FINAL: UNIT 5: Heart and Lung Transplants Flashcards
With organ transplants there is always a
Native Organ–belongs to pt, needs to be replaced
Donor Organ—-organ coming from somewhere/someone else
see pics
PTs Role in:
Pt waiting for transplant
Pt receiving transplant
Pt recovering from transplant
see pics
Donors can supply up to ____ organs
8
Selection Guidelines: For all transplants
*Recipients
- MUST BE Ambulatory w/ Rehab potential
- Satisfactory nutritional status w/ Normal BMI
- b/w 18-30
- Appropriate Mental State
- NO intellectual disability
- Must comprehend and accept procedure, risks an complications
- satisfactory psychosocial profile & good support system
- *Downs pts do NOT qualify
- Motivated and compliant w/ tx
- Adequate financial resources for meds and follow
- $10,000 liquid in bank
- Absence of contraindications
EXCLUSION Criteria
- Active/Recent malignancy (<5yrs cx free)
- Other end-organ failure or dysf
- Current smoking or subs abuse (past 6mos)
- Untreated psychiatric disorders
- ex. Bipolar
- Known active infection
- TB, HIV, Sepsis
- Hx of non-compliance
- Unsatisfactory nutritional status
- Obesity or severe malnutrition
- Lack of social support
- Poor rehab pot.—–> THIS IS WHERE PT COMES IN!!!
- PT can SHOW the pt is functional and has ability to rehab
Hx Transplantation Milestones
- 1963
- first lung transplant
- 18d survival
-
1967
- first heart transplant
- 18d survival
-
1980-1990
- Long term survival achieved***
AFTER Transplant……what is req’d???
Lifetime immunosuppressant*
Immunosuppressive Therapy for ANY transplant
3 Modalities of Therapy:
- Induction
- Maintenance
- Rejection
Immunosuppressive Therapy for ANY Transplant
1. Induction
Used in the IMMEDIATE PERI-TRANSPLANT Pd.
*when risk of rejection is HIGHEST and potent immunosuppression is needed
Immunosuppressive Therapy for ANY Transplant
- Maintenance
Cont’d for recipient’s lifetime w/ reduced doses of drugs
*every 12hrs vs. 2x/day
Immunosuppressive Therapy for ANY Transplant
3. Rejection
IF recognized, higher doses and potent IV immunosuppressants are used
Meds for ANY transplant
***
Immunosuppressants
- Ex. Prednisone—–Steroid
-
REMEMBER W/ STEROIDS
- Main MSK SE==> Myopathy
-
REMEMBER W/ STEROIDS
*ALL meds begin as IV and are changed to PO when approp.
Other Meds for ANY transplant other than immunosuppression
- Antifungal prophylaxis
- Corticosteroids
*Immunosuppression is a lifelong commitment —–> prevents rejection while min. SEs
Heart Transplant Eligibility:
3 Dis’s that lead to transplant:
-
1. Cardiomyopathy
- Dilated
- Hypertrophic
- Restrictive
- Preserved EF
- Reduced EF
-
2. HF
- Preserved EF
- Reduced EF
-
3. Congenital Heart Dis.
- ALL UNIT 4 DIS’S
Heart Transplant Eligibility
Eligibilty Checklist
- Adv’d HF or MAX medical therapy
- Freq. hospitalizations
- Deterioation of clinical status
- Poor prognosis w/out transplant
- agree <2 yrs to live w/out transplant
- NO add. medical options
- All other guidelines met
Evaluation Testing for Heart Transplant
FULL WORK UP
Ex’s:
- 24 hr urine screen—-assess kidney function
- chest x-ray
- colonoscopy
- blood tests
- type
- electrolytes
- Infectious dis’s
- mammogram
- PSA—-Prostate Specific Antigen
- Dental exam
- Echo
- cardiac cath
Listing System
Heart Transplant
1A:
*Considered FIRST
- Pts are HIGHEST priority
- Must stay in hospital due to meds or machine
- LVAD, BiVAD, ECMO
- Vent. dependent
- IV Inotrope (strength)
- Limtd life expect w/out transplant
Listing System
Heart Transplant
1B Status
*Considered 2nd IF NO 1A Match
- 2nd highest priority
- Can live outside hospital
- May req. sm amts of IV meds or LVAD
Listing System
Heart Transplants
Status 2
NO IV meds
NOT hospitalized
Clinically stabe BUT terminal dx
CHDs
Listing System
Heart Transplants
Status 7
Pts are listed for transplant BUT have been removed from active list
infection, life event, insurance, finances
Factors influencing Compatibility
Heart transplants
5:
- Blood Type, ABO compatibility
- Listing Status (1A, 1B, 2)
* LONGER wait==HIGHER priority
- Listing Status (1A, 1B, 2)
- Days on waiting list
- Cavity Size
- Geographic Loc.
* *Heart can be stored for 4-6hrs*****
- Geographic Loc.
*NOTE: More MEN are donors—> more risky behavior
2 Sx Approaches
Heart Transplant
-
Anterior Axilla Approach
* MOST COMMON
* **RIB 4
-
Anterior Axilla Approach
-
Sternotomy
* *Sternal Precautions- NO lifting
- NO overhead
- NO valsalve
- NO using just one arm to get up or move—-USE BOTH
-
Sternotomy
What is the BIGGEST PROBLEM AFTER Heart Transplant?
Denervated heart****
*takes awhile for the heart to become stim’d w/out help from SA Node…..
*WARM-UP IS KEY!!!
POST Heart Transplant Complications
Complications assoc’d w/ Sx:
- Rejection
- Infection
- Ischemic injury
Post Heart Transplant Complications
Comps assoc’d w/ Transplantation:
- INC susceptibility to infections
- Cx
**BOTH are bc you are on immunosuppressants for LIFE
Post Heart Transplant Comps
Comps assoc’d w/ Immunosuppressive Drugs:
- MYOPATHY***
- PT plays huge role in this/recognizes it!!!
- SEs of long term oral glucosteroids and other immunosuppress drugs (SEE ABOVE)
- Osteroporosis/penia
PTs Role in Heart Transplant
Rehab Phases
POST-Transplant
In general key points
- Expect a blunted HR response to EX due to lack of SNS activation/denervation of heart—–> WARMUPS!!!
- DELAYED sinus tachy
- DELAYED INC SBP
- DELAYED tolerance to ex.
- Pts CAN obtain partial reinnervation of the ANS over time*
- CONSTANTLY check for s/s of infection/rejection
- ADDRESS WHOLE PATIENT!!!!!
PTs Role in Heart Transplant
Rehab Phases
POST-Transplant
Other key things to remember Dr. Macfarlane mentioned
- Only terminate Warm-up when you see an INC in HR
- means the heart is finally stimulated
- *remember the heart will act like the body is RESTING when its NOT
- We NEED an INC in HR to INC blood flow to body*
- ADDRESS WHOLE PATIENT, not just endurance
- EX. Quad strength in CV pts linked to long-term success!!!
Explain this slide
Denervated Heart vs. Innervated Heart
-
Denervated Heart
- expect blunted HR response —-> just like BetaBlockers
-
*REMEMBER
- The denervated heart is now going to rely on circulating Epi and NE to attach to the SA node receptors bc ANS NOT ATTACHED TO SA Node
- Catecholamines: Wait to kick SA node in
- Expect Delayed recover after Ex. ***
S/S of Rejection/Infection
Heart Transplant
SIGNS ARE THE SAME—-this is what makes it difficult and why it is IMPERATIVE you monitor this!!!
- HEART Specifically:
-
S3 gallop–> Lub, Dub, Dub
- S3 sound blood hits walls of HEART, not VALVES
- Arrhythmias
- JVD
-
S3 gallop–> Lub, Dub, Dub
- OTHER:
- Fever >100 degs/fever/chills
- Changes in BP
- Resp distress
- Dyspnea
- Fatigue
- DECd EX tolerance and capacity
- Wt. gain
- Edema
**Remember these all look A LOT like signs of infection/sickness too!!!
Lung Transplantation Eligibility
Broken down by Categories of Diseases
See pics
Lung Transplant Eligibilty
General List
- End Stage lung dis. on max med. therapy
- FREQ. hospitalizations
- Deterioration of clinical status/ADL
- O2 dependency
- Poor prognosis W/OUT transplant
- NO add. medical options
- All other guidelines met
see pics for guidelines broken down by Dis. Category
Lung Transplant
Listing System
PT Eval
What are the components of this?
- Ht
- Wt
- Lung Dx code
- Functional status and 6MWT—PT
- assisted ventilation
- Supp. O2
- Current ABG
Lung Transplant
Listing System uses what score?
Lung Allocation Score LAS
HIGHER score===HIGHER on list
Lung Transplant
Listing System
Disease specific categories
-
COPD:
- %Predicted FVC: <60% w/ hypoxemia
- FEV1 <25%
- NOTE: Obstructive, LOOW
-
Pulm HTN: remember NORM Pulm aa SBP <25
- >55mmHg w/ life exp <3yrs
- Pulm AA mean press & systolic press
-
IPF: Idiopathic Pulm Fibrosis
- <60% Vital Capacity
Factors influencing Compatibility
Lung Transplant
- Blood type, ABO compat.
- Listing status (LAS score)
- Days on waiting list
- Thoracic cavity size
- Geographic Loc.
Lung Transplant
Sx approaches
- Clamshell Incision
* ONLY RESTRICTION post transplant is NO driving and NO sitting in front of air bag for 6mos
- Clamshell Incision
- Mediansternotomy
* *Sternal Precautions- NO lifting >10lbs
- NO valsalve
- NO bending/twisting
- NO using just one arm to get up, USE BOTH
- Mediansternotomy
Post Lung Transplant Comps
Comps assoc’d w/ Sx:
- Rejection
- Infection
- Ischemic injury
-
Bronchial issues
- anastomoses dysf—–no collateral blood supply
-
Atrial arrhythmias
- A-fib COMMON***
Post Lung Transplant Comps
Comps assoc’d w/ Transplant:
- INC susceptibility to infections (PNA)
- Cx
- Diaphragmatic dysf
-
SLT: Single Lung Transplant–Complications*
- Initially dec perfusion to donor lung
- Chronic native lung hyperinflation causing displaced mediastinum, DEC V/Q of donor lung
Post Lung Transplant Comps
Comps assoc’d w/ Immunosuppressive Drugs
- SEs of long term oral glucosteroids and other immunosuppress. drugs
- MYOPATHY!!!
- osteoporosis/penia
PTs Role in Lung Transplant
Rehab Phases
POST-Transplant
In general key points
- LUNGS ARE NOW DENERVATED
-
DELAY in bronchodilation w/ onset of exertion due to denervation nature of the lung
- *USUALLY DO NOT obtain partial reinnervation of the ANS like the heart
- CONSTANTLY check for s/s of infection/rejection
- same as heart except now INC in sputum prod.
-
ADDRESS WHOLE PATIENT, not just endurance
-
*90% anxiety in lung patho’s
- pts scared
-
*90% anxiety in lung patho’s
PTs Role in Lung Transplant
Rehab Phases
POST-Transplant
Other key things to remember Dr. Macfarlane mentioned
- WARM-UPS are ESSENTIAL for Lung Transplant
- Warmup must be LOWER MET lvl than your intended Ex. MET lvl
- *remember LUNGS are now deinnervated
- WARMUP
- 2-5mins
- LOWER intensity exercise as warmup
- some endurance component
S/S Rejection/Infection
Post Lung Transplant
LUNG IS GENERAL
- Sputum production
- DECd lung function
- O2 desat
- Altered ABG
- Hypoxemia—-> LOW O2
- Hypercapnia—-> HIGH CO2
- ***Lung biopsy via bronchoscopy===> GOLD STANDARD for dx of rejection
S/S Rejection/Infection
Lungs
Gen. List
*Remember these s/s look similar!!!!!
- Fever>100degs/fever/chills
- Changes in BP
- Resp distress
- Dyspnea
- Fatigue
- DEC Ex tolerance and capacity
- Wt Gain
- Edema
LUNG/HEART Transplant
If LESS THAN 3yr Life Expectancy
What things should you incorporate?
- EDUCATE
- Functional mobility
- ID mm imbalances and strength
- Strengthen MAJOR MM GROUPS—Glutes/Quads
-
MM endurance
- those awaiting heart transplant—> “Cardiac Rehab parameters—REVIEW THESE
- Optimize breathing patterns
- Address anxiety/depression
- yoga/mobilization w/ breathing
-
Prevent sedentary lifestyle despite progressive deterioration of lungs
- DEC strength and diaphragmatic impairments adversely affect ex. capacity
POST-OP Transplant
Heart and Lung
Acute Care:
-
Monitor VITALS
- Conditional Breathlessness Dyspnea–> usually related to mm fatigue and anxiety
- Skin care
-
Pulm mgmt/Chest PT/Segmental breathing
- diaphragmatic breathing
- INSP. hold—-count insp, pause, exhale
- biofeedback
- pursed lip
- airway clear. techs
- aspiration common—-> assess BEFORE trendelenberg pos
- functional mobility
- assist in weaning process off mech. vent.
- strength train
-
EDUCATE
- anxiety, coping mechs, breathing w/ mobility
POST-OP Heart/Lung Transplant
Acute Care:
BED POSITIONING
- HOB >30degs to prevent aspiration
- IF unable to get OOB, place bed in chair pos when hemodynamically stable
POST-OP Heart/Lung Transplant
Acute Care:
SLT POSITIONING (Single Lung Transplant)
- Pos. pt w/ donor lung side UP, native lung DOWN to promote DRAINAGE
- ex. L. lung transplant—lay on R. side
POST-OP Heart/Lung Transplant
Acute Care:
DLT: Double Lung Transplant
POSITIONING
- Pos. pt supine for and rotate ASAP, every 2hrs
- SAME W/ HEART TRANSPLANT
POST-OP Heart/Lung Transplant
Acute Care:
POSITIONING DURING REJECTION
Donor lung DOWN to optimize perfusion
Acute Care
POST-OP Heart/Lung Transplant
POSITIOINING in gen.
OUT OF BED AS SOON AS MEDICALLY STABLE
Post-Op Heart/Lung Transplant
In-pt rehab
- pts function optimized @ 3-6mos post-transplant
- Functional mob.
- UE/LE mm endurance/strength
- posture training/scapular strength
- Chest PT
- Pt specific impairs
POST-OP Heart/Lung Transplant
Home PT
*Transition to OP PT ASAP bc pts function is optimized @ 3-6mos post-transplant
*so after 3-6mos you want to get them into OP PT bc they are at the best their going to be w/ other PT methods
Post-Op Heart/Lung Transplant
Outpatient PT
-
Scar mgmt
- avoid ST restrict/dec rib mob/chronic pain
- STM and rib mobs of T/S and ribcage
- *mult studies have found DEC FEV1, DEC VO2max and DEC daily activity compared to healthy people of same age, ADDRESS IT
- DO NOT UNDERDOSE!!!
-
EXERCISE PRESCRIPTION:
- Progressing aerobic endurance ex
- INC mm strength
- *LE weakness is one of primary cause of ex limitations—-NOT dyspnea
- INC endurance tol and ADL function
- spirometry vol’s
- GOALS:
- community acts w/out fatigue
- *Risk of re-admission is high——- optimize function and pulm status as early as possible
Phys Activity Levels After Lung Transplant
*Take Home Message: Ceiling effect reached 3-6mos
*DO NOT UNDERDOSE——ALWAYS ROOM FOR PROGRESSION!!!
SEE STUDY BELOW
POST-OP Care
Heart/Lung transplant
Infection Control
- Infection control is KEY
- hand washing
-
Staff wears a mask in pt environment
- *LUNG transplant
- avoid flowers & plants in room
- NO lab jackets/coats in room
**65% of pts post-op transplant will get an infection**