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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 67-71

The importance of pulmonary rehabilitation in lung transplantation


1 Department of Pulmonary Medicine, Pulmonary Rehabilitation Unit, PSG Institute of Medical Sciences and Research, PSG Hospitals, Coimbatore, Tamil Nadu, India
2 Department of Pulmonary Medicine and Critical Care, PSG Institute of Medical Sciences and Research, PSG Hospitals, Coimbatore, Tamil Nadu, India
3 Department of Pulmonary Medicine, PSG Institute of Medical Sciences and Research, PSG Hospitals, Coimbatore, Tamil Nadu, India
4 Department of Allied Health Sciences, Sri Ramachandra Institute of Higher Education and Research (DU), Chennai, Tamil Nadu, India

Date of Submission01-Apr-2020
Date of Decision18-Jun-2020
Date of Acceptance30-Jun-2020
Date of Web Publication03-Mar-2021

Correspondence Address:
Manivel Arumugam
Senior Physiotherapist, Department of Pulmonary Medicine, PSG Institute of Medical Sciences and Research, PSG Hospitals, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejop.ejop_29_20

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  Abstract 


Lung transplantation is now the standard of care for nonreversible end-stage lung disease and leads to dramatic improvements in pulmonary function, quality of life, and survival. Pretransplant pulmonary rehabilitation (PR) can optimize potential recipients and widen or open a “transplant window” period. Given the potential for long wait times in our country, ongoing PR is crucial to ensure recipient fitness. Postoperative rehabilitation is an integral part of care of the recipient and may extend beyond hospital discharge. We present the case of a 42-year-old female who underwent bilateral lung transplantation for advanced interstitial lung disease and discuss the challenges and our approach to PR in this setting.

Keywords: Interstitial lung disease, lung transplantation, pulmonary rehabilitation


How to cite this article:
Arumugam M, Ramanathan RP, Thacker J, Rajagopala S, Govindharaj P. The importance of pulmonary rehabilitation in lung transplantation. Eurasian J Pulmonol 2021;23:67-71

How to cite this URL:
Arumugam M, Ramanathan RP, Thacker J, Rajagopala S, Govindharaj P. The importance of pulmonary rehabilitation in lung transplantation. Eurasian J Pulmonol [serial online] 2021 [cited 2021 Sep 19];23:67-71. Available from: https://www.eurasianjpulmonol.com/text.asp?2021/23/1/67/310720




  Introduction Top


Lung transplantation is now the standard of care for nonreversible end-stage lung disease and leads to dramatic improvements in pulmonary function, quality of life, and survival. Worldwide, more than 4000 lung transplants are performed annually.[1] The outcome of lung transplantation depends upon the underlying disease, recipient selection, donor factors, surgical approach, and center volume. Center volume affects outcome by affecting surgical approaches, optimum immunosuppressant, and effective use of pulmonary rehabilitation (PR). Pretransplant PR can optimize potential recipients and widen or open a “transplant window” period. Given the potential for long wait times in our country, ongoing PR is crucial to ensure recipient fitness. Postoperative rehabilitation is an integral part of care of the recipient and may extend beyond hospital discharge. While much has been published about the other aspects affecting transplantation outcome, very little emphasis has been placed on PR in this setting. We present a patient who underwent bilateral lung transplantation for advanced interstitial lung disease and discuss the challenges and our approach to PR in this setting.


  Case Report Top


A 42-year-old female with chronic respiratory failure related to interstitial lung disease associated with autoimmune features on long-term oxygen therapy was referred for lung transplantation during an acute exacerbation. Transplant assessment was deferred, and the acute exacerbation [Figure 1] was managed with high-flow nasal oxygen and steroids. When she improved and oxygen requirements stabilized, the core team members, including the pulmonologist, transplant surgeon, anesthetist, PR therapist, dietician, and psychiatrist completed a multidisciplinary meeting and decided to initiate her listing. She was listed in the hospital and state registry for lung transplantation on completion of her assessment with the infectious disease specialist, nephrologists, cardiologist, dentist, and other ancillary specialists. She was started on regular PR program after obtaining informed consent to maintain and improve exercise tolerance, lung mechanics, and peripheral and respiratory muscle function, with an aim of reducing the risk of perioperative complications. Prerehabilitation assessment was undertaken by a dedicated PR therapist (First author), and it included a 6-min walk test[2] performed according to the American Thoracic Society guidelines with 5 L/min of oxygen support [Table 1]. The protocol initiated and continued up to the day of lung transplantation is summarized in [Table 2].
Figure 1: (a) Preoperative chest radiograph. (b) Preoperative high-resolution computed tomography scan

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Table 1: Outcome measures

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Table 2: Protocol of pulmonary rehabilitation programme (pretransplant)

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She received bilateral lung transplants at 1 year of listing. Transplantation was performed sequentially under cardiopulmonary bypass through a clamshell incision; the donor was a 14-year-old with brain death due to status epilepticus. The postoperative period was uneventful without the need for extracorporeal membranous oxygenation or nitric oxide. Steroids, cyclosporine, mycophenolate (mofoetil), and analgesia were initiated and titrated according to protocol.

Phase I PR was initiated 24 h postsurgery; the treatments administered initially were positioning, airway clearance and bronchial hygiene, chest wall mobility exercises, and limb exercises. On the 5th postoperative day, her respiratory function, cough, hemodynamics, and neurological status were deemed adequate, and a spontaneous breathing trial (SBT) with pressure support (PS) of 8 cm H2O was performed for 30 min. She failed SBT, and a decision on slow PS decrements was taken. Chest X-ray was taken and assessed for airway clearance [Figure 2]. She was continued on PS mode with chair mobilization for 15–30 min twice daily. Active upper limb exercises were initiated with ergo meter. Lower limb strengthening exercises were performed with weight cuffs and thera band tubes. Endurance training was given with portable mini-leg cycle. While intubated and with intensivist oversight and adequate endotracheal tube protection, she was mobilized to standing position and marching exercises were performed. Commode privileges were instituted. She could be extubated to 3 L/min of oxygen and shifted to room by day 10 with the above protocol. Her subsequent hospital course was uneventful, and she was discharged at 30 days posttransplantation on stable immunosuppressant with a plan for the second phase of PR lasting for 3 months.
Figure 2: (a) Chest radiograph on the first postoperative (b) Chest radiograph one month after transplantation. (c) Chest radiograph three months after transplantation

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The protocol of our Phase II Rehabilitation program is shown in [Table 3]. The program was initiated thrice weekly for 3 months with a home-based exercise program; regular walking, breathing exercises, resistance exercises with water bottles, and sand bags was also encouraged. Serial outcome measures at the 2nd week, 4th week, 12 week, 6 month, and 1 year are summarized in [Table 1]. The results show an appreciable increase in clinical variables, functional walk capacity[2] (from 53.5% to 86.63% predicted), and functional independence measure score changes from moderate assistance to completely independence in self-care activities. Physical activity index also changed from “sedentary” to “active healthy.”
Table 3: Protocol of pulmonary rehabilitation programme (posttransplant)

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  Discussion Top


Postoperative rehabilitation is an integral part of care of the posttransplant recipient. It begins when the patient medically stable (Phase-I; acute phase), Phase-II (early outpatient/intensive monitoring phase) begins days after discharge from hospital and lasts up to 6–12 weeks according to the patient's need and followed by Phase-III and Phase-IV can be initiated after the completion of Phase-II.

In our case report, we expressed our PR program with appreciable outcome measures after double-lung transplantation, at present, the patient not having any oxygen and Bi-level positive airway pressure support. Here, we presented appreciable outcomes after the Phase-II rehabilitation programs, if it can be continued up to Phase III and Phase IV and regular care, the patient's survival and quality of life will be better. In our knowledge, there is no study related to PR program for lung transplantation in India. We hope that researchers can initiate research toward PR program and outcomes with lung transplantation patient's, morbidity, mortality, increasing the survival years after transplant. This study may guide some information to the rehabilitation professional who involving in organ transplantation.

In India, there are no large studies with outcomes after lung transplantation.[3],[4] Prasad et al. 2019 reported that “there is an urgent need to initiate a lung transplant registry where all the lung transplant cases and their outcomes should be maintained to identify problems unique to our geographic locale,” likewise PR program for lung transplant patients and outcomes also be wanted to document.[5] Three cohort studies demonstrated positive effects of exercise training on muscle function and exercise capacity in the long-term posttransplant phase.[6],[7],[8] This study also found similar good outcomes in the patient with lung transplantation.


  Conclusion Top


In our case report, we have taken objective measurements as an outcome which is easier to practice rather than the disease-specific quality of life outcome measures and also able to replicate the outcomes after a year and regular follow-up. Each and every case will differ from treatment program and outcomes, so the researchers and practitioners should go according with patients and current practice guidelines. The team involvement is very essential in the every part of rehabilitation program and patient's education. This may help other researchers to conduct study with large number of patients and outcomes after transplantation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chambers DC, Yusen RD, Cherikh WS, Goldfarb SB, Kucheryavaya AY, Khusch K, et al. The registry of the international society for heart and lung transplantation: Thirty-fourth adult lung and heart-lung transplantation report-2017; focus theme: Allograft ischemic time. J Heart Lung Transplant 2017;36:1047-59.  Back to cited text no. 1
    
2.
Ramanathan RP, Chandrasekaran B. Reference equations for 6-min walk test in healthy Indian subjects (25-80 years). Lung India 2014;31:35-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Elumalai RS, Somasundaram G, Vaidyanathan K, Venkatraman R, Nainar M, Rahulan V. Single lung transplantation in India: An initial experience. Indian J Chest Dis Allied Sci 2013;55:101-3.  Back to cited text no. 3
    
4.
Madhu Sankar N, Kurian VM, Rajan S, Ninan B, Ajit M, Cherian KM, et al. Heart-lung transplantation in India: Initial experience. Indian Heart J 2003;55:185-7.  Back to cited text no. 4
    
5.
Prasad KT, Sehgal IS, Dhooria S, Agarwal R, Singh RS, Singh H et al. Experience of the first lung transplantation performed in public sector in India. Lung India 2019;36:66-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Vivodtzev I, Pison C, Guerrero K, Mezin P, Maclet E, Borel JC, et al. Benefits of home-based endurance training in lung transplant recipients. Respir Physiol Neurobiol 2011;177:189-98.  Back to cited text no. 6
    
7.
Guerrero K, Wuyam B, Mezin P, Vivodtzev I, Vendelin M, Borel JC, et al. Functional coupling of adenine nucleotide translocase and mitochondrial creatine kinase is enhanced after exercise training in lung transplant skeletal muscle. Am J Physiol Regul Integr Comp Physiol 2005;289:R1144-54.  Back to cited text no. 7
    
8.
Stiebellehner L, Quittan M, End A, Wieselthaler G, Klepetko W, Haber P, et al. Aerobic endurance training program improves exercise performance in lung transplant recipients. Chest 1998;113:906-12.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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