Physical Therapy in Heart and Lung Transplantation and Mechanical Assist Devices
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Transcript of 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
StatisticsUM=60 a yearDemographics
Gender: 3males : 1 femaleAge: <65, typical 50-65
Heart TransplantationCommon 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 ListStatus1A: 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 transplant7: took off the list temporarily, for infection, etc
Tissue Match: antigen, antibody reaction
Time to transplant
Median Sternotomy: Implications for PT
Facility Dependent10# lifting restriction until sternum
heals Includes lifting/pushing/pulling Implications for mobility?
Full shoulder range as tolerated to pain (no ROM restrictions)
Operative Procedure
Techniques
Orthotopic heart transplant: removed most of the pt’s heart and replaced it 95% of the donors heart.
Post Operative ChangesDenervation of HeartLoss of Vagus Nerve
Role of Vagus Nerve: parasympathetic HR control, decreases HR when
Implications for PT: we need to be aware of HR control not adapting, elevated resting HR.
Post Operative ChangesDenervation of Heart Implications for PT
Loss of Vagus Nerve Prolonged warm up and cool down neededElevated resting heart rateBlunted HR response to exercisePredicted HR formulas no longer appropriate for
useLack of cardiac ischemia sensation
Lung Transplantation
StatisticsUM: 40-45 year,
nationally 1500Demographics
Gender: 1:1Age: 50-64
most, rare >655yr survival
50%
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 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 Procedure
• Thoracotomy Incision
• Single Lung Transplant
• Loss of Vagus Nerve: lose sensory of lungs filling and need to cough
Operative Procedure• Clamshell
Incision• Double Lung
Transplant• Loss of
Vagus Nerve
• Loss of carina
Operative Procedure
Thoracotomy incision
Clamshell incision Implications for PT
10 lb. lifting restriction on involved side for thoracotomy (bilateral for clamshell)
Airway ClearanceSplinted Cough Technique: pressure on incision
to help decrease painTeach volitional coughingBed Mobility (thoracotomies vs. clamshell:
either side.
Post-Operative IssuesMedications/Side effects
Rejection
Return to Independent Function
Exercise
Lifestyle ModificationPregnancy, decrease risk of heart disease
(ex: diet, exercise)
MedicationsAnti-rejectionCyclosporine:
increase potasium, tremour
TacrolimusMycophenolatePrednisone:
cortico-steroids, steroid induced myopathy
Anti-InfectionAcyclovirGancyclovirBactrimNystatinSporanox
Medication Side Effects
Side Effects of Steroids Anabolic Versus CorticosteroidsSide Effects of Corticosteroids
Corticosteroid Induced Myopathy Proximal muscle weakness, 2 female: 1 male
Other Symptoms Hyperglycemia HTN Myalgias Osteoporosis
Medication Side Effects
Corticosteroid Induced Myopathy Implications for PT ?
Focus on strengtheningEducationHome Exercise Program for continued
strengthening Self Targeting/Monitoring Self Progression
Medication Side Effects
Elevated Potassium: 3.5 to 5 is normal Implications for PT ?
Aware of lab values and effects on exerciseMonitoring for:
Muscle weakness Tremors Flaccid paralysis Slow pulse/EKG changes Oliguria
Medication Side EffectsImmunosuppression Implications for PT ?
Not treat if ill, good caregiver hand-washingAttempt to see isolation patients afterEducation for lifestyle changes
Pets: not allowed to clean litter boxes Gardening: need to wear gloves Crowded environments, visitors, masks Construction Hand-washing Group exercise