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PTHER 544 - Cardiorespiratory > 18. Lung Transplant > Flashcards

18. Lung Transplant Flashcards

1
Q

Lung transplant: Indications

A
  1. COPD and COPD with Alpha- Antitrypsin Deficiency (leading indication, 1/3 of all lung transplants)
  2. Idiopathic pulmonary fibrosis
  3. End stage lung disease (often dual heart and lung failure)
  4. Pulmonary disease of airway, parenchyma, or vasculature
  5. CF, Bronchiectasis, Sarcoidosis, Pulmonary HT
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2
Q

What does BODE stand for?

A

B Body-mass index
O Airflow Obstruction
D Dyspnea
E Exercise capacity

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3
Q

Lung transplant: selection guidelines

A
  1. Near end stage lung failure (failing on maximal mx management/no management with limited life expectancy ~2yr)
  2. COPD with BODE of 7-10 plus PaCo2 > 50mmHg, PHTN, FEV1 < 20%
  3. CF - FEV1 < 30% increasing O2 requirements, hypercapnia, PHTN
  4. Higher likelihood of 5 yr post-transplant survival (>80%)
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4
Q

Lung transplant: maximize successful outcome

A
  • free of comorbidities and free to withstand procedure
  • less than 65yrs
  • compliant with mx care
  • physiologically and socially capable of managing complex medical regimens
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5
Q

Lung Transplant: CI

A
  • Sign. chronic disease to other organs
  • Obseity (BMI > 35) or malnutrition
  • Tobacco or substance abuse (within 6mo)
  • HIV, AIDS, untreatable chronic illnesses (Hep B, C)
  • Sepsis, liver failure, organ failure, malignancy, CAD, life-limiting disease
  • Red flag: 6MWT < 200m
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6
Q

Lung transplant: Pulmonary function test

A
  • FEV1 < 20 (COPD) - 30(CF)% predicted
  • FEV1/FVC < 70%predicted
  • Obstructive: FEV1 less than 25%
  • Restrictive: Fev1 less than 70%
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7
Q

Lung transplant: arterial blood gases

A
  • Hypoxemia: PaO2<55-60mmHg)
  • Hypercapnia: PaCO2 > 55mmHg
  • diminished diffusion capacity = fibrotic condition
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8
Q

Lung transplant: Functional status

A
  • NYHA class III-IV

- Limited 6MWT but > 200m

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9
Q

NYHA Classes

A
  1. No symptoms. no limitation to ordinary physical activity
  2. Mild symptoms. Mild SOB or angina and slight limitation during ordinary PA
  3. Comfortable only at rest. Marked limitation in activities due to symptoms even during less than ordinary activity (walking 20-100m).
  4. Severe limitation, mostly bed bound. Experience symptoms even at rest.
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10
Q

COPD - MRC grades

A
  1. Not troubled by SOB except with strenuous activity
  2. SOB when hurting/walking slight uphill
  3. Walks slower than contemporaries because of breathlessness/has to stop for breaths when walking at own pace
  4. Stops for breath after a few minutes or ~100m
  5. Too breathless to leave house and when dressing/undressing
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11
Q

Lung allocation score

A

Based on medical urgency and net benefit.

Other factors: age, height, weight, DM, mechanical ventilation, 6MWT, cardiac index, PaCO2

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12
Q

Risk Factors

A
  1. previous thx sx/chest wall deformity - makes removal of lung difficult because of adhesions, increasing risk of bleeding/nerve damage.
  2. nutritional health, immunocompromised
  3. prednisone > 20mg/day
  4. significant vascular disease
  5. severe cachexia/obesity (BMI<17 or >30)
  6. Osteoporosis, DM slows healing and rehabilitation
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13
Q

Listing status

A

Reasonable candidate and no outstanding issues = listed for transplant
Status:
0: on hold = inappropriate for transplant (test result pending, complication that requires mx, change in status)
1: stable
2: in hospital or rapidly deteriorating

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14
Q

Stages of transplant (6)

A
  • referral
  • assessment and listing
  • 6 week rehab program
  • waiting
  • peri-operative
  • living with transplant
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15
Q

Clinical presentation of end stage respiratory failure

A
  • severe dyspnea/angina
  • malnutrition
  • cachexia (muscle wasting, generalized weakness, debility)
  • fatigue, insomnia
  • osteoporosis
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16
Q

6-week rehab: aerobics (what are patients assessed for?)

A
  • functional mobility
  • exercise capacity
  • supplemental oxygen needs
  • begin progressive exercise program
17
Q

6-week rehab: strength training (what and why)

A
  • free weights and resistive training
  • balance
  • posture correction
  • pain, body image, breathing technique
18
Q

Quantify risk in age to lung transplantation

A
  • age brings a spectrum of age-related disorders that may significantly increase morbidity.

age 60 = half life (point ~50% of recipient will die at least 1-2 years early compared to those younger)

19
Q

Survival by disease: COPD vs. Pulmonary fibrosis

A

significant survival difference related to underlying pulmonary disease

  • COPD have superior 1-, 3-, and 5-year unadjusted survival rates compared with pulmonary fibrosis
20
Q

Waiting for transplant (lung vs. other organs)

A

much longer compared to heart and liver due to

  • number of candidates
  • organ type
  • program location
  • die waiting for transplant

Donor/recipient matching:

  • blood type
  • size (weight, height, circumference)
  • listing status/date
21
Q

Surgery types: what is a

  • thoracotomy,
  • clamshell/sternotomy
A

Thoracotomy = single lung transplant

cleanshell/sternotomy = double

Other types:

  • heart-lung
  • lobar
22
Q

General Complications

A
  1. Acute rejection
  2. Graft dysfunction
  3. Nerve injury (peripheral neuropathy foot drop)
  4. Infection
  5. Haemodynamic instability (arrhythmia, hypo-/hypertension, coagulation, bleeding)
23
Q

Airway complications

A

ranges from mild to complete dehiscence

  • frequent bronchoscopy to assess anastomoses and formation of stenosis
  • can surgically repair, re-transplant, balloon dilation, stent placement
24
Q

Lung transplant: ICU

A
  1. Assessment
  2. Chest care = percussion & vibrations, DB&C
  3. Mobilizations = ROM, bed exercises, foot and ankle pump, tilt table, transfers supine-sit-chair-stand
  4. Pain management = support bought, proper body mechanics
25
Q

Acute rejection:

  • presentation
  • treatment?
A

occurs in 50% of patients in the first month, marked by

  1. decreased FEV1 on PFT
  2. Infiltration on CXR/pleural effusion
  3. Decreased SaO2, especially during exercise
  4. Fatigue, malaise, SOB, cough, fever

Treatment: 3 day pulsed IV solumedrol (corticosteroid)

26
Q

Medication: anti-rejection and immunosuppressant

A 
Daclizumab
Cyclosporine
Tacrolimus
Sirolimus
Prednisone
27
Q

Medication: Prevent/Treat infection

A

antibiotics and antifungals

28
Q

Medications: Protect GI

A

Antacids, Zantac, Losec

29
Q

Medication: CNS AE

A
  • tremor, tingling, confusion, seizure, stroke, headaches, blurred vision, insomnia, depression
30
Q

Medication: MSK AE

A
  • osteoporosis
  • myopathy
  • joint pain
  • avascular necrosis
31
Q

What is pulmonary denervation

A
  • transection of pulmonary autonomic nerve (at distal tracheal during heart/lung or major bronchi in single/bilateral lung transplant)
  • not essential for spontaneous respiration or survival
  • decreased cough despite preservation of the laryngeal cough reflex
  • reduced mucocilliary activity (encourage deep breathing & voluntary cough
32
Q

Discharge criteria

A
  • Medically stable
  • transfer with minimal assist (bed-chair-stand;
  • stand-by assist: toilet, tub, car
  • walk safely with or without gait aids
  • independent stair climbing
  • equipment only needed on temporary bassi
33
Q

Post-operative management: 3 months following

A

Remain in Edmonton 3 months after transplant

  • clinic 2x/work
  • blood work, PFT, CXR
  • Daily rehab
34
Q

Post-operative management: 3 month follow up

A
  • ABG
  • Bronchoscopy
  • CXR
  • VQ scan, CT chest
35
Q

Post-operative: exercise performance

A

substancial improvement in capacity

  • 40-60% improvement in peak O2 consumption
  • improved SaO2 (>90%)
  • age-appriorate HR réponse to exercise
  • increased 6MWT
36
Q

Post-operative: what limits exercise capacity after transplant?

A

leg fatigue

  • impaired oxidative capacity in skeletal muscle
  • compromised peripheral circulation
  • immunosuppresant medications
  • severe reconditioning pre-operatively
37
Q

Post-operative: factors limiting rehabilitation

A
  1. Pre-op debility, muscle wasting
  2. Pre-morbid conditions
  3. Heart/lung denervation
  4. hyper-/hypotension
  5. cardiac dysrhythmia
  6. peripheral edema
  7. anemia
  8. pain (splinting, immobility)
  9. drug-related complications (neurotoxicity, nephrotoxicity)
  10. Acute rejection, injections
38
Q

Living with a transplant: long-term management

A

patients are expected to monitor their healthy frequently

  • spirometry
  • bp
  • blood work
  • weight and temperature

report monthly to biannual clinical visits

39
Q

Living with a transplant: What outcome measures are used for:

  1. General health
  2. Emotional health
  3. Disease-specific
  4. General function
  5. PFT
A
  1. General health: MOS SF-36
  2. Emotional: Beck Depression Inventory
  3. Disease-specific: Chronic respiratory questionnaire
  4. General function: 6MWT, Borg RPE
  5. PFT: FVC, FEV1

PTHER 544 - Cardiorespiratory (12 decks)

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