Thoracic Organ Transplantation

what are PT implications after a heart transplnat (how will the patient present)

median sternotomy

chest tubes, arterial line, swann-ganz catheter

epicardial pacing wires

2P waves since 2 SA nodes if biatrial surgical technique

what are the main activity implications of heart transplant?

resting HR is higher, 90-110

HR and SV respond more slowly

peak VO2 is lower

monitor EKG and BP

extended warm-up and cool down required

orthostatic hypotension is common

what are suggested guidelines for exercise post-op heart transplant?

resting HR less than 120

systolic BP less than 190, diastolic BP less 110 at rest

aim for RPE of 3-4 on the 0-10 scale during inpatient stay

no significant arrhythmias or angina

exercise HR not more than 40 beats above rest

no diastolic drop or increase greater than 15 mmHg during exercise

what are effects of exercise training?

little or no change in resting HR

a small increase in peak HR

no change in resting SV or CO

VO2 max is between 50-70% of age/gender matched controls

improved FEV1

what type of exercise testing should you use for patients with a heart transplant?

can use a treadmill or cycle

step protocol or 6 min walk test are also effective

because of delayed and blunted respone in HR

in some patients within 1-4 years post-transplant they can regain sympathetic innervation, so HR coudl be used

what shoudl aerobic prescription be for a heart transplant?

wlaking/cycling/swimming

RPE less than 5/10 on modified BORG scale

daily exercise

30 min in a day

warm-up and cool down should be emphasized

what is exercise prescription for strength?

all major muscle gruops, particularly proximal muscles

low-moderate intensity (50% of 1RPM at most)

1-2 sets of 10-15 reps

2-4 days/week

avoid isometrics

what are guidelines for flexibility?

start in upper body 6-12 weeks after surgery due to sternotomy

UE and LE’s

minimum 2-3 days

what are complications from a single lung transplant?

V/Q mismatch

mechanics is never normal due to disease and residual impairments in non-transplanted lung

what are some PT implications for a lung transplantation?

intensive respirtaory PT required

thoractomy precautions

patient should lie on non-operative side to reduce post surgical edema, assist with drinage, promote inflation of new lung

respiratory isolation

what are PT implications for a double lung transplantation?

intensive respiratory PT required

incisional precautions

patient should avoid supine lying to minimize secretion retention

respiratory isolation

what are the main changes in pulmonary status after lung transplant?

VO2 max-between 40-60% of age/gender matched controls

anaerobic threshold reduced compared to normal

RR mildly elevated at rest

disruption of the vagal and autonomic nerves

restrictive physiology is present with a decrease in TLC

may have bronchial hyperresponsive with exercise

what are some PT interventions for lung transplantation?

postural drainage

airway suctioning

vibration/gentle percussion

diaphragmatic breathing

coughing exercises

use of incentive spirometer ‘

acapella

most monitor O2 sats

what are the effects of exercise training for lung transplant?

improved minute ventilation

respiratory pattern may improve

improved VO2 from baseline but still reduced

RR with exertion decreases, less dyspnea

patient should wear a mask when aroudn people

what types of exercise testing is used for lung transplantation?

6 minute walk, cycle or treadmill sub max

testing used to prescirbe exercise at an appropriate level

functional tests may also be effective

systemic hypertension can be adverse effect

always monitor O2 sats and have supplemental O2 availible

what are aerobic exercise prescription?

walking,swimming, cycling

upper cycle ergometer may even be used for endurance

THR 60-80% of peak HR

RPE less than 5/10

1-2 sessions per day

3-7 days per week

20-30 minute sessions

duration is more important than Intensity

what shoudl strength and flexibilty look like in lung transplantation?

strength: low resistance, high reps, emphasis on proximal muscles, 3 days per week

flexibiilty: daily, consider tai chi

what is the warm-up and cool down RPE?

warm-up: 1/10

exercise at RPE of 3-4/10

what are complications for hyperacute rejection from transplants?

ischemia and necrosis

within 48 hours after transplant

caused by ABO incompatibility and cytotoxi antibodies

patient will have general malaise and high fever

non-reversible

only treatment is removal of organ and immediate retransplantation to survive

what are complications from acute rejection?

treatable and reversible

occurs within the first year

most patients have some degree of acute rejection due to foreign antigens from the graft

treated with change in immunosuppresive drugs

first signs may be seen as soon as 4-10 days

what are general signs and symptoms of acute rejeciton?

sudden weight gain

peripheral edema

fever, chills, sweating, malaise

dyspnea

decreased urine output

electrolyte imbalances

increased BP

swelling and tenderness at graft site

what is chronic rejection for transplants?

after first year

deteroriation of the graft is gradual and progressive

immunosuppressive durgs do not stop this type of rejection

increasing immunosuppresive drugs may slow the process

what are complications for chronic in heart transpant patients?

acclerated atherosclerosis and myocardial fibrosis

increasing blockage of coronary arteries

MI is consequence

why would you see PT for chronic rejection?

arrythmias, dyspnea, dizziness, resting BP higher, BP response to exercise

what are complications for chronic rejection in lung transplants?

progressive dyspnea

increasing airflow obstruction

FEV 1 is affected

what would you see as a PT for chronic rejection from lungs?

Increased RR, SOB on exertion, COPD symptoms

what do immunosuppressive agents do?

inhibit or prevent activity of immune system

prevent the rejection of the transplanted organ

non-selecrive, the immune system loses the ability to fight normal infections

side effects are common

what are PT implications for immunosuppresive medications?

tremor

leukopenia

arthralgia

osteoporosis

toxic to kidneys and liver

edema

insomnia

paresthia

what are long term compliations of organ tranaplant?

acclerated atherosclerosis, hypertension, and hyperlipidemia

infections

cancers

osteoporosis

steroid myopathy with muscle weakness

glucose intolerance

nephrotoxicity

delayed wound healing

gastrointestinal complications