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ORGAN TRANSPLANT AnON 727

• Because the transplanted heart is denervated, the recipi�

ent does not experience anginal chest pain or pressure.

Myocardial ischemia is silent but can manifest as atrial or

ventricular arrhythmias and with symptoms of dyspnea,

lightheadedness, or an increased RPE.'2 While the patient

exercises, a cardiac nurse should closely monitor the

telemetry for arrhythmias.IO•12 Complaints of chest pain

from the recipient may be due to the sternal incision and

musculoskeletal manipulation during surgery.42

• The electrocardiogram of a heart transplant recipient

has two P waves, as both donor and recipient sinoatrial

nodes remain functional. The retained atria of the recipi�

ent generates a P wave; however, it does not cross the sur�

gical suture line and therefore does not produce a

ventricular contraction. Only the donor P wave can conduct an electrical response leading to a contraction of the heart (i.e., the donor P wave is followed by a QRS complex from the donor heart).22.24

• Because fatigue is a sign of rejection or ischemia, it is

important to monitor day-to�day changes in a patient's

exercise tolerance and keep the patient's nurse or physician notified of any significant changes.3'

• Patients should follow sternotomy precautions; they are

nOt allowed to push, pull, or lift anything heavier than 10

Ib for 2 months after their surgery.

Lung Transplantation

Major indications for lung transplantations include the followingJ,4,'6:

• COPD (with FEYI of less than 20% of predicted value)

• Cystic fibrosis (with FEY I of less than 30% of predicted value)

• Emphysema

• Bronchiectasis

• Primary pulmonary hypertension

• Pulmonary fibrosis

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AClITE CARE HANDBOOK FOR I'HYSICAL THERAI'ISTS

• Eisenmenger's syndrome (a congenital heart disease in which

there is a defect of the ventricular septum, a malpositioned aortic

root that over-rides the interventricular septum, and a dilated pulmonary artery)

• Alpha,-antitrypsin deficiency

Less-frequent indications include the following':

• Sarcoidosis (see Appendix IO-A)

• Eosinophilic granuloma (growth in the bone or lung characterized by eosinophils and histocytes)

• Scleroderma

Contraindications to lung transplantation include the following 16:

• Poor left ventricular cardiac function

• Significant coronary artery disease

• Significant dysfunction of other vital organs (e.g. liver, kidney,

cenrral nervous system)

• Active cigarette smoking

There are three types of surgical procedures for lung transplantation:

J.

Single-lung transplantation. This is the most common surgical

technique and is indicated for all types of end-stage lung disease, except

cystic fibrosis and bronchiectasis.3 It involves a single anterolateral or posterolateral thoracotomy in which the right or left cadaveric lung is transplanted into the recipienr,l6

2.

DOl/ble-lung or bilateral hlllg trm/splalltatioll. With double-

lung transplantation, the left and right lungs are transplanted

sequenrially into one recipient, with the least functional lung resected

and replaced first." The incision used is a bilateral anterior thoracotomy in the fourth or fifth intercostal space. Some surgeons also may perform a transverse sternotomy to create a "'clamshell" incision,I6

Patients with cystic fibrosis and bronchiectasis require double-lung

transplantation to remove both infected lungs. It is also the preferred

procedure for patients with pulmonary hyperrension,3.17

ORGAN TRANSI'I.Af\.'TATION

729

3.

Livillg dOllar lobar trallsplalltatioll. Transplantation of lobes

involves bilateral implantation of lower lobes from two blood-groupcompatible, living donors.' The donor's lungs are larger than the recipients for the donor lobes to fill each hemithorax.' This procedure

is performed primarily for patients with cystic fibrosis. In addition,

patients with bronchopulmonary dysplasia, primary pulmonary

hyperrension, pulmonary fibrosis, and obliterative bronchiolitis may

benefit from a lobar transplantation.s.u

Indication of Lung Function Post Trallsplant

For parienrs with pulmonary vascular disease, single- and double-lung

transplantation results in an immediate and sustained normalization of

pulmonary vascular resistance and pulmonary arterial pressures.] This

is accompanied by an immediate increase in cardiac output. Arterial

oxygenation generally returns to normal, and supplemental oxygen is

no longer required, usually by the time of hospital discharge.'

The maximum improvement in lung function and exercise capaciry

is achieved within 3 to 6 months afrer transplantation, once the limiting effects of posroperative pain, altered chest wall mechanics, respiratOry muscle dysfunction, and acute lung injury have subsided.'·'

After double-lung transplantation, norma) pulmonary function is usually achieved. However, in single-lung transplantation, lung function improves but does not normalize fully, owing to the disease and residual impairment of the remaining nontransplanted lung. Lung volumes and flow rates improve to two-thirds of normal in single-lung transplantation.4 Most lung transplant recipients are therefore able ro resume an active lifestyle, free of supplemental oxygen, with less dyspnea and improved exercise tolerance.

Postoperative Care and ComplicatiOlls

Ineffective postoperative airway clearance occurs after lung transplantation. Recipients present with an impaired cough reflex, incisional pain, altered chest wall musculoskeletal function, and diminished mucociliary clearance. Coughing and deep breathing must

be relearned, because the lung is denervated" After extubation,

aggressive bronchopulmonary hygiene is performed every 2-4 hours,

while the patient is awake." Physical therapists, respiratOry therapists, and nursing staff provide this intensive pulmonary carc. This

730 ACUTE CARE HANDBOOK I:OR PHYSICAL TIIERAI'ISTS

includes postural drainage, airway suctioning, vibration, gentle percussion, diaphragmatic breathing, coughing exercises, and use of an incentive spirometer and flutter valve device to maximize lung expansion and prevent atelectasis and pneumonia. The large quantity of secretions (20-60 ml per day) is generally thick and blood tinged, and

can lead to volume loss and consolidation in the transplanted lung if

not suctioned or expectorated.12 Bronchopulmonary hygiene is a crucial part of the postoperative care, as it helps mobilize secretions and prevent atelectasis and mucous plugging.