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Let's hear it for lungs.

LET'S HEAR IT FOR LUNGS

Emphysema patients who, by the millions, are struggling to breathe should take heart in the work of a man named Joel Cooper. Help may be on the way in the form of lung transplants-- not this year or next, but soon, we hope.

The Post interviewed transplant surgeons with the question, "What could you do to help all these emphysema patients who are suffocating for want of oxygen in their blood?' Emphysema patients pose a special problem because replacing one lung won't suffice. The over-inflatable, emphysematous lung would steal the air from the new lung, while the new lung would get most of the blood needing oxygen.

At present it is easier to get a transplant of the heart with both lungs than it is to obtain a double lung transplant.

Of all the heart and lung transplant surgeons, Joel Cooper seems by far the most optimistic about the possibility of transplanting two donor lungs into emphysema patients. "Not yet--we need to do more animal models first, but perhaps in two years,' he predicts.

He has good reason to be optimistic about lung transplants. On the opposite page, you see him flanked by two successful "one lung' transplants. Both these patients had only a short time to live with rapidly advancing pulmonary fibrosis, a kind of lung disease that causes the hardening and scarring of lung tissue. "In this disease the lung soon becomes like a brick' says Dr. Cooper. "Instead of being spongy and soft it becomes increasingly very hard and fibrous. In fact, on microscopic section, it's almost unrecognizable as a lung. It's unbelievable. When you remove the lungs from these people and look at the tissue under the microscope, you almost can't recognize it.'

Pulmonary fibrosis is quite different from emphysema but just as devastating--the lungs aren't able to transfer oxygen and carbon dioxide across the membranes. One big difference: primary pulmonary fibrosis victims can receive one new lung and keep the other. In emphysema, however, a mechanical problem--too much of the inhaled air flowing into the bad lung--leaves the new lung with insufficient oxygen. Hence, double lung transplants are necessary.

In emphysema the elasticity of the lung, which allows it to fill and empty in a coordinated fashion, is gone because the architecture of the lung is totally disrupted and destroyed by inflammation of the alveolar membranes.

Ninety-five to 99 percent of emphysema cases are caused by smoking cigarettes. Because excessive smoking became prevalent after World War II, the number of people dying from emphysema is growing rapidly. There are an estimated 10 million sufferers in the United States today, and probably 30 million if we count all those with mild-to-moderate forms of the disease. Today emphysema is a truly devastating disorder that costs our country about $10 billion per year for medical care and loss of productivity. At the end of the road, emphysema patients who are suffocating could be useful, productive human beings again if only they could be given some way to perform the function of their hollowed-out, useless lungs. For these people, lung transplants or artificial lungs could mean survival and the ability to work again.

Unlike emphysema, pulmonary fibrosis, fortunately, is relatively rare. Because no one knows what causes 50 percent of the cases, any of us could get it at any time. This lung disease progresses more rapidly than emphysema, and a patient can reach the end stage in three or four years from onset.

Dr. Cooper has proved that patients need no longer accept pulmonary fibrosis as a death sentence--provided sufficient donors can be found, anyone with this tragic disease might have a second chance.

Dr. Cooper is a booster for the lung patient. "Most of the transplant work has been done by the cardiovascular surgeons, and they have a bias, naturally, to those with heart problems,' says Dr. Cooper. He is a chest man first and foremost, and he wants to pursue lung transplants. Today if someone needs both lungs and a new heart to be transplanted, Dr. Cooper prefers to call it a lung-heart transplant instead of heart-lung.

Dr. Cooper's team includes six thoracic surgeons, two anesthesiologists --20 people in all. One of his teammates ascribes Dr. Cooper's success to his unique ability to orchestrate. ". . . He's a great administrator. Doing a transplant is a logistical nightmare, and Dr. Cooper pushes and prods and gets a large number of people to pull in the same direction.'

We asked Dr. Cooper, "Why so few lung transplants?'

Dr. Cooper: After 20 years of no success with lung transplants, people became discouraged and were giving it up. Now, we have done two in a row [Hall and Assenheimer], and those patients are quite healthy and living normal lives. That shows lung transplants work, just as Stanford Medical Center and others have shown that heart-lung transplants work. Thus it becomes a question of which is the best operation under what circumstances. So we seem to have a conflict. We know they need the operation; we know they are going to die without it. The will is there. They are willing to take the risks. And yet if we choose unwisely--if we, for example, had tried some deathbed rescues with single lung transplants, as has all too often been done in the past, and had failed for those reasons--then for another 10 or 20 years lung transplants would be finished.

Dr. SerVaas: But emphysema patients are dying every day. To save them you would have to do both lungs, wouldn't you?

Dr. Cooper: The emphysema patient does not need two lungs. For his needs, one lung is sufficient. But if the other lung is left in, it will affect the function of the new lung adversely, and therefore both lungs have to come out. It is an absurdity to put a heart in somebody who does not need it, but it so happens that at the present state of the art there are only, at the moment, two operations involving lung transplantation; one is the single lung, which we have now shown works, and one is the combined heart-lung. But we are working in the laboratory and hope to have a double lung transplant model soon. Then we hope that for someone who has to have both lungs out, we can put in two lungs.

Dr. SerVaas: What could be done now for an advanced emphysema patient who can't breathe?

Dr. Cooper: At the present time, we are very interested in emphysema. But we have to say that we are not yet prepared to take out both lungs and put in two new lungs: Therefore, for this phase in history, we would accept throwing away the heart and putting another one in. Technically, that is the only way it can be done, even though one would hope that we would be smart enough down the line. The patient's problem is going to be that he has a huge chest from emphysema and the new normal lungs are not going to completely fill the space. That might potentially be a problem.

Dr. SerVaas: Unless you have a very large donor?

Dr. Cooper: Yes, we are prepared to deal with that, I think.

Dr. SerVaas: What about the emphysema patient on prednisone?

Dr. Cooper: Another problem. That's a very good point. As a result of our research for several years into why lung transplants were failing, one of the major conclusions that we drew was that the use of prednisone for immune suppression was probably a very major factor in previous failures.

With the new drug cyclosporin, one can avoid prednisone in the early postoperative period. All we try to do is avoid it for three weeks until the wounds have healed.

What we really showed was that when you combine all the hazards--one, an airway connection that is actually a somewhat tenuous one because the blood supply is poor; with two, exposure to the air and hence infection; three, off and on the ventilator; and four, a high dose of prednisone with all its problems, particularly its tendency to promote infection --in retrospect it isn't surprising that there were so many failures.

So we now eliminate prednisone. In fact, the Stanford heart-lung group has adopted, I believe, the same policy on the basis of our work. We all try if possible to avoid much, if any, prednisone in the first few weeks.

Now what does that mean? For our program, whether it is the lung program or the combined lung-heart, we won't accept somebody if he is dependent on prednisone. Many people are on prednisone as a last, desperate attempt.

Dr. SerVaas: And you mean they can't get off?

Dr. Cooper: Yes, but if they can't get off it, then we think that is a very major contraindication [condition that renders a particular treatment undesirable]. You have to wean them off prednisone so their own adrenal glands begin to function again.

I have had many calls from emphysema patients in the last month because there was a program on a cable news network that showed our two lung recipients out of bed, walking down the hall and on the exercise bicycle. They pointed out that these are fairly unique. But one mistake a TV announcer made when showing Tom Hall walking outside in the cold wintry weather with his wife was saying this man had emphysema. He had pulmonary fibrosis.

So I have had probably 40 inquiries about emphysema--all of them are virtually over the age of 60. I have called and written back saying, unfortunately, we can't consider anybody over 50. The truth is we are considering a few people over 50, but not with emphysema--not at this time. We do think that emphysema poses particular problems because of the space and because the respiratory muscles are stretched out. As you know, as the chest gets larger, the diaphragm becomes very flat and loses a great deal of its contractile ability.

Dr. SerVaas: But you think you could get these people in ahead of time to rehabilitate them?

Dr. Cooper: Oh, we insist upon it. The patient with emphysema is gasping and oxygen dependent 24 hours a day. Such, of course, was the case with our last two transplants. These people were both on oxygen 24 hours a day and would turn blue if they tried to do any exercise. They were in wheelchairs.

One of the things we learned after our first single-lung transplant--the one done a year and a half ago-- was although we had a good lung in the patient and his oxygen levels were very good, he couldn't do anything, and we were very disappointed in the first couple of weeks.

We thought to ourselves--gee, what is going on here? The we realized that if you have been on oxygen for 24 hours a day and you have restricted lung function, unlike the restricted heart problems, you can't do anything anytime. As a result, your muscles are shot. You are so out of training that even if you now have a normal lung you can't use it for a while.

So we started him on a rehab program of treadmill wind exercises, and this was astounding. You know, each week he could do twice what he could do the week before. And he continued improving and improving and improving. We learned a lesson: We won't transplant anybody with lung disease until we have a maximum go at rehabbing them in advance.

Now again this is the difference between our programs. We are lung oriented. Therefore we bring these patients into the hospital, where they go on an active program. It is true that they can't do too much. But they can exercise an arm muscle at one time and a leg muscle at another time and a wrist muscle and so on. We insist on that. We also concentrate on nutritional support.

When we did Monica Assenheimer, we had her programed for six weeks. She gained ten pounds and her exercise tolerance doubled. We got her in shape so that when we got the lung into her, she had enough muscular cular strength to get through the post-operative period. Almost all of the patients that I am aware of elsewhere --who have died after an attempted transplant for emphysema-- would have been done in a cardiac center, not a lung center.

At Stanford the patients are kept on their own expenses--living in a hotel or an apartment. Stanford doesn't do emphysema patients. The reason they have been so successful --and we admire them greatly and have patterned our program after theirs--is that they have adopted very, very strict criteria as to who can be taken. Nobody over the age of 50, nobody on a ventilator, etc. Their patients sit out there at their own expense . . . waiting. We have a different approach. We think that is O.K. for people for heart-lung transplants for cardiac disease, but we don't think we will provide any survivors unless we take the lung patient in advance and do muscle training on them, because of the critical lung problem that they have.

Dr. SerVaas: Are you planning to do emphysema patients soon?

Dr. Cooper: Yes. But only certain ones. I get letters and phone calls every day. And I am virtually turning down every one of them, because we will not take on an emphysema patient over 50.

Dr. SerVaas: Why?

Dr. Cooper: Experience with even such relatively routine transplants as kidney transplants has demonstrated that once you get over 50 your ability to tolerate the rigors of the operation, to bounce back from complications, to tolerate the immunosuppressive drugs, falls off. And therefore when you are dealing with a commodity--a donor organ--which is in very short supply, for which there is excessive demand, you then restrict it to that group where you think you have the best chance.

Again, we are borrowing from the experience of others. The first transplant we did was 58. It was for fibrotic lung disease. And people thought we were crazy. This is why people are getting mechanical hearts now when they need heart transplants--you have got to cut off somewhere, and they have decided on age 50.

My real concern about the emphysema patient is that even if we put normal lungs into him, will he have the strength in his chest to breathe with these lungs to get over the postoperative period and to carry on?

Dr. SerVaas: Recently we had a demonstration of something called a pulmo-wrap. It looks like a sleeping bag and has a motor attached. Would it help them breathe in the postoperative period?

Dr. Cooper: Oh, we call that a sheet ventilator. You crawl in between the sheets, and there is a little Quonset-hut thing that goes over your chest.

Dr. SerVaas: Does that work?

Dr. Cooper: Oh, yes, it is great. It helps. In fact, in our program we plan to try these patients on that to rest the respiratory muscles--to see if, by relieving the constant fatigue, we can strengthen them, because we have a superb respiratory--physiology unit. We are fortunate here in the favorable confluence of a lot of factors, and that is why we have succeeded with the lungs. The other heart-lung transplant centers are all run by cardiac surgeons oriented toward cardiac-failure diseases. We are the only ones I know of who are orienting our program solely toward lung disease.

That's why we jokingly call ours the lung-heart operation, as opposed to the heart-lung operation. It is the same operation, but it emphasizes that it is being done for lung disease. So we would take an emphysema patient, if we thought he met our criteria. We would see how far we could get on the rehabilitation program, strengthening his muscles beforehand, and then try to get the biggest possible donor. Yes, we would be taking risks both for him, of course, as well as for the program, because no one has successfully transplanted an emphysema patient. But we have, in fact, just sent out a letter to pulmonologists across Canada indicating that we are now prepared to take on patients with emphysema, cystic fibrosis and various forms of lung disease for one or the other of the current transplant procedures that we now have.

Dr. SerVaas: What if the emphysema patient says, "I have a perfectly good heart'?

Dr. Cooper: But heart-lung is all we can do now. Again, it is a marvelous operation, but there have been some rejection problems with hearts, and there have been lung deteriorations.

We've been watching Mr. Hall very carefully and have been monitoring his pulmonary function for about a year and a half. He has shown no signs of it yet. I mentioned the cardiac thing because it is important. Why should you have a new heart, when all the problems of rejection of the heart and advanced coronary-artery disease and things like that can occur? That is exactly the reason we are still pursuing alternatives.

We feel that the heart-lung is the operation down the line for people who must have a new heart and must have new lungs. But there has to be a better way for someone who needs lungs, and that is really the excitement of the single lung transplant.

These two people had good hearts. For example, not only does the single lung transplant let you keep your own heart--it also allows you to have your other lung; for example, the last lady we did had a single lung transplant. She had a very, very serious rejection, and the only thing that kept her alive, as bad as it was, was her other lung.

Dr. SerVaas: Well, if you take an emphysema patient, obviously, where we are now, we are really talking about doing both lungs. Can you keep someone alive if he goes into respiratory failure because of rejection? And if you had need for another lung, it wouldn't be likely you could get one immediately when you need it. Could you keep him alive on a respirator?

Dr. Cooper: What you keep them alive on is an extracorporeal membrane oxygenator. That is what really got us into this work. That has been a longstanding interest of ours. We've used it successfully for up to 20 days on a person whose lungs were not functioning at all. Right at the bedside we had him on a pump just like the heart-lung machine. It was that pump, in fact, that led us into the lung transplant, because so many transplant patients were dying of respiratory failure rejection. And here we had something that we were using for other purposes. It was intended for people who come into intensive-care units and whose lungs could not br maintained. We have used it successfully as an aid in surgery.

The saga was that of a 32-year-old fellow in Atlanta two years ago who had paraquat poisoning, an herbicide that causes irreversible lung damage. He got the poison in his system when he was down in Georgia and was on the ventilator and getting worse and worse. Of course it is known that with paraquat poisoning, one can never get better. It is inevitably fatal.

But he had a very smart physician who first of all called Stanford and asked if they would accept him. They said no, we don't take someone who is on a ventilator for transplants, because we can't keep him alive. So his physician called Frank Vieth in New York, who was at the time doing some lung-transplant work, and said, "Would you take this fellow for a lung transplant?' Dr. Vieth said, "Yes,' and the doctor in Georgia said, "How are you going to keep him alive until you get a donor? Do you have a membrane oxygenator?' He said, "No, we don't have that.' The physician answered, "Thank you very much.'

Then he called Boston and he called the Massachusetts General Hospital, where I did my training, and they said, "Well, we have a membrane oxygenator, but we don't have anybody who does lung transplantation. Why don't you call Dr. Cooper in Toronto? So they called us. We happened to be the only people in the world who had a combined interest in lung transplantation and the support.

So we flew him up, kept him alive for five days on the extracorporeal circulation and transplanted his lung, a single lung. It worked very well. We got him off the extracorporeal device. At five days, however, the paraquat, which was still in his body tissues, reached out and attacked the new lung, and it went into failure. So then we really were up the creek.

After consultation with the family we decided on a "Star Wars' bailout. We put him back on the extracorporeal support device--the artificial lung--for 19 more days, kept him alive for 19 days, while we cleared the paraquat from his system with dialysis. Then we got another donor. This time, instead of taking out the original transplanted lung--as bad as it was, it was still better than his own other lung, which was all infected-- we took out the opposite lung and did another transplant.

He lived for three months with good lung function but ultimately died of complications of his poisoning. So it wasn't a success in that he did not get out of the hospital, but we took a critically ill person and got not one but two lungs into him, and both of them survived for over a month.

There had only been three people living even a month after lung transplants up to that point, and we knew we were on the right track.

What happened was, he became paralyzed from muscle damage from the paraquat, so he was left on the ventilator. Although his lungs were clear and he had good oxygenation on room air, he needed a ventilator, and eventually he had complications of the ventilator and artery erosion from the tracheotomy tube. Ultimately he had a stroke, and mercifully, died, because increasingly his muscles were becoming wasted from the paraquat.

It was never reported or recognized before, because no one in the world had ever lived that long after such a major paraquat insult. Here we had sort of managed to bail him out of the respiratory aspects and then saw, of course, the long-term effect that hadn't been recognized. He was a nurseryman and used the poisonous herbicide in spraying plants and must have inhaled some of it.

One of the things we have that others don't have is a support device and experience with it. So if we do a transplant, and there is rejection, we can sustain the patient. With the single lung transplants we have been lucky--the other lung carries them. If we did heart-lung transplants or a combined double lung such as in this gentleman's case, and he rejected and we couldn't keep him going, we would then put him on this device.

Dr. SerVaas: Yours is really the only place this device is being used?

Dr. Cooper: No--we are the only ones that combine it with transplants. There are two or three places in North America that have this type of interest in long-term extracorporeal respiratory support. There is also a place in Italy. There are a few places scattered around the world where it is used as we have used it.

People come into an intensive-care unit and become so critically ill that, even with a ventilator and high oxygen and everything else, you can't keep the oxygenation up.

The PO2 falls lower and lower, and they are about to die. As a desperate effort you hook them up to this extracorporeal device. It has to be capable, of course, of not just doing it a couple of hours, like the heart-lung machine does in the operating room. It has to be capable of sustaining day after day and week after week as a lung function.

Dr. SerVaas: Do you have any idea how long it might work?

Dr. Cooper: I think, frankly, two weeks is a long time. You start getting into problems with infection, etc., and although we have gotten away with using it for 20 days, one would hope not to need it more than 7 days to two weeks. You use it when you are buying time and hope that the underlying problems are reversed.

Dr. SerVaas: And hope that you can get a donor quickly?

Dr. Cooper: . . . another transplant or, on the other hand, if it is rejection, you would hope that you are going to get over it and then be able to carry on.

Dr. SerVaas: How soon do you think you can do the double lung transplant?

Dr. Cooper: Well, we have an operation, but we think we had better try it on animals for a couple of years first. I think it will be two years before we are ready to do both lungs without the heart.

Now if an emphysema patient with a good heart came to us, we would say, "Look, you're right, it is crazy to have to put in a new heart. It so happens, however, this is all we have to offer or all that anybody else has to offer at this time.'

The critical part is timing. It is quite important that they do it while they are still strong. If they wait too long, they don't have a chance. If you do it too soon and you fail, you feel you have used up some valuable time. Thus we do it in somebody who has a disease that is progressive, where they are not only disabled but becoming worse, and where we feel they have a limited lifetime, and they have the will to try anything and take any risks in order to get up on their feet and out again.

Dr. SerVaas: So much is written about most medical breakthroughs. Why hasn't there been more coverage of lung transplants in the press?

Dr. Cooper: When we did Tom Hall, we didn't say a word, and nobody knew about it because we didn't tell anybody about it. I said, "Look, there is no trick to putting in the lung--the trick is to have success.' So at six weeks when Tom left the hospital for the first time we let the press know about the operation. Now, of course, it does not make the same kind of press as a man who is struggling for his life. But as far as I am concerned, it is the right time to do it. The time we really made the hoopla was when he had been out of surgery for one year. We said, O.K., now we can call that successful; now we are willing to tell people about it.

Photo: Dr. Joel Cooper of Toronto General Hospital has given new hope to lung patients everywhere. This dedicated surgeon became the first to successfully transplant a lung into patients suffering from respiratory failure. "The two-lung operation is not here yet but may be only two years down the road.'

Photo: No two people are more thrilled at Dr. Cooper's triumph with lung transplants that Tom Hall and Monica Assenheimer. They are now restored to brand-new lives because of their courage to risk the operation and Dr. Cooper's confidence that he could make the operation successful.

Photo: "The lung is supposed to be soft and spongy,' explains Dr. Cooper to Tom and Monica, "but in your disease it turns into something like a brick.' Finding sufficient lungs for transplants is the biggest herdle. One of 20 lungs offered is usable. The scarcity makes great need for donors.
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Title Annotation:interview with surgeon Joel Cooper
Author:SerVaas, Cory
Publication:Saturday Evening Post
Article Type:Interview
Date:May 1, 1985
Words:4630
Previous Article:Botts runs for his life.
Next Article:How Tom and Monica got their second wind.
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