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Postoperative complications that may develop in the denervated

transplanted lung include pulmonary edema or effusion, acute respiratory distress syndrome, dehiscence of the bronchial anastomosis, and anastomotic stenosis.3 Single-lung transplant recipients may

experience complications of ventilation-perfusion mismatch and

hyperinflation owing to the markedly different respiratory mechanics

in each hemithorax.13 The rate of infection in lung transplant recipients is higher than that of other organ transplant recipients, because the graft is exposed to the external environment through the recipient's native airway. The patient's white blood cell (WBC) and absolute neutrophil count are monitored closely.6 Bacterial pneumonia and

bronchial infections are very common complications that usually

occur in the first 30 days.3,13 Bronchoalveolar lavage is used to diagnose opportunistic infections.17

Clinical manifestations of acute pulmonary rejection in lung transplant recipients include dyspnea, nonproductive cough, leukocytosis, hypoxemia, pulmonary infiltrates as seen on chest x-ray, sudden deterioration of pulmonary function tests (PITs), elevated WBC count, need for ventilatory support, fever, and fatigue.6.12,16 The rejection

typically presents with a sudden deterioration of clinical status over

6-12 hours'7 Daily documentation of the oxygen saturation and the

FEY I is used to monitor and detect early rejection, especially in bilateral lung transplant recipients, because a decline in oxygen saturation or spirometry values in excess of 10% commonly accompany episodes of rejection or infection.J,4,43

Bronchoscopic lung biopsy and bronchiolar lavages are used to diagnose acute rejection. The presence of perivascular lymphocytic infiltrates is the histologic hallmark of acute rejection.3.17 Transbronchial biopsies often do not supply enough pulmonary parenchyma for histologic testing." Instead, cyroimmunologic monitoring of the peripheral blood may be used as a specific diagnostic test for acute pulmonary

rejection. Bronchoscopy is performed routinely and whenever rejection

ORGAN TRANSI)LANTATION

731

is suspected to assess airway secretions, healing of the anastomosis, and

the condition of the bronchial mucous membrane." The first bronchoscopy is performed in the operating room to inspect the bronchial anastomosis.17 To prevent infection and atelectasis, rourine fiberoptic bronchoscopy with saline lavage and suctioning are used to reduce

accumulation of secretions that the recipient is unable to c1ear.1J

Clinical Tip

• If the recipient is intubated, sllctioning may be performed with a premeasured catheter ro prevent damage to

the anastomosis. Suctioning removes secretions and helps

maintain adequate oxygenation.

• After lung transplantation, recipients should sleep in

reverse Trendelenburg position to aid in postural drainage,

as long as they are hemodynamically stable.

• In the intensive care unit, during the first 24 hours after

surgery, patients with double-lung transplants should be

turned side to side. Turning is initiated gradually, beginning with 20- to 30-degree [Urns and assessing vital signs, and then increasing gradually to 90 degrees each way,

every 1-2 hours. Prolonged periods in supine position are

avoided to minimize secretion retention. 12

• Patients with single-lung transplants should lie on their

nonoperative side to reduce postsurgical edema, assist

with gravitational drainage of the airway, and promote

optimal inflation of the new lung.'2

• Bronchopulmonary hygiene before exercise may enhance

the recipient's activity tolerance.

• Schedule physical therapy visits after the patient

receives his or her nebulizer treatment and after the patient

is premedicated for pain control. Incisional pain can limit

activiry progression, deep breathing exercises, and coughing. Also, splinting the incision with the use of a pillow can help reduce incisional pain while coughing.

• Lung transplant recipients follow strict thoracotomy

precautions. They are nOt allowed to lift anything heavier

than 10 lb. They are restricred to partial weight bearing

of their upper extremities, which may limit the use of an

assistive device.

732

AClJTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

• Patients are on respiratory isolation precautions; exercise is performed in the recipient's room. All staff muSt mask, gown, and glove on entering the patient's room for

approximately I week. However, the recipient may ambulate in the hallway, if a protective mask is worn.

• Always monitor the recipient's oxygen saturation

before, during, and afrer exercise. If the patient is on

room air at rest, supplemental oxygen may be beneficial

during exercise to reduce dyspnea and improve activity

tolerance. The lung transplant recipient should maintain

an arterial oxyhemoglobin saturation greater than 90%

with activity.41

• Multiple rest periods may be required during activity at

the beginning of the postoperative period to limit the

amount of dyspnea and muscle fatigue. Rest periods can be

gradually decreased so that the patient advances toward

periods of continuous exercise as endurance improves.

Heart-Lung Transplantation

Heart-lung transplantation is performed on patients who have a coexistence of end-stage pulmonary disease and advanced cardiac disease that produces right-sided heart failure.'2

Indications for HLT include the followingl·8•24:

• Primary pulmonary hypertension

• COPD

• Cystic fibrosis

• Pulmonary fibrosis

• Eisenmenger's syndrome

• Irreparable cardiac defects or congenital heart disease

• Advanced lung disease and coexisting left ventricular dysfunction or extensive coronary arrery disease

The heart and lung of the donor are removed en bloc and placed in

the recipient's chest. The anastomosis to join the donor organs is at

ORGAN TRANSI'LANTATION 733

the trachea, right atrium, and aorta.8•U Postoperative HLT care is

similar to the heart and lung post-transplant care previously discussed. Rejection of the heart and lung allografts occurs independent of each other.24 Bacterial pneumonia from contamination in the

donor tracheobronchial tree is the most common cause of morbidity

and mortaliry afrer HLT.8

Bone Marrow Transplantarion

BMTs are performed only afrer conventional merhods of trearmenr

fail to replace defecrive bone marrow. BMT recipients receive healthy

marrow from a living donor in an attempt to restore hematologic and

immunologic functions. The three rypes of BMTs are allogeneic, syngeneic, and autOlogous transplants.

I .

An allogeneic transplant is one in which bone marrow is

harvested from an HL A-matched donor and immediately infused

into the recipient after cytoreduction therapy. The donor may be

related or unrelated.

2.

A syngeneic transplant is one in which bone marrow is

harvested from an identical twin.

3.

An alltologolls transplallf is one in which the donor and

recipient are the same. Bone marrow is harvested from the patient

when he or she is healrhy or in complete remission. The marrow is

then frozen and stOred for future reinfusion.

One type of autologous BMT is rhe peripheral blood srem cell

(PBSC) transplant. Stem cells are primirive cells found in bone marrow or circulating blood that evolve into mature blood cells (whire cells, red cells, and platelets). The parient's PBSCs are harvesred by

leukapheresis. During leukapheresis, the patient's blood is circulated

through a high-speed cell separator in which the peripheral srem

cells are frozen and srored, and the plasma cells and eryrhrocyres are

reinfused into the patient. The patient may require three to seven

harvests to achieve an adequate number of srem cells.' The PBSCs

are rein fused after rhe parient receives lethal doses of chemotherapy,

radiation, or borh. Allogenic PBSC transplant may be performed

from a donor or by using umbilical cord blood from a newborn

The hematologic recovery afrer PBSC rransplant is 10-12 days,