Why rehabilitation post lung transplant is critical to ensure optimum success of procedure

Human lungs. Image courtesy Pearson Scott Foresman/Wikimedia Commons

Lung transplant is an established treatment for patients with end-stage lung disease. It is a surgical procedure to replace a diseased or failing lung with a healthy lung, usually from a deceased donor.

Several modifiable pre- and post-transplant factors contribute to a wide range of physiological and psychological changes which need to be addressed and effectively managed.

It is well established that rehabilitation plays a major role in the pre and post-operative management of patients. It involves working in partnership with the patient, their family and caregivers and a comprehensive multidimensional medical team- towards a common goal of maximising the potential and independence of the patient and to promote a holistic health. It is the process of helping an individual achieve the highest level of function, independence, and to enhance their overall quality of life.

Global review of literature depicts that with the involvement of a multidisciplinary team of experts contributes greatly to the well-being of the patient.

The rehabilitation team typically includes physical therapist, exercise physiologist, psychologist and nutritionist.

The transplant trajectory is complex and intensive, and patients usually experience this period as extremely stressful. Along with the functional impairment – the patients also undergo significant degree of emotional distress. With the prevalence rates of anxiety and depression being high in transplant candidates and recipients, there is a strong need for psychological rehabilitation along with physical rehabilitation for their overall holistic wellbeing. Pre- and Post-transplant psychological support is an important, but overlooked, element in optimising transplant outcomes, particularly in lung transplant recipients who have some of the highest rates of complications and distress following transplantation.

In order to evaluate exercise capacity and function in lung transplant candidates and recipients, a combination of aerobic testing, muscle function, mobility testing and assessment of physical activity is utilised. Along with this- a comprehensive psycho-social assessment is carried out where patient’s understanding regarding the medical illness, process of transplant, willingness/desire for treatment, compliance and care of lifestyle factors, along with the patient’s present emotional and mental state, past psychiatric history is elicited. Based on the test results, a comprehensive rehabilitation programme is planned.

Rehabilitation can be divided into two broad categories:

1. Pre-operative Rehabilitation or Prehabilitation
2. Post-operative rehabilitation

Prehabilitation

Participating in a supervised pulmonary rehabilitation programme is recommended to assist with prevention of further deterioration and improvement in symptoms, understanding of the condition and enhancing the quality of life. The goal is to promote a better functional recovery post-transplant. Most of the patients awaiting transplant are recommended to be subjected to prehabilitation as indicated.

The prehabilitation is feasible and improves the quality of life by:

• Effective chest clearance and lung expansion techniques
• Maintaining or improving physical activity levels
• Maintaining or improving cardiorespiratory fitness
• Preparing the patient for the transplant surgery
• Psychological interventions to enhance coping

Post-operative rehabilitation

Inpatient rehabilitation

Early post-operative rehabilitation

Post-operative rehabilitation starts immediately after surgery once the patients is stabilised, where the initial focus is on maintenance of bodily systems, as well as to assist the patient with the weaning of ventilator/supplemental oxygen and facilitate early mobility.

It typically begins in ICU and then continues in wards with the goal to improve:

• pulmonary hygiene and lung capacity
• General mobility
• Functional capacity
• Muscle strength and endurance
• Emotional coping
• Facilitate discharge from the hospital

Rehabilitation in wards can be further escalated to frequent walking, cycling, strengthening and stair climbing.

Outpatient rehabilitation

An outpatient rehabilitation programme may begin as soon as possible after hospital discharge. A tailor-made exercise programme is prescribed keeping in mind individual patient goals. The outpatient rehabilitation programme facilitates regaining the muscle mass and strength lost during prolonged illness and the disuse associated with prolonged illness along with adequate emotional coping to regain a sense of normalcy in their day to day lives.

The comprehensive programme typically includes:

• Aerobic exercises
• Resistance training
• Flexibility exercises
• Breathing retraining
• Psycho-social counselling
• Nutritional intervention which makes it an efficacious rehabilitation programme

Remotely monitored (tele-health) home based exercise, or pedometer based walking interventions might serve as alternatives to supervised outpatient rehabilitation interventions in the long-term post-transplant phase.
Both inpatient and outpatient rehabilitation have proven to be beneficial for patients before and after lung transplant by improving exercise capacity, promote adaptive coping and overall quality of life.

With recent research showing reduced risk of cumulative mortality in patients of lung transplant- which was attributable to Pre and Post-Transplant rehabilitation, and with other studies depicting greater survival rates among patients even after five years- Rehabilitation should be seen as an essential service offered across all levels of the health care system. We encourage patients to enrol in rehabilitation programme pre-operatively and continue the journey post operatively for an optimal gold standard of care.

The author is Consultant – Rehabilitation and Sports Medicine, Sir HN Reliance Foundation Hospital. Views are personal.

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