Physical Therapy in Lung Transplantation

Physical Therapy in Lung Transplantation Lung transplantation requires the skillful attention of a health care team to provide optimal results. The physical therapist is an integral part of this team, providing expertise in exercise testing and prescription in all phases, from initial evaluation through postoperative rehabilitation and beyond. In addition, the physical therapist promotes effective ventilation, offers techniques for enhanced coughing and mucociliary clearance, and provides treatment of the musculoskeletal system. Lung transplantation is reserved for patients in whom all other treatments have been exhausted. It is important for the physical therapist to stay abreast of the evolving field of lung transplantation, including medications and complications. The physical therapist has a critical role in helping lung transplant recipients achieve optimal function, increased survival, and improved quality of life. [Downs AM. Physical therapy in lung transplantation. Phys Ther. 1996;76: 626- 642.1

Key Words: Cardiopulmonaly physical therapy; Exercise; Lung; Pulmonaly, thoracic surgery; Rehabilitation; Transplantation.

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Physical Therapy . Volume 7 6 . Number 6 . June 1 9 9 6

ung transplantation is used throughout the world as a treatment for end-stage lung disease. Increasi r ~ gnumbers of physical therapists are being exposed to these patients, and they also are being challenged to maintain optimal function and level of activity for patients awaiting lung transplantation. Treatment of a lung transplant recipient requires knowledge of possible complications and their effects on activity and of the appropriate progression of activity postsurgi.cally. Although much of the physical therapy for lung transplant recipients is similar to that for patients with other organ transplants, the unique properties of the lung present the clinician with additional considerations. Physical therapy for lung transplant recipients requires a sound grasp of pulmonary anatomy and physiology as well as knowledge of pulmonary disease and normal and abnormal responses to exercise.

History of Lung Transplantation Hardy,' in 1963, performed the first human lung transplant at the University of Mississippi after many years of laboratory study. The patient died of renal failure and malnutrition after surviving for 18 days. Successive attempts at different centers were made over the next 20 years, but there was no long-term ~ u c c e s s . ~ There - ~ was a need to improve bronchial healing because the portion of the main-stem bronchus where the transplanted lung is attached is predisposed to ischemia, having no systemic arterial blood supply.L6The use of high dosages of steroids immediately after transplantation also resulted in delayed healing.' To remedy this problem, an omen-

tal wrap or omentopexy around the bronchial anastomosis was i n t r o d u ~ e dThe . ~ omentum, a fatty, vascular tissue attached to the intestines, was brought u p from the abdomen and wrapped around the anastomosis to p r e vide an adequate blood supply to the bronchus. In 1983, the omentopexy procedure was used by Cooper at the University of Toronto to perform the first successful single-lung transplant on a patient with end-stage pulmonary fibrosis.Yhree years later, Cooper and colleagues'" performed the first successful double-lung transplant on a patient with end-stage emphysema. Recent modifications of lung transplantation include foregoing the omentopexy technique and using a prcl cedure for telescoping the bronchus to diminish the ischemic area." Single-lung transplants are becoming increasingly frequent for patients with pulmonary vascular disease and for patients with chronic obstructive pulmonary disease. The development of living related lobar transplantation by Starnes at the University of Southern California has expanded the available donor pool.I2 The introduction of new forms of immunosuppressive medications continues to alter the protocols at different lung transplant centers.'"

Indications Lung transplantation is generally reserved for patients with irreversible, end-stage pulmonary disease.l4-l"andidate selection criteria include limited life expectancy due to pulmonary disease, limited use of steroids (less than 10 mg per day), n o major coronary artery disease, no other systemic disease, and an age of less than 50

AM Downs;, PT, CCS, is Cardiopulmonary Specialist, Department of Physical Therapy/Occupational Therapy, University of North Carolina Hospitals, CB 7600, 101 Manning Dr, Chapel Hill, NC 27514 (USA), and Instructor, Division of Physical Therapy, Department of Medical Allied Health Professions, School of Medicine, The University of North Carolina at Chapel Hill. This article was adapted from a presentation at the Combined Sections Meeting of the American Physical Therapy Association; February 61-12, 1995; Reno, Nev. ?'hz\ ailzcl~ronc submatted Ju[y 11, 1995, and rons arceptd Manh 15, 1996.

Physical Therapy . Volume 76 . Number 6 . June 1996

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Table 1. Tests and Procedures for Lung Transplant Evaluationo Laboratory Arterial blood gases Complete blood count Electrolytes-BUN-creatinine-liver function tests Chest roentgenogram Sputum culture Urinalysis Pulmonary assessment Pulmonary function tests Ventilation/perfusion scan Computed tomography scan when indicated Cardiac assessment 12-lead electrocardiogram Echocardiogram MUGA scan Right heart catheterization when indicated Coronary angiography for patients >40 y of age Other Bone density scan when indicated "Adapted li-0111 Esan TM, Kaiscr I.R, Cooper I D . 1.1111gtranspla~~tation. (:z~rr / ' l ~ h / Si~rr.1!4H!J;2ti:673-752. B U N = l ~ l o o d urea, . nitrogen; MUC,A=rnnltiple garcd acquisition.

years for double-lung transplantation and of less than 60 years for single-lung transplantation.17 In addition, candidates should be nonsmokers and should be ambulatory, possess adequate social support and psychological stability, and demonstrate compliance with medical regimens. Criteria for patient selection have been modified at various centers.1X,i9 Indications for single-lung transplantation include chronic obstructive pulmonary disease (including alpha-] antitrypsin deficiency), pulmonary fibrosis, and primary pulmonary hypertension. Through 1994, emphysema and alpha-1 antitrypsin deficiency accounted for almost 60% of all single-lung transplants performed.") The shortage of donors makes it prudent to use single-lung transplantation whenever possible, as only 1 out of rvery 10 to 15 potential donors has lungs suitable for transplantation.'I Double-lung transplantation is indicated for patients with an infective process (eg, cystic fibrosis, bronchiectasis) and also has been performed for chronic obstructive pulmonary disease, pulmonary fibrosis, and primary pulmonary hypertension. Patients with cystic fibrosis comprised more than 35% of patients with double-lung transplants performed through 1994, with more than 30% performed for emphysema and alpha-1 antitrypsin deficielicy.")

patients with primary pulmonary hypertension comprised more than 9% of patients with single-lung transplants and 10% of patients with double-lung transp l a n t ~ . ~Discussion " continues on the rnost appropriate surgery for this challenging p o p ~ i l a t i o n . ~ ~ , ~ ~ Pediatric lung transplantation statistics have been reported for patients who are less than 18 years of age. Cystic fibrosis is the primary indication for double-lung transplan tation in children, whereas primary pulmonary hypertension is the primary indication for single-lung transplantation.'Vediatric lung transplantation also has been performed for congenital heart disease.

Donor/Recipient Matching There is a shortage of suitable donors for transplantation; only 1 out of every 10 to 15 available donors has lungs suitable for transplantation." Requirements for the donor lung(s) are strict. The donor must have a partial pressure of oxygen of 300 mm Hg on 100% oxygen with 5 cm of positive end-expiratory pressure, a normal chest roentgenogram, clear bronchoscopy, and no significant chest trauma or pulmonary contusion.I4 In matching a donor with a prospective recipient, the guidelines include compatibility of ABO blood group, of thoracic dimensions (chest circumference measurements as well as chest roentgenogram evaluation), and of predicted lung volumes based o n height, age, and gender.I4 Human leukocyte antigen matching is not currently used to match donor to recipient because of the increased time required to receive the test results. The United Network of Organ Sharing maintains a list of eligible recipients. Priority o n the list is determined primarily by the date the candidate was placed on the list. The only distinction between diagnoses or clinical status of the patients placed o n the lung transplant waiting list involved the crediting of 90 additional days to patients with idiopathic pulmonary fibrosis.'"

Evaluative Studies As the waiting period for a transplant has increased, it has become more difficult for referring physicians to estimate the appropriate timing for lung transplant evaluation. In this process, many factors must be considered in addition to declining pulmonary function, including the frequency of hospital admissions, sensitivity of infecting organisms to antibiotics, and the functional status of the patient.'"

After an initial screening, a decision may be made to proceed with a formal evaluation, and the patient is admitted for a short hospital stay or studies may be Primary pulmonary hypertension had initially been scheduled on an outpatient basis. These studies provide treated with heart-lung transplantation, but more information about the presence of an active systemic recently isolated single- or double-lung transplantation r o u g h disease, renal or hepatic insufficiency, severe right venhas been used with varying s u c ~ e s s . ~ i ~ 2 ~ ~ 2 T h 1994,

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tricular dysfunction, or significant cororiary artery disease, any of which could be contraindications to lung tran~plantation.'~ Pulmonary studies assist with quantifying the severity of impairment of diffusion capacity, ventilation, and gas exchange. The evaluation procedures are listed in Table 1. In addition, many members of the hlng transplant team conduct interviews or evaluations of the lung transplant candidate (Tab. 2). The lung transplant coordinator schedules the evaluation, compiles the results, facilitates communication among team members, and communicates with the prospective transplant candidate and his or her family.

Table 2.

The results of the evaluative studies are discussed by the lung transplant team members, and the determination of candidacy is made. The varied perspectives of members of the lung transplant team are the key to forming a comprehensive view of the patient's current status and accepta'bility for transplantation. Physiological and psychosocial factors and fiscal resources all play important roles in the outcome of the transplantation process. The importance of receiving accurate information is paramount to the patient's decision to pursue transplantation. The members of the lung transplant team should provide a realistic picture of lung transplantation and its outcomes.

Physical Therapy Evaluation The physical therapist identifies causes and effects of impaired ventilation and gas exchange, as reflected by the lung transplant candidate's cardiopulmonary status and fur~ctionalcapacity. The therapist should assess the patient's ventilatory effort, musculoskeletal function, mucociliary clearance, and exercise tolerance.'" Breathing or ventilation assessment is initiated by taking a histo~yof the patient's symptoms (eg, shortness of breath, dyspnea o n exertion) and their effect on functional ability. Observation of the patient includes the skin color, breathing pattern and depth, preferred body position, use of accessory muscles of respiration, and work of breathing. Palpation of the chest wall provides information about the movement of the diaphragm and other muscles of respiration and areas of decreased chest expansion. Components of the musculoskeletal evaluation assess mobility, general or musculoskeletal strength, and posture and establish a baseline against which future comparisons may be made." Range of motion of the thoracic and cervical spines and shoulder girdle should be assessed, as limitations in these areas may restrict thoracic expansion. Postural deviations and muscle group imbalances may result in decreased diaphragmatic excursion, and assessment of these factors also should be included.

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Evaluation by Lung Transplant Team Members" Medical staff

Medical history Nature and progression of lung disease Smoking history Prior surgery Medications, including steroid history Physical examination

Physical therapist

Exercise tolerance test and exercise prescription Musculoskeletal assessment Cough/mucociliary clearance

Dietician

Ideal body weight Caloric intake

Social worker

Psychosocial assessment

Psychologist/psychiatrist

Psychological testing

"Adapted from Egan TM, Kaiser LR, Cooper,ID. 1.i1rigtranspl;~lilation.Cur7 hob1 S71rlg 1989;26:673-752.

Several assessments assist with evaluation of mucociliary clearance. The patient's report of symptoms (eg, audible wheezing, coughing, sputum production) and previous history of airway clearance techniques and their effectiveness should be obtained. The lungs are auscultated for the presence of crackles and wheezes, and the quality and productivity of coughing and the quantity and consistency of sputum are evaluated. The conventional treatment for secretion clearance remains postural drainage and percussion. The evaluation period p r e vides an opportunity to introduce alternative methods for airway clearance that may be more effe~tive."~-'~ The physical therapist also assesses the patient's exercise tolerance. Exercise tolerance is determined at the time of the initial evaluation for lung transplantation and at intervals during the waiting period in order to reassess the patient's status. An exercise tolerance evaluation should be omitted in patients with primary pulmonary hypertension in whom exercise testing is not appropriate; this is determined o n an individual basis2' The &minute walk test (6MW) is a widely used assessment of exercise tolerance in patients with pulmonary d i ~ e a s e . ' " ~ ' T h e 6MW was adapted from the original 12-minute field test..?' In conducting a 6MW, the patient is encouraged to cover as much ground as possible over a flat, measured course in 6 minutes. Supplemental oxygen is administered as needed to maintain oxygen saturation above a prescribed level (usually 88%-90%). The patient is allowed to stop and rest as needed, but the clock is not stopped. The tester needs to carry all necessary equipment and needs to walk slightly behind the patient, allowing the patient to set the pace unencumbered. Due to the effects of learning and motivation, it is essential to repeat the 6MW and report the better

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e f f ~ r t . Given ~ ~ . ~the ~ low functional status of patients with end-stage lung disease, it may be necessary to administer the test on different days to allow ample recovery time. Reports of 6MW evaluations for lung transplant candidates from various centers average from 100 to 400 m,17,34-36

.~~ lation cited as the reason for the exercise l i m i t a t i ~ nIn another group of lung transplant candidates with varying diagnoses undergoing exercise testing, limitations in aerobic capacity were shown.40In this study, the reduction in aerobic capacity was attributed to a combination of abnormalities in ventilation and circulation.

The 6MW can be administered in a clinic or hospital corridor using only a stopwatch, a portable pulse oximeter, and portable oxygen, if needed. The 6MW is easily reproducible," well-tolerated by most patients, and not time-consuming, making it inexpensive. Because the 6MW is self-paced, even patients with severe limitations are able to complete the test. A disadvantage of the 6MW is the inability to record the patient's ventilatory parameters or electrocardiographic activity during the exercise test; the pulse oximeter provides information about heart rate, but telemetry is necessary to obtain information about dysrhythmias. The 6MW also is difficult to administer postoperatively when patients attain a higher exercise capacity and are able to run.

The physical therapy evaluation is used to develop an individual exercise prescription for the patient and to provide input to the lung transplant team about the candidate's exercise limitations. Regardless of whether the candidate is scheduled for transplantation, the information gained from the evaluation should be provided to the patient, family, and referring physician. This information is useful in prescribing appropriate activity/ exercise guidelines for the patient. The physical therapist (in conjunction with the physician) may counsel the patient about supplemental oxygen needs during exercise. In addition to endurance exercise, instruction in breathing exercises, relaxation techniques, energy conservation measures, and mobilization/flexibility exercises may be prescribed, as indicated.

Exercise tolerance in patients with pulmonary disease may be assessed using a treadmill or cycle e r g ~ m e t e r . ~ Education ~ Exercise levels should be advanced by small increments After a candidate has been accepted onto the waiting list, in work load (0.5 metabolic equivalents [METs] per the process of educating the patient and significant stage) and may be continuous or discontinuous with others continues. The physical therapist plays an imporshort durations at each stage.37A standard Bruce prototant role in this process because the therapist may be col treadmill test is not well-suited for most patients with asked to reassess the exercise tolerance of the patient pulmonary disease.s7This test, however, has been modduring the waiting period. Because the time from evalified to include stages 0 and !h in addition to the uation to the time of transplant can be as long as 2 years, standard stages. This modification allows patients who it may be beneficial to schedule an education session are incapable of exercise at stage 1 to be asse~sed.:~" when the candidate nears the top of the list to review Some centers use their own submaximal treadmill test components of physical therapy intervention in the protocols for purposes of evaluation and subsequent postoperative period. ree~aluation.'~ Discussions about the postoperative period conducted Exercise testing on a treadmill allows closer physiologic prior to transplantation will provide the patient with monitoring of ventilatory and hemodynamic parameters realistic expectations. Topics to discuss include the than does the 6MW and, because it is externally paced, typical preoperative and postoperative courses; the does not require repetition for increased reliability.3s intensive care environment; mechanical ventilation of Reevaluation of high-functioning transplant recipients is the lungs; airway clearance; and treatments such as more easily accomplished on a treadmill or cycle breathing control and coughing maneuvers, body posiergometer. These tests, however, are more expensive tioning, chest wall mobility exercises, and mobilization and more technically difficult to perform than the 6MW and activity progression. and depend on availability of equipment. Complete cardiopulmonary exercise testing is not routinely performed as part of the evaluation for lung transplantation, but Howard et a13' have reviewed a few cardiopulmonary exercise studies that have been reported. In cardiopulmonary exercise studies of patients with primary pulmonary hypertension or Eisenmenger's syndrome (cyanosis, particularly during exercise, resulting from right to left intracardiac shunt), transplant candidates exhibited severely reduced aerobic capacity, with abnormalities in the pulmonary circu-

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These issues may be addressed in a classroom setting with a group small enough to encourage questions and discussion and in one-on-one discussions during exercise sessions. A lung transplant support group that meets regularly is valuable in combining education with social support.

Preoperative Rehabilitation Candidates waiting for a donor are encouraged to stay as active as possible, and some candidates are able to enroll


in a local pulmonary rehabilitation program for supervised exercise. When a candidate's name approaches the top of the waiting list, some lung transplant programs require the patient to relocate near to the center so that they can participate in a monitored exercise program.41.,"This program enables them to be followed by the medical staff and to be readily available at the time of transplantation.

Level 0-no shortness of breath, can count to 15 (takes about 8 s) without taking a breath in the sequence

I I I

Level 1-mild shortness of breath, can count to 15, but must take one breath in the sequence; continue at this intensity Level 2-moderate shortness of breath, needs two breaths to count to 15; this is the desired level of intensity Level 3--definite shortness of breath, must take three breaths in the sequence of counting to 15; reduce intensity of exercise

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The need for rehabilitation in the preoperative period arises from limitations in exercise tolerance, decreased I Level 4-severe shortness of breath, unable to count or speak; I strength and thoracic mobility, and altered posture. cease activity Thus, preoperative rehabilitation should include trainIf the patient completes the sequence at any level by rushing to ing to improve ventilation and mucociliary clearance, complete the sequence, add a plus "+" to the level. and exercise with aerobic, strengthening, and stretching components, with supplemental oxygen, as indi~ated.~" Figure 1. Dyspnea index. Reprinted with permission from Sadowsky SH, RohrkemThe goal in the preoperative phase of rehabilitation is to per KF, Quon SYM. Activity end-point guidelines. In: Rehabilitation of enhance the physical condition of the patient to withCardiac and Cardiopulmonary Recipients. Stanford, Calif: Stanford stand the stresses of lung transplantation. Education University Hospital; 1986: appendix I. about all aspects of lung transplantation should continue during this period.

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Each patient should have a specific exercise prescription that inc:ludes guidelines for mode, intensity, frequency, and duration of exercise. Progression of exercise should occur at an individual rate. Acute changes in the patient's status, sometimes requiring hospitalization, must be expected as a result of the progression of the disease. These changes require reevaluation of the exercise prescription and a possible cessation of exercise until the patient is clinically stable.44 Modes for aerobic exercise may include the cycle ergometer and the treadmill, or a combination of these modes. .A stair climber may not be tolerated initially, but will be useful for patients with higher exercise capacity or for patients who have increased their exercise tolerance over time. Although the increased ventilatory demand of upper-extremity exercise versus lowerextremity exercise may contribute to dyspnea in patients with pu:lmonary disease, upper-extremity exercise training has been safely implemented in rehabilitation prog r a m ~ . ~In " , ~patients ~ with severe pulmonary disease, however, upper-extremity exercise has been shown to result in decreased exercise duration and may result in dyssynchronous thoracoabdominal breathing, demonstrating the need for caution when using this mode of exercise in patients awaiting lung tran~plantation.~~ Exercise intensity must be determined for each individual, and. it must be carefully m o n i t ~ r e dThe . ~ ~appropriate exercise intensity for a patient with lung disease can be determined using a variety of methods individually or in combination. Target heart rates have been applied to patients with pulmonary disea~e.4~ An exercise program that uses 60% of peak heart rate (as determined by an exercise test) as a target has been shown to increase Physical Therapy . Volume 76 . Number 6 . June 1996

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exercise tolerance."-48 In severe lung disease, predicted maximal heart rates are not reached with exercise testing because exercise is limited by pulmonary, riot cardiac, function. This finding points to the need for a tool that can be used to prescribe and monitor exercise intensity by dyspnea." The dyspnea index shown in Figure 1 is such a tool. This index involves noting the number of breaths a patient must take while counting from 1 to 15.49Another measure is the dyspnea scale, a four-point scale (ie, 1-4) by which the patient rates the degree of dyspnea during exercise." An alternative, the Borg Rating Scale of Perceived Exertion (RPE),Snis a measure of the overall effort needed during an activity (or at rest) (Fig. 2). In using the RPE scale, the patient is asked to take into account all bodily sensations that contribute to the effort of exerci~e."~ This scale has been used with patients who have pulmonary disease to complement the information gathered with other measure~.~l The frequency and duration of the exercise prescribed depend on the patient's level of exercise capacity. Interval training may be more appropriate than continuous exercise for patients with end-stage lung disease because of its decreased ventilatory demand.97The rest periods can gradually be decreased and the exercise intervals can be increased to progress the patient to continuous exercise.37Because interval training incorporates rest or periods of relatively lower exercise intensity, the session may be spread over a prolonged period of time and tolerated well. Patients who are able to exercise at very low levels (less than 3 METs) benefit from shorter periods of exercise (5-10 minutes) performed more often during the day. For patients who are able to tolerate moderate levels of exercise (3-5 METs), daily

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Original RPE Scale 6 7

9

Very, very light

Very light

10

11

Fairly light

12 13

Somewhat hard

14 15

Hard

16 17

Very hard

18 19

Very, very hard

20

Category-Ratio RPE k a l e

0

Nothing at all

0.5

Very, very weak

1

Very weak

2

Weak

3

Moderate

4

Somewhat strong

5

Strong

6 7

Very strong

exercise is recommended. Once a patient is able to exercise for 20 minutes continuously, he or she may exercise four or five times a week with the goal of completing 30 minutes of continuous exercise. The exercise prescription should include an individual strengthening program, often using ~hera- and@,* free weights, or items found at home. Chest mobility and postural correction should be addressed with a prescription of individual stretching and flexibility exercises to improve thoracic expansion. Proprioceptive neuromuscular facilitation diagonal patterns, for example, can be used to increase thoracic mobility. Impaired mucociliary clearance may be augmented by techniques for improving coughing and airway clearance. Several techniques are available to supplement or replace conventional postural drainage, percussion, and coughing." Some techniques use controlled breathing to mobilize secretions. The active-cycle-of-breathing technique uses alternate periods of breathing control, thoracic expansion exercises, and huffing with an open glottis in place of coughing." Autogenic drainage is a method using three different levels of breathing in a controlled fashion to mobilize pulmonary ~ e c r e t i o n s . ~ ~ , ~ ~ Additional equipment is required for other techniques. Positive expiratory pressure therapy uses collateral ventilation to mobilize secretions with a mask or mouthpiece apparat~s.2~ The Flutter valvet is a pipe-like device used to interrupt expiratory airflow. It promotes secretion mobilization with a combination of positive expira~~The tory pressure and airway o ~ c i l l a t i o n . ~ ~ ThAIRapym systemf consists of a vest worn by the patient and tubing that connects to an air-pulse generator. This device provides various frequencies of oscillation to provide increased expiratory flow for clearance of airways.ZHUse of these techniques requires an evaluation as to their effectivenesswith each patient, and additional treatment sessions may be needed for the patient to become independent in the use of these methods.2H

8 9

10

Very, very strong

*

Maximal

Figure 2. Borg scales for rating of perceived exertion (RPE): (top) original RPE scale; (bottom)revised category-ratio RPE scale. Reprinted with permission from Barg GAV. Psychophysical bases of perceived exertion. M e d Sci Sports Exerc. 1982; 14:378, 380.

Some interventions are intended to improve function of the pulmonary system. Diaphragmatic and segmental breathing exercises increase lung volume and improve gas exchange." Exercise training of inspiratory muscles may be indicated to improve their function." Other interventions are meant to help the patient adjust to the low functional capacity caused by pulmonary disease. Energy conservation techniques can be useful in helping a patient accomplish daily activities with less effort expended and to spread the effort throughout the day. Relaxation techniques may be used to decrease the energy used in overac-

" T h e Hygenic Corp, 1245 Home Ave. Akron, O H 44310. Scandipharm lnc, 22 Inverness Center P k y , Suite 910. Birmingham, AL 95242. :ThAlRapym Vest, American Biosystems Inc, 1375 M'olters Blvd, St Paul, 51N 551 10.

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Physical Therapy. Volume 7 6 . Number 6 .June 1996

tive muscles and to decrease the anxiety that may be present in patients with pulmonary disease. The regular and extended contact that the physical therapist has with the patient during the waiting period for a transplant puts the therapist in a unique position. The physical therapist may be the first rnernber of the transplant team alerted to an exacerbation of a medical problem or a marked decline in a patient's status requiring medical attention. Many patients and family members come to depend o n the physical therapy staff for support and encouragement during the time many transplant recipients refer to as the most frustrating of the entire transplantation process.

Exercise Responses of Patients With End-Stage Lung Disease Patients with end-stage lung disease demonstrate reduced exercise t ~ l e r a n c e . ~ W l o smonitoring e of a patient'!; response to exercise enables the physical therapist to titrate the exercise program to achieve the optimal rate of progression while limiting untoward consequences. An initial or baseline measurement should be taken, and measurements should also be recorded during exercise and duiring recovery. The patient's respiratory rate, oxygen saturation, heart rate, blood pressure, RPE or dyspnea ratings, and amount of supplemental oxygen needed to maintain oxygen saturation at an appropriate level should be monitored. Auscultation of breath sounds, hand-held spirometry measures (forced vital capacity and forced expiratory volume in 1 second), and weight also are noted." The need for supplemental oxygen is determined by the exercise evaluation. A physician's order or a standing order should be obtained to allow titration of the oxygen to maintain an appropriate level of oxygen saturation during exercise and recovery. Continuous pulse oximetry is used throughout the exercise session. Exercise should be terminated, at least temporarily, and the exercise prescription altered if any of the following adverse effects are observed: tachycardia greater than 85% of predicted maximum heart rate, bradycardia, blood pi-essures greater than 180/110, an increase in diastolic pressure greater than 20 mm Hg or a drop in systolic pressure, chest pain, severe dyspnea, blurred vision, deterioration in neurological status, or an oxygen saturation of less than 85% despite maximum oxygen s~pplementation.~~ The likelihood of exercise-induced hypoxemia during aerobic exercise and the increased demand on the cardiopulmonary system during resistive exercise neces-


sitates stringent monitoring of all exercise program c o m p o n e n t ~ . ~ . ~ Wat esafe r and optimal level of exercise has been determined, the patient can be placed on a home program with education in recognizing unfavorable responses and guidance as to when to seek out medical attention. Improvements in exercise capacity and functional status have been reported in patients with severe lung disease following exercise training, even though lung function did not improve."-" Increased exercise capacity has been shown to reduce morbidity after thoracotomies.(~() Compared with education alone, pulmonary rehabilitation has been shown to increase exercise performance and to decrease muscle fatigue a n d shortness of breath." Even though pulmonary function continues to decline in lung transplant candidates, exercise tolerance, independence with activities of daily living, and quality of life all improve during the preoperative waiting period. Improvements in the 6MW distance have been demonstrated during the preoperative phase of rehabilitation and are believed to improve postoperative recovery. 17,%5,44'

Surgical Technique The incision used for a single-lung transplant is a standard posterolateral thoracotomy.14 If either side is equally suited to transplantation, the left side is preferred because the surgery is easier technically.'" Double-lung transplants were initially performed via a median sternotomy with a tracheal a n a s t o m o ~ i s Sub.~ sequently, transplantation with bilateral main-stem bronchial anastomoses was used." Currently, the procedure is performed with sequential single-lung transplants, using separate bronchial anastomoses in which cardiopulmonary bypass is needed much less frequently." The incision used for this procedure is a bilateral transverse thoracosternotomy, also known as the "clamshell incision."" This approach provides the surgeon with increased exposure of both pleural spaces and with better control of bleeding. The technique of omentopexy was introduced to address the problem of poor bronchial healing at the anastomo~ i sA. ~ small upper midline incision is made to mobilize the omentum from the colon. The ornentum is brought upward into the chest and wrapped completely around the bronchial anastomosis and secured." Omentopexy was utilized in the first successful lung transplant surgery and was used routinely for years at various lung transplant centers with the aim of improving bronchial healing. Currently, however, omentopexy is used far less frequently, as other surgical and perioperative strategies have been introduced.

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Another technique for revascularizing the anastomosis involves use of the internal mammary artery. In this technique, the internal mammary artery and the surrounding tissue are mobilized from the anterior chest wall, and the pedicle is wrapped completely around the anastomosis and ~ e c u r e d . "Yet ~ another approach aimed at addressing the problem of poor bronchial healing is the telescoping technique.]] This technique involves overlapping one ring of the bronchus and shortening the length of donor airway to minimize problems with blood supply. Khaghani et a164 conducted a randomized study to compare wrapping the anastomosis of a single-lung transplant with omenturn, wrapping the anastomosis with an internal mammary artery pedicle, and not wrapping the bronchus. The results demonstrated that none of these techniques prevented complications with bronchial healing; patients from all three groups required bronchial dilatation, and one patient from each group required a stent."The authors pointed to the shortened bronchus in the unwrapped anastomoses as a key to minimizing the amount of potentially ischemic tissue. Egan and Cooper describe the surgical aspects of lung transplantation in this way: Transplantation of the lung ... is a complex logistic undertaking requiring a large team of professionals who attend to ... patient selection, preoperative rehabilitation, donor selection, postoperative care, immunosuppression, rehabilitation, and long-term follow-up. The operation itself represents an integral, but small, cornponent.""~2~'~)

Acute Postoperative Rehabilitation

Body positioning and mobilization by the physical therapist in the acute postoperative period is important. Bed rest has many negative effects on the cardiopulmonary system, including orthostatic intolerance, reduced ventilation, increased resting heart rate, and decreased oxygen ~ p t a k e . " ~Body - ~ l positioning and mobilization have been shown to benefit oxygen transport by promoting better ventilation-perfusion matching and enhancing arterial o x y g e n a t i ~ n .Changing ~ , ~ ~ ~ ~the ~ patient's position from supine to side lying or upright has been noted to increase drainage from chest tubes, and positioning to augment the drainage of pulmonary secretions has been shown to be e f f e ~ t i v e . ~ ~ - ? ~ Decreased mucociliary clearance has been demonstrated in denervated lungs.67 Altered mucociliary clearance may contribute to an increased susceptiblilty to infection in the early postoperative period.""hese factors underlie the importance of assisting the patient with airway clearance. Clearance of pulmonary secretions should be initiated on the first postoperative day, provided the patient is stable, and may be needed three or four times each day initially.Z7 Postural drainage with shaking or vibration may be better tolerated than percussion due to incisional and chest tube discomfort. Transplant recipients who are mechanically ventilated may benefit from a combination of shaking and hyperinflation with a manual ventilation bag." After extubation, the patient may prefer using the active-cycle-of-breathing technique or a Flutter valve, if the patient is familiar with this technique or this device. Positive expiratory pressure therapy has been used in the posttransplantation peri0d.~7 the secretions become less copious and the patient becomes more independent in clearing the airways, the frequency of airway clearance treatments is decreased. Need for secretion clearance is assessed daily, but treatments usually become unnecessary by the time of discharge from the hospital.

The physical therapist should be cognizant of the many issues confronting the transplant recipient in the immediate postoperative period. Problems following lung transplantation include impaired gas exchange, shunt, impaired mucociliary clearance, and disrupted lung fluid balance.14 In addition, these problems are confounded by intubation and mechanical ventilation, proAn effective cough is crucial to secretion removal. In the longed static positioning during surgery, immunosuplung transplant recipient, an ineffective cough results pression, pain, recumbency, and restricted m0bility.'~.2~ from incisional pain and decreased sensation in the transplanted airway due to lung denervation.I4 Adequate Denenration of the transplanted lung(s) and interruppain control, optimal positioning, and modifications in tion of the pulmonary lymphatics play a part in the coughing technique can improve the effectiveness of altered pulmonary physiology after lung transplantation. coughing. The upright sitting position should be Lung denervation causes a ventilation-perfusion imbalencouraged for coughing, as it has been shown to ance until recovery of autonomic function occurs and produce the greatest expiratory flow r a t e ~ . ~ W ucoughff contributes to decreased mucociliary ~ l e a r a n c e . " * ~ T h e ing, performed without closure of the glottis, has been increase in extravascular water from disrupted pulmoshown to produce a larger volume of expired air at a nary lymphatics is evident in decreased pulmonary comhigher flow rate than conventional c0ughing.7~Huff pliance, radiologic evidence of congestion, and an coughing also takes less effort and is less painful than increased arterial-alveolar gradient.41,66.6" regular coughing, making it ideal for use with patients postoperatively. In patients who are unable to generate

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Physical Therapy . Volume 7 6 . Number 6 . June 1996

substantial airflow, the technique of stacking breaths before the expulsion phase can increase the effectiveness of a cough. Splinted coughing, with a pillow against the incision, is helpful in decreasing pain.

physical therapist, the patient pushes the wheelchair filled with equipment while a nurse follows with the intravenous pole(s). The wheelchair provides support for the patient much like a rolling walker.

Initially, mechanical ventilation and oxygen requirements rnay be quite high, but patients are weaned from these supports as early as possible. In the initial postoperative period, patients with obstructive lung disease often have inadequate inspiratory force to ventilate their relatively noncompliant lungs."; In addition, many patients after single-lung transplantation continue to exhibit a1 rapid respiratory rate and increased reliance on accessory respiratory muscles.x0These sequela are presumably due to the continued input from a native diseased lung as well as anxiety. These patients benefit from training in breathing strategies to decrease the sensation of dyspnea and to improve ventilation efficiency." It ]may be helpful to display the pulse oximetry readings to assure the patient that oxygenation is adequate, even though the patient may complain of dyspnea. Continuous pulse oximetry allows the patient to be weaned from supplemental oxygen more quickly. After extubation, use of an incentive spirometer throughout the day is encouraged.

Protective or reverse isolation precautions are observed after transplantation in order to protect these patients, who have suppressed immune systems as a result of transplant medications. For visitors and health care workers entering the patient's room, thorough hand washing is imperative. A mask is worn by those who enter the room and by the patient when leaving the room. Avoiding contact with persons with infections is another precaution .26

Incisional pain may limit activity progression, deep breathin,g exercises, and coughing. Considerable pain mav originate from the chest tube sites and the abdomen if an omental wrap is used. Epidural analgesia has been effective in managing pain, allowing the patient to engage rnore willingly in the process of rehabilitation. Decreased mobility is evident in the transplant recipient, due not only to incisional discomfort but also to various equipment in the intensive care unit that limits movement in bed. A temporary decrease in exercise tolerance occurs postoperatively despite the patient's best efforts at preoperative rehabilitation. The demands of transplant s~u-gery,including prolonged static positioning, prolonged anesthesia, and postoperative recumbency for a minimum of 24 hours, limit the capacity for exercise in the period immediately after transplantation. Progressive activity is initiated on the first postoperative day, beginning with range-of-motion exercises and progressing to transfers out of bed to a chair and then to ambulation. In the intensive care unit, ambulation is very laboir intensive, especially if the patient continues to require mechanical ventilation. For patients who require mechanical ventilation, an additional health care provider use:s a manual ventilation bag during ambulation. All the necessary equipment, including portable oxygen, pulse oximeter, chest tube drainage containers with portable !suction, and bladder catheter drainage bag, are placed into a wheelchair. With assistance from the

Physical The!rapy . Volume 76 . Number 6 . June 1996

After the patient leaves the intensive care unit, rehabilitation continues to focus on alveolar ventilation, mucociliary transport, and ventilation-perfusion matching to maximize the efficiency of oxygen transport. The most important components include mobilization, breathing control and coughing maneuvers, and, if necessary, airway clearance techniques. Close monitoring allows the patient to proceed with rehabilitation at an optimal rate throughout the acute postoperative period. The extensive amount of treatment time required in this stage allows the physical therapist to become aware of changes in the patient's status and to alert the transplant team to possible complications of transplantation. General mobility improves as the patient's ambulation distance increases and participation in activities of daily living progresses. Thoracic mobility may be improved by instructing the patient in chest and upper-extremity mobilization exercise^.^^ Breathing exercises should be incorporated into thoracic mobility and cardiovascular exercise regimens, coughing and airway clearance, and general activities. When the patient's ambulation distance allows, the patient may ambulate to an isolation exercise room (if available) to begin a progressive exercise program using a treadmill and cycle ergometer. This setting allows the patient to progress further with cardiovascular endurance and strengthening without coming into contact with other patients. Prior to discharge from the hospital, the patient begins stair climbing. For many patients, this is a hallmark of recovery, as most patients have been restricted from this activity by their pulmonary disease. The therapist should set physical therapy goals to be achieved prior to discharge from the hospital, including improved ventilation, effective and independent secretion clearance, improved thoracic mobility, increased endurance and strength, independence in activities of

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daily living, and ability to continue with an exercise/ activity program at home. Most patients do not require the use of supplemental oxygen at the time of discharge, although a few patients will continue to require it for exercise sessions.

modified. A &minute walk may be performed just after discharge from the hospital. Maximal cardiopulmonary exercise testing on a treadmill or cycle ergometer is generally performed 3 months after surgery when the patient may be more stable and free of medical cornplicati~ns.~~.H'

At the time of discharge, the patient (or family of a pediatric patient) should be able to proceed independently with a daily regimen of recording (1) measurements obtained with a hand-held spirometer, (2) vital signs, (3) self-medication, and (4) self-monitoring of exercise intensity.'(' The patient should know the normal limits of these values and when to contact the transplant team. By the time a patient leaves the hospital, he or she is well on the way to improved function and improved quality of life.

Following lung transplantation, pulmonary function is no longer the limiting factor to exercise. Patients, therefore, often develop musculoskeletal limitations to increased activity. Patients are now able to perform exercise and other activities at a higher level of intensity. This increased exercise intensity emphasizes problems of muscle group imbalances, postural deviations, and incorrect exercise technique. Shinsplints, back pain, and the need for shoe orthotic devices are some of the complaints that have been identified. Physical therapy Outpatient Pulmonary Rehabilitation for these complaints allows the patient to continue rehabilitation more comfortably and effectively, which After discharge from the hospital, patients are often ~ , ~increase ~ expected to continue pulmonary r e h a b i l i t a t i ~ n . ~ ' . ~will adherence to an exercise program in the Because patients come to lung transplant centers from long term. inany different geographical areas, many programs require recipients to live nearby, permitting supervised, At the time of discharge to their hometown, patients are monitored outpatient exercise at the center. This followed by their local physicians for laboratory work requirement allows the patient to be closely followed and routine medical care. Patients return to the lung medically by the transplant team while he or she contintransplant clinic for regular visits, which include bronchoscopy/biopsy to screen for rejection or infection and ues to work on increased function, strength, and endurance. follow-up with members of the lung transplant team. Exercise testing is conducted at regular intervals for The physical therapist who treated the patient during months to years after lung transplantation. Figure 3 depicts a model of an exercise program from evaluation the acute period after the transplant should communicate with the therapist who supervises the outpatient through follow-up after transplantation. exercise sessions, especially when these two programs Exercise Responses in Lung Transplant take place in different facilities. The method(s) used to prescribe and measure exercise intensity and areas Recipients After lung transplantation, there is considerable restorawhere reinforcement of teaching is needed should be tion of functional ability in patients who were previously shared. Knowledge of the patient's hospital course and debilitated. Improvement in exercise tolerance has been response to increased activity in the acute setting will demonstrated by an increase in &minute walk distances assist the outpatient therapist in individualizing the A report from one cenafter transplan tation. 17,2773443'i.HY exercise program. ter indicated that no lung transplant recipients stopped An exercise program consisting of four to five 30-minute a maximal symptom-limited exercise test because of sessions of continuous exercise weekly should be well dyspnea; the chief cc~mplaintwas lower-extremity pain.3H tolerated in this phase of rehabilitation. The work load on both the treadmill and the cycle ergometer is Cardiopulmonary exercise testing, including analysis of increased during the aerobic component of the exercise maximal oxygen uptake, has demonstrated areas of' limitation in exercise capacity after lung transplantation. program, and stair climbi~lgand an arm ergometer may be added to the exercise session. Strength and postural Aerobic capacity, as judged by maximal oxygen uptake, assessments should be continued in addition to an remains reduced (32%-60% of the predicted ~ a l u e ) . + " , ~ : ~ individual program of strengthening and stretching Ross et a14" report a low ventilation-perfusion ratio with exercises. The target heart rate method of prescribing exercise in transplanted lungs, suggesting this mismatch exercise intensity is more valid after transplantation, is one possible cause for the decreased aerobic capacity. when pulmonary limitations to exercise are lessened. Nonetheless, ventilatory factors do not appear to limit exercise. Respiratory rate increases appropriately with During outpatient therapy, exercise tolerance should be exercise, hypoxemia occurs only infrequently during reevaluated periodically and the exercise prescription exercise in single-lung transplant recipients and is not a

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limiting factor, and breathing reserve at peak exercise remains in the normal to high range.38.40-H1~X4 The limitations in exercise performance of lung transplant recipients have been attributed to various peripheral F a ~ t o r s . ~ ~These , ~ : ~ .factors ~~ may include abnormalities in the peripheral circulation and peripheral neuromuscular structure and f~inction." It has been suggested that the m~iscledeconditioning and atrophy that occur before surgery play an important role in the decreased exercise performance exhibited after lung transplan tatio~l.:1X,40,81.X:i

Preoperative Program Initial Evaluation exercise evaluation and prescription musculoskeletal evaluation cough/airway clearance Nonresident (based on evaluation) local pulmonary rehabilitation/home program Resident (based on evaluation] pulmonary rehabilitation at UNC Clinic Visit (every 3 mo]

Exercise capacity continues to improve during the first exercise evaluation year following lung transplantation, with the largest ~ ~ to UNC area (when near the top of donor improvement occurring within the first 3 m o ~ l t h s . ~ , ~ ~ ~ Move Even with a reduced capacity for maximal exercise, Exercise Program modera1.e levels of work and exercise are achieved, and educational session the majority of recipients report overall satisfaction with exercise program their state of physical health.:38.M'.8' lung transplant support group

Medications

Postoperative Program

Lung transplant recipients require multiple medications. These medications may be divided into three categories. The largest and most important category is medications prescribed for immunosuppression. Another group of medications is used for prophylaxis or treatmeilt of infection. Additional medications are required to combat the side effects of medications required for transplantation, which vary from patient to patient.

Inpatient Intensive Care Unit mobiIization/ambulation cough/mucociliary clearance Floor ambulation cough/mucociliary clearance thoracic mobility

Immuno~s~~ppressive medications prevent the body from rejecting; an organ from another source. The protocol fbr long-term maintenance of immunosuppression may include cyclosporine (CyA) or FK 506, azathioprine Ini(Imuran), and corticosteroids (prednisone). tially, prednisone was not i~seciduring the acute postoperative period because it impaired bronchial healing. Currently, however, low-dose steroids are started immediately p o ~ t o p e r a t i v e l y . ~ ~ ~ E p i s oof d e rejection s are treated with pulse doses of methylprednisolone to boost immunosuppression. Recently, a new oral form ofcyclosporine (Neoral) has become available. This medication was developed to increase absorption, thereby decreasing the amount of medicine required. Long-term studies have not been conducted o n this medication.

Isolation Exercise Room cardiopulmonary conditioning Discharge independent activities of daily living stair climbing

14'3153'tj.w

Patients with cystic fibrosis require additional medications because of their underlying disease. These medications include gastric motility agents to prevent ileus, ketoconazole to slow the metabolism of cyclosporine, and pancreatic enzymes. "'

list)

Outpatient Exercise Program at UNC (6 wk or more) exercise evaluation cardiopulmonary conditioning strength training independent home program Discharge community program/home program Clinic Visit (quarterly) exercise evaluation

~i

3.

Scfematic of the University of North Caroli~ na (UNC) Hospitals exercise regimen for lung transplantation.

Medicatilons are given routinely to treat or prevent bacterial:, viral, and fungal i n f e c t i ~ n . ~Many " ~ ~ additional medications are used in the treatment of trans-


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plant recipients. A full discussion of these medications is beyond the scope of this article.

Complications The most common problems in the acute postoperative period are infection and acute cellular rejection. Of these complications, infection has been identified as the greater cause of early death (within 6 months of transplantation) .R6,H7 The treatment of infection is targeted at the identified organism. Based on histological eiamination, acute rejection is graded on a scale of 0 to 4, with 0 showing no abnormality and 4 being severe. Acute rejection is treated with a high-dose burst of steroids to augment immunosuppression. Both infection and rejection are manifested by low-grade fever, leukocytosis, and an increased arterial-alveolar oxygen gradient.H7 A decrease in pulmonary function tests and decreases in both arterial oxygen saturation and exercise tolerance often result. The physical therapist is often the first person to report hypoxemia with exercise or a decrease in exercise tolerance and can alert the lung transplant team to a change in the patient that may indicate rejection or infection.

lung disease that appears to result from chronic rejection.H7,99,94 The term "bronchiolitis obliterans syndrome" is used to connote graft deterioration secondary to progressive airways disease, whereas the term "bronchiolitis obliterans" is reserved for histologically proven diagnoses." The prevalence and mortality rates of bronchiolitis obliterans syndrome exceed 50% and 40%, re~pectively.~~

Outcomes Figures from the Registry of the International Society for Heart and Lung Transplantation demonstrate a steady, continued increase in lung transplantations performed worldwide since their introduction, although current figures suggest that the growth appears to have platea~ed.~O Through February 15, 1995, 2,465 single-lung transplantations and 1,344 double-lung transplantations, performed at a total of 111 centers, have been reported. For single-lung transplantation, patients with emphysema and alpha-1 antitrypsin deficiency had improved survival over patients with pulmonary fibrosis and primary pulmonary hypertension. The overall survival rates for single-lung transplantation are 67% at 1 year, 57% at 2 years, 49% at 3 years, and 42% at 4 years. The 1-year survival rate for bilateral/double-lung transplantation is 67%, and the 3%-year survival rate is 47%."'

Other complications are directly related to lung transplant surgery. Adult respiratory distress syndrome/diffuse alveolar damage - is an ischemic-reperfusion injury - . related to poor graft preservation." Airway complicaOne measure of the success of lung transplantation is tions include anastomotic dehiscence, necrosis, and the recipient's ability to return to work and participate in bronchial stenosis requiring stenting or d i l a t a t i ~ n . ~ " ~ ~ sports and leisure activities. Most transplant recipients Trauma to the phrenic nerve may occur during surgery, have been able to return to work or household resulting in a prolonged wean from mechanical ventilad u t i e ~ . ~ "Still ~ " others participate in classes at a local tion, dyspnea, and a paradoxical breathing pattern, all of YMCA or health club without limitations, and some which contribute to a decrease in exercise t01erance.~~ recipients have been able to return to strenuous activities such as waterskiing or surfing. Transplant recipients Immunosuppressive medications also can lead to comdemonstrate their return to "very active, athletic lives" at plications. The nephrotoxic effect of cyclosporine is well the biannual US Transplant Games.97High satisfaction documented and can cause both acute and chronic with physical and emotional well-being has been renal insufficien~y.~~ Hypertension is a recognized side reported by more than 50% of surviving recipients. effect of cyclosporine, with a reported incidence of 66% Those recipients with suboptimal medical outcomes who Exercisein one study of transplant recipient~.~(j-~* reported lower satisfaction stated they were more satisassociated hypertension has been noted, even when the fied with their lives than they were prior to resting blood pressure is within normal limits." Cyclotransplan tation .!j6 sporine contributes to neurologic - complications, commonly causing involuntary tremors and, less often, seizures. l",HVo~ttran~plant lymphoproliferative disorder is Recent Advances in Lung Transplantation Complications following lung transplantation may be so related to the use of immunosuppressive medications, particularly azathioprine. As a result of long-term steroid severe that retransplantation is the only possibility for use, lung transplant recipients may develop steroid continued survival. Retransplantation has been performed for bronchiolitis obliterans, graft failure, intracmyopathy, osteoporosis, and glucose intolerance, necessitating the use of insulin. table airway problems, severe acute lung rejection, and miscellaneous complications. A multicenter survey of 63 Infection remains the leading cause of mortality even 6 lung retransplantation operations demonstrated survival rates of 35% at 1 year and 32% at 2 years, signifimonths after lung transplantation.lThe second leading cause of late mortality in lung transplant recipients is cantly worse than the survival rates for first-time transbronchiolitis obliterans, an inflammatory obstructive plant recipient^.",^ Controversy exists as to the ethics

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Physical Therapy. Volume 76 . Number 6 . June 1996

of offering retransplantation to lung transplant recipients in the face of a donor shortage for all candidates. Among patients with bronchiolitis obliterans, pulmonary function deteriorates again shortly after retransplantation, placing doubt on this indication for lung retran~plantation."~ Another recent advance in the donor/recipient process has been the introduction of living related lobar transplantation.l2 In this surgery, a lobe is taken from each of two family members and reimplanted in a small adult or child. This technique is well suited to pediatric patients or patients with cystic fibrosis, who tend to be of small stature. Starnesloo pioneered the technique and has reported a 1-year survival rate of 86%. The major limitation to lung transplantation is the lack of available donors as the number of candidates listed for lung transplantation continues to rise. The United Network of Organ Sharing reports the number of candidates listed for lung transplantation in the United States at more than 1,700 people as of April 1995.1°1One proposal for increasing the number of organ donors is a system of mandated choice in which all adults would be required to prospectively record whether they wish to become organ donors when they die; the decision could not be revoked by family members.10'

Conclusion The process of lung transplantation from initial evaluation through postoperative rehabilitation and beyond is endeavor, requiring the skillful attention of a a compl~~x health care team to direct its course. The physical therapist plays a key role in the management of patients with lung transplants, providing expertise in exercise testing a.nd prescription of exercise preoperatvely and postoperatively. The physical therapist also should educate the patient and his or her family in order to promote independence and a lifetime habit of exercise. In addition, knowledge of musculoskeletal assessment and treatment, airway clearance and breathing techniques, and monitoring for complications of lung transplantation during activity are necessary to improve the outcome. The physical therapist providing care for this challenging patient population needs to stay abreast of new developments in the evolving field of transplantation. As the interval from patient evaluation to transplantation lengthens, and many physical therapy departments are attempting to reduce staffing, research should be undertak.en to determine the most effective utilization of rehabilitation resources. Issues warranting investigation include the most appropriate exercise testing for the preopera.tive and postoperative periods, timing and


duration of treatment, use of strength versus endurance modalities, and the most effective exercise intensity assessment. Lung transplantation is not a cure for end-stage lung disease; it should only be used for those patients for whom no other therapeutic option has been successful. The morbidity and mortality associated with the longterm use of immunosuppressive medications, the surgical risks, and the acute and long-term complications of transplantation are substantial. Fortunately, for many patients, the benefits outweigh the risks, providing increased survival, improved level of function, and satisfaction with quality of life. Acknowledgments I thank Dr Thomas Egan for my introduction to the exciting and challenging realm of lung transplantation and my colleague, Constance Arnold, for her pioneering work in lung transplantation rehabilitation at the University of North Carolina Hospitals. References 1 Hardy JD, Webb WR, Dalton ML, et al. Lung homotransplantation in man. J A M . 1963;186:1065-1074. 2 WhiteJ, Tanser PH, Anthonisen NR, et al. Human lung homotransplantation. Can Med Assoc J. 1966;94:1199-1209.

3 Shonoi K, Hayata Y, .4oki H, et al. Pulmonary lobe homotransplantation in human subjects. A m J Surg. 1966;111:617-648.

4 Derom R, Barbier F, Ringoir S, et al. Ten-month survival after lung homotransplantation in man. J Thorac Cardiouasc Surg. 1971;61:835846.

5 Mills NL, Boyd AD, Gheranpong C, et al. The significance of bronchial circulation in lung transplantation. J T h ~ r a cCardiouasc Surg. 1970;60:866-878.

6 Nelems JMW, Rebuck AS, Cooper JD, et al. Human lung transplantation. Chest. 1980;78:569-573.

7 Goldberg M, Lima 0,Morgan E, et al. A comparison between cyclosporin A and methylprednisolone plus azathioprine on bronchial healing following canine lung autotransplantation. J Thmuc Cardiovasr Surg. 1983;85:821-826.

8 Morgan E, Lima 0,Goldberg M, et al. Successful revascularization of totally ischemic bronchial autografts with omental pedicle flaps in dogs. J Thorac Cardiouasc Surg. 1982;84:204-210.

9 The Toronto Lung Transplant Group. Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med. 1986;314:1140-1145. 10 Patterson GA, Cooper JD, Dark JH, et al. Experimental and clinical double lung transplantation. J Thorac Cardiouasc Surg. 1988;95:70-74. 11 Calhoon JH, Grover FL, Gibbons WJ, et al. Single lung transplantation: alternative indications and technique. J 7'horac Curdiouasc Surg 1991;101:816-825. 12 Starnes VA, Lewiston NJ, Luikart H, et al. Current trends in lung transplantation. J Thorac Cardiouasc Surg 1992;104:1060-1066. 13 Armitage JM, Kurland G, Michaels M, et al. Critical issues in pediatric lung transplantation. J Thorac Cardiouasc Surg. 199.5;109:6065.

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14 Egan TM, Kaiser LR, Cooper JD. Lung transplantation. Curr Pro61 Surg. 1989;26:673-752. 15 Cooper JD. Patterson GA, Trulock EP, et al. Results of single and bilateral lung transplantation in 131 consecutive recipients. J 7'horrrc (;ardiovasr Surg. 1994;107:460-471.

35 DeHoyoa AL, Patterson GA, Mai~rer JR, et al. Pulmonary transplantation: early and late results. J Thorn6 (,'ardiovasr Surg. 1992;103:295306. 36 Ma1 H , Sleiman C, Jebrak G, et al. Functional results of single-lung transplantation for chronic obstructive lung disease. A m J Hus/~irCrit Carp Mrd. 1994;149:1476-1481.

16 Egan TM, Detterbeck FC, Mill MR, et al. Improved results of lung transplantation for patients with cystic fibrosis.,] Thorar Cardiovo.sr.Si~rg. 1995;109:224-235.

37 A CSM (iuzdzlznesfor fi:xPrcise 7'estzng and Prestnptzon. 4th ed. Philadelphia, Pa: Lea & Febiger; 3991:60-62, 86-109. 134-165.

17 Egan TM, U'esterrnan JH, Laoibert (IJ Jr, et al. Isolated lung transplantation for end-stage lung disease: a viahle therapy. A n n 7'horac Suvg, 199?;53:.5YO-596.

38 Howard DK, lademarco EJ. Trulock EP. The role of cardiopulmonary exercise testing in lung and heart-lung transplantation. Cltn Chrsl Mpd. 1994:1.5:405-420.

18 Levine SM. Anzueco A, PetersJI, et al. Single lung trnnsplantation in patients with systemic disease. O'hr\t. 1994;105:837-841

39 Theodore,J, Morris AJ, Burke CM, et al. Cardiopulmonary function at maxirnum tolerable constant work rate exercise following human heart-lung transplantation. (:hes/. 1987;92:433-43%

19 Low DE, Trulock EP, Kaiser LK, et al. Lung - transplantation of ventilator-dependent patients. (:Ire,\/. 1992;101:8-1 1. 20 Hosenpud JD. Novick &I, Breen. TJ, et al. The Registry of the International Society for Heart and Lung Transplantation: Twelfth official report-1995. J Herlrf I,?olfi. 7i-nn.splant. 199.5;14:805-H 15. 21 Cooper JD, Pearson FG, Patterson GA, et al. Technique of successful lung transplantation in humans. ,]Thorac f:r~rdiovasr Surg. 1987;93: 173-181. 22 Levine SM, (;il)l)ons M[J,Bryan CL, e t al. Single lung transplantation fi)r p r i ~ i i a ~pyu l ~ i ~ o n ahypertension. y (:ltn.f. 1990:YX:1107-1 115. 23 Levine SM, Jenkinson, SG, Bryan CL, et al. Ventilation-perf~uion inequalities dul-ing grnft rejection in patients undergoing single lung transplaritation for prinia~ypi~lmonaryhyperterision. Chest. 1992;IOI: 401-40.5. 24 Kaye MP. Pediatric thoracic transplantatio~i:the world experience. J Hrc11t Lung Tu~n.\plrrnt.1993;12:S344-S3.50. 25 Ilrritrd Netu~orl(oJ Organ Sharing (IINOS) Polic,y #3.7. Richmond, Va: United Network of O r p n Shari~ig. 26 Butler BB. Physical therapy in heart and lung transplantation. In: Hillegas E, Sadowski S, eds. Cnrrliof~ulmonrr~ Phssical Therapy. 3rd ed. St Lmuis, Mo: Moshy-Year Book Inc; 39Y5:404-422. 27 Biggar DC, Malen JF, Trulock EP, et al. Pulmona~yrehahilitation before and after lung tra~isplantation.In: Kasaburi R, Petty TL, eds. Prinri/~lr,sand Prrcrticc. ofl'illmonoty Hul~rbilitntiorz.Philadelphia, Pa: M'B Saunders Go; 1993:459-467. 28 Downs AM.