone (to protect the donor lung and medical staff) and managing the extreme fragility of these patients. Here’s how they pulled it off:

Step 1: Prove the Virus Was Gone

Before even considering LT, the team ran repeated COVID tests on samples from multiple sites (nose, lungs, blood, feces). Two patients had briefly positive fecal tests, but these were later confirmed to be non-infectious viral fragments—not active virus. This was critical: Transplanting into an actively infected patient would destroy the donor lung.

Step 2: Build a “Safe Zone” for Surgery

COVID is highly contagious, so the team transformed operating rooms into negative-pressure environments (air flows out, not in) and equipped staff with grade 3 protection (the highest level):

  • Positive-pressure head covers (to prevent foggy goggles and keep air clean).
  • Full-body protective suits.
  • Rehearsals for nonverbal communication (gestures for tools, sutures) since masks muffled speech.

A “coordinator” role was created to link the surgical team inside the OR with experts outside—using real-time video/voice to solve problems fast.

Step 3: Get the Right Lungs, Fast

Donor lungs came from deceased brain-dead donors (all COVID-negative) and were matched to recipients via China’s national organ allocation system. Even with long transport distances (128–1470 km), a “green channel” for organ transport kept cold ischemic time (how long lungs are without blood) as short as possible—critical for graft survival.

Step 4: The Surgery

All three patients had bilateral LT (both lungs replaced) because their damage was so widespread. To manage unstable hearts (from pulmonary hypertension), the team used intra-op veno-arterial (VA)-ECMO to support circulation during surgery.

One patient required an emergency heart transplant mid-surgery (his heart failed during lung removal), but bleeding complications led to his death. The other two had smoother surgeries: Their old lungs were removed, donor lungs were stitched in, and they were weaned off VA-ECMO before leaving the OR.

Results: Two Survivors, Lessons Learned

Two of the three patients lived—and their recovery was faster than expected:

  • Day 1 post-surgery: Both were awake and responsive.
  • 37–40 hours post-surgery: Weaned off ECMO (their new lungs worked!).
  • Early rehab: Started swallowing exercises, limb movements, and sitting up within days. By day 22, one patient could go 8 hours without a ventilator.

Their donor lungs looked perfect on scans—no signs of rejection or infection. Regular COVID tests (nasopharynx, blood, feces) remained negative.

What the Explanted Lungs Told Us

The removed lungs revealed why these patients couldn’t breathe:

  • Extensive scarring and bleeding: Fibrosis filled the air sacs, while blood clots blocked small vessels.
  • Mucus plugs: Sticky buildup in airways made gas exchange impossible.

These findings matched China’s COVID-19 pathology guidelines but were far more severe—proof that late-stage COVID can destroy lungs beyond repair.

Key Takeaways: Who Should Get an LT?

The study identified three non-negotiable criteria for COVID patients to qualify for LT:

  1. Irreversible lung failure: Even with maximal support (MV/ECMO), lungs aren’t recovering.
  2. Virus-free status: Multiple negative COVID tests (no active infection).
  3. No other organ failure: Kidneys, heart, or liver must be working well enough to survive surgery.

LT isn’t for everyone—but for these patients, it was the only way to avoid death.

What’s Next?

Two survivors are a small number, but this study breaks new ground:

  • ECMO as a “bridge to transplant”: For COVID patients on long-term ECMO, LT may be a viable option.
  • Protection works: No medical staff got infected—proof that strict PPE and protocols keep teams safe.
  • Early rehab matters: Starting exercises soon after surgery helped patients regain strength faster.

But questions remain:

  • Long-term survival: Will the survivors stay healthy? Immune-suppressing drugs (to prevent rejection) increase infection risk.
  • Viral relapse: Could dormant virus reactivate? The team is monitoring patients closely.
  • Scaling up: How do we make LT available to more COVID patients with fibrosis?

Why This Matters

This is the first case series of COVID patients on ECMO getting lung transplants. It shows that with careful planning, LT can save lives in the most desperate COVID cases. The success didn’t just come from surgeons—it relied on:

  • Government support: Green channels for organ transport, fast ethical approvals.
  • Teamwork: Critical care doctors, anesthesiologists, and pathologists working in sync.
  • Technology: Real-time video to connect experts and keep surgery on track.

For patients with irreversible COVID-19 lung damage, LT isn’t a “cure”—it’s a second chance. And for doctors, it’s a blueprint for how to tackle the next wave of post-COVID complications.

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