Lung transplantation and Role of physiotherapy in transplantation

1. LUNG
TRANSPLANTATION
AND ROLE OF
PHYSIOTHERAPY
Dr. Shahbaz Ahmad PT
DPT[UIPT][UOL]
MS-MSK-PT [UIPT][UOL]*
Lecturer [LIHS][LCPS]

3. LUNG TRANSPLANTATION:
Lung transplantation or pulmonary transplantation is a surgical
procedure in which a patient's diseased lungs are partially or totally replaced
by lungs which come from a donor.
Donor lungs can be retrieved from a living donor or a deceased donor.
A living donor can only donate one lung lobe. With some lung diseases a
recipient may only need to receive a single lung. With other lung diseases
such as cystic fibrosis it is essential that a recipient receive two lungs.
While lung transplants carry certain associated risks, they can also extend
life expectancy and enhance the quality of life for end-stage
pulmonary patients.

4. CAUSES OR REASONS FOR
TRANSPLANTATIONThe most common reasons for lung transplantation:
 Chronic obstructive pulmonary disease (COPD),
including emphysema;
 Idiopathic pulmonary fibrosis;
 Cystic fibrosis;
 Idiopathic (formerly known as "primary") pulmonary
hypertension;
 Replacing previously transplanted lungs that have
since failed;
 other causes, including bronchiectasis

5. TYPES OF LUNG
TRANSPLANTATION:

6. TYPES OF LUNG
TRANSPLANTATION:
Lobe
A lobe transplant is a surgery in which part of a living
or deceased donor's lung is removed and used to
replace the recipient's diseased lung. In living
donation, this procedure requires the donation of
lobes from two different people, replacing a lung on
each side of the recipient. Donors who have been
properly screened should be able to maintain a normal
quality of life despite the reduction in lung volume. In
deceased lobar transplantation, one donor can provide
both lobes.

7. TYPES OF LUNG
TRANSPLANTATION: CONTI:
Single-lung
Many patients can be helped by the transplantation of a single
healthy lung. The donated lung typically comes from a donor
who has been pronounced brain-dead.
Double-lung
Certain patients may require both lungs to be replaced. This is
especially the case for people with cystic fibrosis, due to the
bacterial colonization commonly found within such patients'
lungs; if only one lung were transplanted, bacteria in the native
lung could potentially infect the newly transplanted organ.

8. Heart–lung
Heart–lung transplant
Some respiratory patients may also have severe cardiac
disease which require a heart transplant. These patients
can be treated by a surgery in which both lungs and the
heart are replaced by organs from a donor or donors.
A particularly involved example of this has been termed a
"domino transplant" in the media. First performed in 1987

9. POST-OP CARE
 Immediately following the surgery, the patient is placed in
an intensive care unit for monitoring, normally for a period of a few
days.
 The patient is put on a ventilator to assist breathing.
 Nutritional needs are generally met via nasogastric tube.
 Chest tubes are put in so that excess fluids may be removed.
 Because the patient is confined to bed, a urinary catheter is used.
 IV lines are used in the neck and arm for monitoring and giving
medications. Special care is taken to look for rejection of organ or
infection

12. POST-OP CARE: CONTI:
After a few days, without any complications, the
patient may be transferred to a general inpatient ward
for further recovery. The average hospital stay
following a lung transplant is generally one to three
weeks, though complications may require a longer
period of time.
After this stage, patients are typically required to
attend rehabilitation gym for approximately 3 months
to regain fitness. Light weights, exercise bike,
treadmill, stretches and more are all a part of the
rehabilitation programme.

13. PHYSIO
THERAPY ROLE
IN LUNG
TRANSPLANTATI
ONPre-op
Post-op

14. 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
relieve some of the fears of operations.

15. Clearing lung Fields
 The patient must be discouraged 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.
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.

16. 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, or too less the mediastinum is shifted In both instances there will be loss
of breath and a danger of heart being compromised.
Rate and depth of respiration are recorded. 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.

17. After operation:
If the patient is stable and is not on ventilator usually initially patient is on ventilator
 Expansion breathing exercises for all areas of the lung. Foot and ankle
exercises
More often the treatment involves
 The techniques of breathing control
 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 Airway clearance and few breathing exercises with
postural drainage

18. Day-1 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

19. 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.

20. GENERAL REGIMEN:
lower extremity
• In bed
• Knee to chest
• Hip abduction/adduction (supine)
• Ankle pumps
• Straight leg raise
• Hip abduction in side lying etc.
• In the chair
• Hip flexion
• Knee extension
• Sit to stand etc.
• In standing
• Standing calf lift
• Mini-squat (wall squat)
Upper extremity
• In bed (on the mat)
• Biceps curl
• Triceps curl
• Bench press
• Anterior arm lift
• Strength/Postural Exercises
• Neck and trunk
• Shoulder circles;
• Cervical range of motion;
• Trunk lateral flexion

21. 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.
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
paradoxical 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.

22. 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
demonstrate 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.

24. Long term management
 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.
 Activities are introduced at intensity such that patient’s
subjective description of his level of exertion is very light or
light.
 The intensity is subsequently progressed to the level of

25. Post surgery long term rehab:
 Treadmill Warm up 12 minutes
 Bicycle ergometer Endurance/aerobic fitness 5-40minutes
 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
 lower limb strengthening 1-15 minutes
 Wobble Boards Ankle/Knee stability 1-5 minutes