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Physical Therapy in Heart and Lung Transplantation and Mechanical Assist Devices

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Physical Therapy in Heart and Lung Transplantation and Mechanical Assist Devices. Kim Dosch, PT Tina Fields, PT, CCS 06/20/2013. Heart Transplantation. Statistics UM=60 a year Demographics Gender: 3males : 1 female Age: <65, typical 50-65. Heart Transplantation.

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physical therapy in heart and lung transplantation and mechanical assist devices
Physical Therapy in Heart and Lung Transplantation and Mechanical Assist Devices

Kim Dosch, PT

Tina Fields, PT, CCS

06/20/2013

heart transplantation
Heart Transplantation
  • Statistics
    • UM=60 a year
    • Demographics
      • Gender: 3males : 1 female
      • Age: <65, typical 50-65
heart transplantation1
Heart Transplantation
  • Common Diagnoses: heart failure, myocarditis, etc
  • Pre-operative condition: mechanically vented, Pacemaker
  • Exclusion from the transplant list: cancer, drug/alcohol abuse, compliant with medical regiment, insurance coverage, pulmonary hypertension, kidney failure
the transplant list
The Transplant List
  • Status
    • 1A: most critical status, increased risk of death in next 7 days, min transplant time of 59 days.
    • 1B: ventricular assistant device >30 days, can go home, average time to transplant is 115 days.
    • 2: everybody else on transplant list that is not 1A or 1B >365 days till transplant
    • 7: took off the list temporarily, for infection, etc
  • Tissue Match: antigen, antibody reaction
  • Time to transplant
operative procedure
Operative Procedure

Median Sternotomy

Implication for PT: sternum approximated

median sternotomy implications for pt
Median Sternotomy: Implications for PT
  • Facility Dependent
  • 10# lifting restriction until sternum heals
    • Includes lifting/pushing/pulling
    • Implications for mobility?
  • Full shoulder range as tolerated to pain (no ROM restrictions)
operative procedure1
Operative Procedure
  • Techniques
    • Orthotopicheart transplant: removed most of the pt’s heart and replaced it 95% of the donors heart.
post operative changes
Post Operative Changes
  • Denervation of Heart
    • Loss of Vagus Nerve
      • Role of VagusNerve: parasympathetic HR control, decreases HR when
    • Implications for PT: we need to be aware of HR control not adapting, elevated resting HR.
post operative changes1
Post Operative Changes
  • Denervation of Heart
    • Implications for PT
      • Loss of Vagus Nerve
      • Prolonged warm up and cool down needed
      • Elevated resting heart rate
      • Blunted HR response to exercise
      • Predicted HR formulas no longer appropriate for use
      • Lack of cardiac ischemia sensation
lung transplantation
Lung Transplantation
  • Statistics
    • UM: 40-45 year, nationally 1500
    • Demographics
      • Gender: 1:1
      • Age: 50-64 most, rare >65
      • 5yr survival 50%
lung transplantation1
Lung Transplantation
  • Common Diagnoses: A: Obstructive lung disease, B: Pulmonary vascular disease, pulmonary hypertension, C: cystic fibrosis and amino deficienties D: restrictive lung disease (idiopathic pulmonary
  • Pre-operative condition
  • Exclusion from the transplant list same as heart transplant
the transplant list1
The Transplant List
  • Lung Allocation Score: score 0-100
    • 1 predicted post-op survival, 2 waitlist survival, 3 transplant benefit, 4 rare allocation. The higher the score the more critical the patient.
  • Tissue Match: antigen, antibodies
  • Time to transplant: depends on lung allocation score,< 30 days-5 years, typical is 6 monthes-2years
operative procedure2
Operative Procedure

Thoracotomy Incision

Single Lung Transplant

Loss of VagusNerve: lose sensory of lungs filling and need to cough

operative procedure3
Operative Procedure

Clamshell Incision

Double Lung Transplant

Loss of Vagus Nerve

Loss of carina

operative procedure4
Operative Procedure
  • Thoracotomy incision
  • Clamshell incision
    • Implications for PT
      • 10 lb. lifting restriction on involved side for thoracotomy (bilateral for clamshell)
      • Airway Clearance
      • Splinted Cough Technique: pressure on incision to help decrease pain
      • Teach volitional coughing
      • Bed Mobility (thoracotomies vs. clamshell: either side.
post operative issues
Post-Operative Issues
  • Medications/Side effects
  • Rejection
  • Return to Independent Function
  • Exercise
  • Lifestyle Modification
    • Pregnancy, decrease risk of heart disease (ex: diet, exercise)
medications
Medications
  • Anti-Infection
    • Acyclovir
    • Gancyclovir
    • Bactrim
    • Nystatin
    • Sporanox
  • Anti-rejection
    • Cyclosporine: increase potasium, tremour
    • Tacrolimus
    • Mycophenolate
    • Prednisone: cortico-steroids, steroid induced myopathy
medication side effects
Medication Side Effects
  • Side Effects of Steroids
    • Anabolic Versus Corticosteroids
    • Side Effects of Corticosteroids
      • Corticosteroid Induced Myopathy
        • Proximal muscle weakness, 2 female: 1 male
      • Other Symptoms
        • Hyperglycemia
        • HTN
        • Myalgias
        • Osteoporosis
medication side effects1
Medication Side Effects
  • Corticosteroid Induced Myopathy
    • Implications for PT ?
      • Focus on strengthening
      • Education
      • Home Exercise Program for continued strengthening
        • Self Targeting/Monitoring
        • Self Progression
medication side effects2
Medication Side Effects
  • Elevated Potassium: 3.5 to 5 is normal
    • Implications for PT ?
      • Aware of lab values and effects on exercise
      • Monitoring for:
        • Muscle weakness
        • Tremors
        • Flaccid paralysis
        • Slow pulse/EKG changes
        • Oliguria
medication side effects3
Medication Side Effects
  • Immunosuppression
    • Implications for PT ?
      • Not treat if ill, good caregiver hand-washing
      • Attempt to see isolation patients after
      • Education for lifestyle changes
        • Pets: not allowed to clean litter boxes
        • Gardening: need to wear gloves
        • Crowded environments, visitors, masks
        • Construction
        • Hand-washing
        • Group exercise