Heart and Lung Transplants/Rehab Flashcards
most common organ waiting lists
kidney -81% liver -11.4 heart -3 lung -1
organ transplant process
deceased donors –> organ procurement organization –> UNOS computer system –> transplant center –> candidates
to avoid conflict of interest, what is the rule
neither the physician of the donor nor the physician that pronounced the death may participate in the organ transplantation
transplant center has how long after it is offered a donor organ
1 hour
organs may be matched by…
tissue match
blood type
length of time on the waiting list
immune status/antigens
distance between the potential recipient and the donor
degree of medical urgency (for heart, liver, lung and intestines)
brain death requirements
coma/unresponsive
absence of motor responses to pain in all extremities
absence of brain stem reflexes
apnea
organ type and waiting times
heart -230 days lung -1068 days heart lung -if heart available, lung will go with it liver -796 days kidney -1121 days
survival rates at 1 year
- heart
- lung
- liver
- kindney
heart -87% lung -100% liver -90% kidney -95%
survival rates at 5 years
- heart
- lung
- liver
- kidney
heart -73% lung -51% liver -77% kidney -81%
what else do you need to be a donor apart from having it on your driver’s license
in a will
sign up with the national registry
ethical considerations of transplants
utility -maximize benefit to all -consider survival and QOL justice/equity -fair distribution -medical benefits (sicker 1st) respect for persons -right not to donate -transparency
which is more important for transplants, justice/equity or respect for persons
justice/equity
psychosocial aspect or receiving an organ transplant
-two traumatic events that can affect their patient’s thoughts
sense of imminent death
trauma of dealing with the transplant surgery and afternath
end stage diseases that may require a heart transplant
-most to least common
cardiomyopathy (46%) CAD/ishcemic heart disease (45%) restrictive valve disease retransplant or graft failure congenital disease
heart transplant recipient criteria
terminal heart disease no renal/hepatic dysfunctiion no acute infections no recurrent pulmonary infections psychosocial stability no alcohol, tobacco, drug use
heart transplant donor criteria
normal echocardiogram (-) HIV and hepatitis brain death declared age <45 years (some exceptions) no pre-existent heart disease few coronary artery disease risk factors no heart trauma no malignancy no infection
liver transplant recipient criteria
no liver transplant for people who suffer from liver damage due to
- current alcohol or substance abuse
- cancer that has spread to other organs
- advanced heart and lung diseases, a condition of sepsis
- HIV patients
cardiac rehab pre-transplant
-what vitals are monitored
physician/therapist guided program designed to maximize a candidate’s strength and endurance to activity
closely monitored vitals
-HR, BP, O2 sat, dyspnea
early complications seen in patients post-heart transplant
donor organ dysfunction acute rejections renal failure arrhythmias bleeding infection due to immunosuppression denervated heart physiology
denervated heart physiology
the drive through the SA node to increase HR during exercise will be altered in these people
HR response will be slower after transplant
chronic complications post-heart transplant
prone to infection due to immunosuppression
accelerated coronary atherosclerosis
chronic rejection (greatest risk in the 1st year post-transplant
hypertension
heart rejection
- due to…
- what is done to prevent this
cells have antigens on their surfaces. the immune system recognizes the cells as foreign and attacks them
an organ that is not matched can trigger a transplant rejection
patients are “typed.” the more similar the antigens are between the donor and recipient, the less likely that the organ will rejected
acute rejection Sx
organ’s function may start to decrease
general discomfort, uneasiness, or feeling unwell
pain or swelling in the area of the organ (rare)
fever
flu-like symptoms, including chills, body aches, nausea, cough, and SOB
immunosuppression
- result
- caregivers must…
- ______ for life
- what type of drugs do they take?
- side effects
patient is more susceptible to infections
caregivers wear a mask
anti-rejection meds for life
immunosuppression with glucocorticoids e.g. prednisone and solumedrol to suppress body’s natural immune system
cocktail is specific to match time post transplant, type of transplant
side effects
-nausea
-weakness
post-heart transplant rehab: acute phase
- focus on…
- precautions
- exercise guidelines…
- be aware of…
multiple lines and tubes immediately post-transplant
focus on functional mobility - bed mobility, transfers and ambulation
sternal precautions
phase 1 cardiac exercise guidelines
be aware of abnormal HR responses
post-heart transplant: after discharge from hospital
-what is the cardiac rehab program
3x/week program designed to increase candidate’s endurance to activity, strength, balance and overall QOL
closely regulated vital signs during exercise
special considerations with exercise post-heart transplant
denervation
-loss of vagal tone, lack of sympathetic stimulation
patient may not have chest pain during exercise secondary to denervation of the heart
patient will have a higher resting HR which may not increase with exertion (>100)
altered baroreceptor response: HR increases slowly with exercise and then remains elevated for increased time post-exercise
-signals from the aortic baroreceptors normally travel through the vagus nerve
ventricular assist device
- used with what patients
- bridges gap between…
- types
used in patients with non-reversible left ventricular failure at imminent risk for death
bridges the gap between terminal heart disease and cardiac transplantation
LVAD
RVAD
BiVAD
comparison of survival rates for the heart transplant patient vs. LVAD
similar rates
RVAD and LVAD
- implantation location
- motor connects to…
- what is a driveline
implanted in the left upper quadrant of abdomen
motor connects to external control and power components via a percutaneous tube
cable called a driveline extends from the pump, out through the skin, and connects the pump to a controller and power sources worn outside the body
therapy considerations in a patient with a VAD
patient’s VAD is hooked up to a controller when at rest
battery unit can be utilized
when ambulating have 2 extra batteries
early mobilization of LVAD recipients
PT initiated in ICU that focused on early mobilization and ambulation of the patient resulted in improved functional mobility upon time of DC from hospital
physician usually sets rehab parameters based on the flow rate reading
-4.0 and above is considered good
rehab for patients post-VAD implant
-goals
prevent
- muscular atrophy
- respiratory compromise
- decreased skin integrity
rehab for patients post-VAD implant
-plan
progress on POD (post-op day) #1 to bed mobility, transfers
ambulation by POD #2
by POD 10-30, begin progressive aerobic exercise at RPE 11-13 on Borg Scale
light resistance training
lung disease diagnosis groups
-how many groups
group A
group B
group C
group D
group A diseases
obstructive
- COPD
- emphysema
group B diseases
pulmonary vascular disease
pulmonary hypertension
group C diseases
cystic fibrosis
group D diseases
restrictive diseases
- IPF (idiopathic pulmonary fibrosis)
- sarcoidosis
indications for lung transplant
untreatable end-stage pulmonary, parenchymal, and/or vascular disease
absence of other major medical illnesses
substantial limitation of daily activities
-projected life expectancy <2 years
-rehab potential
-satisfactory psychosocial profile and emotional support system
-acceptable nutritional status
-disease-specific mortality exceeding transplant-specific mortality over 1-2 years
relative contraindications for lung transplant
tobacco use within past 6 months age ->65 for single lung ->60 for bilateral ->55 for heart-lung psychosocial instability prednisone use >20-40 mg/day
single lung transplant
- indication
- which is replaced
- better for…
non-septic lung disease
poorest functioning lung replaced
better for older people
bilateral lung
-indication
septic lung disease, cystic fibrosis
pulmonary HTN
living-donor lobar transplant
- best for…
- donation associated with…
- need lobes from _____ donors to form…
best for children
donation associated with 15% decrease in lung volume without change in functional capacity
need lobes from 2 donors to form entire lung for recipient
donor selection
absence of infection of airways or parenchyma
acceptable gas exchange
<60 years old
<20-30 pack years
lung transplant allocation
limited supply
patients are ranked according to severity of disease
lung pre-transplant workup
intense battery of tests to determine if suitable for transplant
must maintain adequate nutrition and conditioning
pre-transplant exercise training may be most important
lung pre-transplant rehab
conditioning - bike or walk respiratory muscle training -spirometry lower extremity muscle training -quads, hamstrings core strengthening UE and trunk ROM back extension strengthening -prevent loss of bone mass -energy conservation
lung transplant acute complciations
hyperacute rejection reimplantation response (reperfusion injury) acute graft dysfunction airway complications infection
lung transplant acute considerations
lines and tubes -chest tubes, ventilator, IVs, foley need to mobilize early full AROM of UEs by discharge from hospital ambulation without assistive device home exercise program self-monitoring of SaO2
lung transplant complications
acute rejection - most have at least one episode
lung transplant acute rejection
- when does it happen
- how it is diagnosed
- symptoms
- Tx
3-6 months spirometry - drop of 10-15% on spirometry indicates rejection diagnosed with biopsy symptomatic -fever, cough, dyspnea, failure to thrive asymptomatic -identified by regular biopsies Tx -immunosuppressive medications
lung transplant chronic complications
chronic rejection
chronic lung rejection
- when
- what
- prevalence
- CMV…
- Tx
6 months to 1 year
obliterative bronchiolitis
present in 40% at 1 year, 60-70% at five years
CMV unknown etiology, but possibly linked to acute rejection
treat with immunosuppressive medications
what is CMV
cytomegalovirus
immunosuppressive complications
osteoporosis
muscle weakness
infections
malignancy
common types of malignancy
Non Hodgkins Lymphoma
squamous cell carcinoma of skin and lip
Kaposi’s sarcoma
osteoporosis
- criteria
- prevalence after 1 year on corticosteroids
bone density 2 SDs below age-matched norms
10-37% develop a fracture in 1st year
chronic corticosteroid and muscle weakness
chronic corticosteroid use causes proximal-limb muscle weakness and type II fiber atrophy
cyclosporine impairs mitochondrial function, decreasing muscle ability to utilize oxygen
poor pre-transplant activity and post-transplant bedrest may cause atrophy and alter metabolic capacity, especially in lower limb
early fatigue
reduced muscle mass, muscle atrophy
lung transplant and infection
rate of infection is higher than other organ transplant recipients
constant exposure to external environment
-recipients wear respiratory masks in public for life
QOL post-lung transplant
improved -mobility -energy -sleep -dyspnea -ability to accomplish ADLs many patients return to work post-transplant
exercise limitations in lung transplant
3 months -SLT 46% predicted -DLT 50% predicted 1 year -same VO2 -improvement in lung function -return to daily activities
aerobic exercise training after heart transplant
-how effective
achieve 95% age predicted max
resistance training after transplant
-functions
prevents vertebral osteoporosis
increases muscle strength (counteracts steroid myopathy)
_____ therapy speeds muscle atrophy
corticosteroid therapy
