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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. Statistics UM=60 a year Demographics Gender: 3males : 1 female Age: <65, typical 50-65. Heart Transplantation.

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Physical Therapy in Heart and Lung Transplantation and Mechanical Assist Devices

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  1. Physical Therapy in Heart and Lung Transplantation and Mechanical Assist Devices Kim Dosch, PT Tina Fields, PT, CCS 06/20/2013

  2. Heart Transplantation • Statistics • UM=60 a year • Demographics • Gender: 3males : 1 female • Age: <65, typical 50-65

  3. Heart Transplantation • Common 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

  4. The Transplant List • Status • 1A: 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 transplant • 7: took off the list temporarily, for infection, etc • Tissue Match: antigen, antibody reaction • Time to transplant

  5. Operative Procedure Median Sternotomy Implication for PT: sternum approximated

  6. Median Sternotomy: Implications for PT • Facility Dependent • 10# lifting restriction until sternum heals • Includes lifting/pushing/pulling • Implications for mobility? • Full shoulder range as tolerated to pain (no ROM restrictions)

  7. Operative Procedure • Techniques • Orthotopicheart transplant: removed most of the pt’s heart and replaced it 95% of the donors heart.

  8. Post Operative Changes • Denervation of Heart • Loss of Vagus Nerve • Role of VagusNerve: parasympathetic HR control, decreases HR when • Implications for PT: we need to be aware of HR control not adapting, elevated resting HR.

  9. Post Operative Changes • Denervation of Heart • Implications for PT • Loss of Vagus Nerve • Prolonged warm up and cool down needed • Elevated resting heart rate • Blunted HR response to exercise • Predicted HR formulas no longer appropriate for use • Lack of cardiac ischemia sensation

  10. http://www.pbs.org/wgbh/nova/eheart/transplantwave.html

  11. Lung Transplantation • Statistics • UM: 40-45 year, nationally 1500 • Demographics • Gender: 1:1 • Age: 50-64 most, rare >65 • 5yr survival 50%

  12. 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

  13. 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

  14. Operative Procedure Thoracotomy Incision Single Lung Transplant Loss of VagusNerve: lose sensory of lungs filling and need to cough

  15. Operative Procedure Clamshell Incision Double Lung Transplant Loss of Vagus Nerve Loss of carina

  16. Operative Procedure • Thoracotomy incision • Clamshell incision • Implications for PT • 10 lb. lifting restriction on involved side for thoracotomy (bilateral for clamshell) • Airway Clearance • Splinted Cough Technique: pressure on incision to help decrease pain • Teach volitional coughing • Bed Mobility (thoracotomies vs. clamshell: either side.

  17. Open Clamshell Incision

  18. Heart OR Lung Transplant: Post Operative Course

  19. Post-Operative Issues • Medications/Side effects • Rejection • Return to Independent Function • Exercise • Lifestyle Modification • Pregnancy, decrease risk of heart disease (ex: diet, exercise)

  20. Medications • Anti-Infection • Acyclovir • Gancyclovir • Bactrim • Nystatin • Sporanox • Anti-rejection • Cyclosporine: increase potasium, tremour • Tacrolimus • Mycophenolate • Prednisone: cortico-steroids, steroid induced myopathy

  21. Medication Side Effects • Side Effects of Steroids • Anabolic Versus Corticosteroids • Side Effects of Corticosteroids • Corticosteroid Induced Myopathy • Proximal muscle weakness, 2 female: 1 male • Other Symptoms • Hyperglycemia • HTN • Myalgias • Osteoporosis

  22. Medication Side Effects • Corticosteroid Induced Myopathy • Implications for PT ? • Focus on strengthening • Education • Home Exercise Program for continued strengthening • Self Targeting/Monitoring • Self Progression

  23. Medication Side Effects • Elevated Potassium: 3.5 to 5 is normal • Implications for PT ? • Aware of lab values and effects on exercise • Monitoring for: • Muscle weakness • Tremors • Flaccid paralysis • Slow pulse/EKG changes • Oliguria

  24. Medication Side Effects • Immunosuppression • Implications for PT ? • Not treat if ill, good caregiver hand-washing • Attempt to see isolation patients after • Education for lifestyle changes • Pets: not allowed to clean litter boxes • Gardening: need to wear gloves • Crowded environments, visitors, masks • Construction • Hand-washing • Group exercise

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