Physiotherapy management post lung transplantation

[katrussianspy]

I have recently started working as a physiotherapist in Cystic Fibrosis, and am currently treating a patient who underwent bilateral lung transplant six years ago. She is now rejecting, but being considered for re-transplantation. She has therefore been coming to the gym to try to maintain as much lung function as we can.

She is concerned about doing resistance training of her upper limbs as she seems to remember being told not to do this. I am presuming this was only valid immediately post-transplant and that it is perfectly safe to do it now?

Thanks for your help guys.

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[sdkashif]

For your convenience I'm describing the physiotherapy of lung transplantation as under;

Preoperative Physiotherapy

This should begin as soon as possible after the patient is admitted. The main aims are to:

1- Gain the patient confidence
2- Clear the lungs fields
3- Teach respiratory control and inspiratory holdings
4- Teach postural awareness
5- Teach arm, trunk and leg exercises
6- Teach mobility about the bed.


Patient’s confidence An explanation of the aim of physiotherapy helps the patient’s understanding. Teaching the exercises to be undertaked postoperatively and answering the patient’s questions helps to allay some of the fears of operations.

Clearing lung Fields

The patient must be discourged from smoking. Shaking, clapping and vibrations with postural drainage if necessary must be used to clear the secretions from the sound lung. Huffing is taught as this is used in preference to coughing postoperatively. The patient is instructed on how to support the wound during coughing and huffing. The arm of unaffected side is placed across the front of the thorax and around the affected side just below the incision side giving firm pressure with the forearm and hand. The upper arm of the affected side reinforces the pressure and the hand fixes the opposite elbow.

Teaching the respiratory control

Inspiratory exercises are taught for the sound lung together with the inspiratory holding. This means that the patient is asked to take a deep breath in, hold, then breathe in a little further, hold, then breathe out.

Breathing control has to be practiced after secretions have been cleared.

Postoperative physiotherapy

It is important to note whether the patient is on oxygen therapy, and whether there is drain in the thorax. This drain may be used to control the amount of fluid in the cavity left by the lung. If there is too much fluid, the mediastinum is shifted to the unaffected side but if there is too little fluid the shift will be to the affected side with over inflation of the lung. In both instances there will be loss of breath and a danger of heart being compromised.

Rate and depth of respiration are recorded. The patient must avoid straining with coughing as this can put at risk the sutures of the bronchial stump. Analgesia may be administered but must not depress the respiratory centre or cough reflex. Inhalations of, for example, benzoin tincture help to loosen the secretions. The aims of physiotherapy are:

1- Clear secretions from the remaining lung
2- Retain full expansion of the lung tissue
3- Prevent circulatory complications
4- Prevent wound complications
5- Regain arm and spinal movements
6- Maintain good posture
7- Restore exercise tolerance

A suitable programme may be as follows.

Day of operation (Surgery am, treat pm)

Patient in half lying with pillow arranged behind the neck and back and possibly both forearms on a pillow on the lap.
Expansion breathing exercises for all areas of the lung. Foot and ankle exercises.

Day1 Post-operation

Half lying-Segmental expansion exercises, shaking or vibrations as necessary, huffing and expectoration with wound support from the physiotherapist.

By the end of the day the patient should be huffing with self support. Foot and ankle exercises. Correct posture should be emphasized to prevent a scoliosis on the scar side.

Short frequent sessions are better than few long ones. In the afternoon, the patient may sit out of the bed. This allows better excursion of the diaphragm. During two of the sessions the arm on the affected side must be moved.

1- Into full elevation
2- Hand behind head
3- Hand behind back
4- Hand touch opposite shoulder

A rope ladder should be provided so that patient can pull on it to move around in bed and sit up.

Day 2 Post-operation

Treatment is continued as above plus on two sessions:
1- Sitting on the edge of the bed
(a) Trunk turning
(b) Trunk bending side to side
(c) Trunk stretching backwards

2- Sitting in chair-Bilateral breathing exercises
3- Walk round bed with trunk erect and arms swinging

Day 3 Post operation

Breathing and huffing is continued as necessary. Other activities continue twice in a day. The patient may join in group therapy.

Day 4 post operation to discharge

The patient continues with group therapy, gets dressed, and walks further and, after the 7th day, practices going up and down stairs with breathing control. Bilateral breathing and trunk and arm exercises are essential.

Stitches come out usually 7-10 days after operation. Two weeks after the operation, the patient is generally discharged with strict instructions to continue the exercise regimen.

Modifications to this programme

Postural drainage may be necessary if the remaining lung does not clear satisfactorily. This involves positioning the patient on the operation side. Tipping must not be used because of the danger of broncho-pleural fistula due to the fluid bathing bronchial stump.

If the air entry to the remaining lung is not adequate, intermittent positive pressure breathing may be used to improve ventilation.

Oxygen therapy and humidification may be necessary. If the recurrent laryngeal nerve is injured, breathing exercises and huffing should clear the secretions. IPPB used with caution at low pressure and only after consultation with surgeon.

If phrenic nerve is damaged, coughing can be ineffective because there is paradoxicaql movement of the diaphragm. IPPB can be used to mobilize secretions and increase air entry.
Incentive spirometry may be helpful to improve the patient’s inspiratory capacity.

Incentive Spirometry

This a technique used to encourage the patient to take a deep breath in when there is hypoventilation after thoracic or high abdominal surgery due to pain or secretions retention. The breathes in through a tube which is attached to a device that illustrate the volume of the inspired air. For example, at low lung volume, a plastic ball rises to the top of the column, at mid lung volume a second ball rises and at high lung volume a third ball rises. So long as the patient holds a deep breath, the balls remain at the top of the columns. Some devices operate by a light coming on when the volume of breath reaches a pre set level. Some devices work on the expiratory phase rather than the inspiratory phase.

Long term management

The patient generally have three month check ups. On these visits to the surgeon it is helpful to have the physiotherapist check exercise tolerance, posture, trunk and shoulder mobility so that patient may have the home activity programme adjusted. The fluid in the cavity left by the removal of lung gradually fills up but must not reach the level of the stump before it has healed in 10-14 days. Slowly it will fill the whole cavity and become organized and fibrosed from the base to the apex over a 2 year period. It is important, therefore, that the patient continues thoracic mobility exercises on a regular daily basis for at least this period of time.

[sdkashif]

In addition to the detail described above, some important points should be considered in the lung (and also hear transplant) patients. Have a look over them as under:

The intensive care area and ward management of the cardiopulmonary transplant patient is similar to that any patient having undergone cardiac or thoracic surgery. The major differences include drug therapy and intensive and comprehensive monitoring necessary because of the potential for rejection and infection. The degree and the duration of the protection isolation of the recipients vary considerably between centers. Some units protectively isolate recipients in laminar air flow rooms, while others only require thorough hand washing before contact with the patient.

The lungs of the hear lungs and lungs recipients are denervated distal to the tracheal or bronchial anastmosis. As a result the recipient ability to cough spontaneously in response to the secretions accumulating distal to anastmosis is impaired.

Post operative physiotherapy is started immediately (30 minutes to 1 hour) post extubation, which is 6-12 hours following transfer to intensive care unit from the theatre. There are occasions, however, when it may be necessary for the physiotherapist to b involved before extubation. This may be to facilitate the removal of secretions. More often the treatment involves the techniques of breathing control when a patient, weaning from ventilator, showing the signs of distress without obvious fatigue. Well supported positioning, utilization of the stimulation and reassurance of hands on instruction alternated with shoulder and soft tissue techniques can bring about the change in the respiratory pattern and rate, and positively affect the arterial blood gases and haemodynamic status. Initial treatment involves:

The active cycle of breathing techniques:
-Breathing control
-Thoracic expansion exercises
-Forced expiration technique
-Gravity assisted position as appropriate

Assisted limb work progressing to active, antigravity limb exercise over the first day and as required as appropriate.

For Hear lung and lungs patients’ gravity assisted positions for middle / lingual and basal segments are incorporated into their daily treatment in acute phase. As a result of denervation of lungs, it is essential to evaluate whether the huff is dry or moist. If it is moist indicating the secretions, appropriate techniques should be employed to clear the bronchial secretions.

Patients may sit out of bed as early as day 1 postoperatively. Patients usually start mobilizing from bed to chair on day 2 or 3. Very debilitated patients may commence the light upper limb programme as early as day 3.
Patient may be transferred to ward as early as day 3 or 4 postoperatively. Once free to mobilize from the bed area, patients are commences on stair climbing and bicycle ergometer gentle work.

Rehabilitation training to improve patient physical condition ( posture, strength, endurance), performing the full range of activities of daily living & appropriate exercise activities, promoting independence in maintaining and monitoring the physical condition. In patient attend the gymnasium 1-2 times daily. Out patients are encouraged to attend the gymnasium 3-5 times weekly. The most effective way of introducing the exercise programe gradually is according to the scale of perceived exertion such as Borg Scale. Activities are introduced at intensity such that patient’s subjective description of his level of his level of exertion is very light or light. The intensity is subsequently progressed to the level of exertion described as some what hard or very hard. Gymnasium exercises used in post transplant rehabilitation programme is as under:

Activity Purpose Time/ repetition

Treadmill Warm up 12 minutes

Bicycle ergometer Endurance/aerobic fitness 5-40minutes

Multigym Quadriceps strengthening 12-30 repetitions

Rowing machine Quadriceps/upper limb/upper trunk strengthening 12-30 repetitions

Weights Upper limbs and shoulder girdle strengthening 1-10 KG, 10-30 repetitions

Minitrampoline Glutei and lower limb strengthening 1-15 minutes

Wobble Boards Ankle/Knee stability 1-5 minutes