1995 OPEN FORUM Abstracts
POST-OPERATIVE RESPIRATORY CARE PROTOCOL FOR LUNG TRANSPLANT PATIENTS - REPORT OF A METHOD.
Lucy Kester MBA,RRT, Barbara Higgins RN, MSN, Marianne Potts RRT. Cleveland Clinic Foundation. Cleveland, Ohio.
Successful lung transplantation began in the early 1980s. The St. Louis International Lung Transplant Registry reports that as of December 31. 1994, 44 centers in the United States and 33 centers outside the U.S. have performed 3,836 transplants which includes 2,346 single lung transplants, 1,252 bilateral sequentials, and 230 en-bloc doubles. Of these, 2,227 were performed in the U.S. Two year survival rates have improved from 51% in the period from 1983-1989, to 68% for 1991-1994. During this time, very little has been written on the post-operative respiratory care delivered to this patient population in spite of the high risk that exists for respiratory complications due to impaired cough reflex from lung denervation, impaired mucociliary action, and immunosupression. Lung transplantation began at the Cleveland Clinic Foundation in 1990. In May of 1991, we instituted a protocol for the post-operative care of lung transplant patients which includes: aerosolized bronchodilator therapy q 4 hours while awake, bronchopulmonary hygiene (with specific techniques for single vs. double lungs) q 4 hours while awake, twice daily peak flow measurements, oxygen titration and ambulation. For postural drainage and percussion/ vibration procedures, single transplants are positioned in the lateral decubitis position with the transplanted lung up. Positioning the native lung up is avoided in an attempt to prevent draining secretions and possibly infection into the new lung. During the bph procedures (postural drainage, percussion/vibration), suctioning, and ambulation, the patient's oxygen saturation should be monitored and oxygen concentration adjusted to maintain an SpO2 of >= 93%, as these procedures may cause the patient's saturation to drop precipitously. When performing deep breathing exercises, single lung transplant patients are instructed to splint, or compress, the native lung side in an attempt to direct air preferentially to the new lung for improved expansion. Peak flow measurements will be performed morning and evening throughout the entire hospital stay and then daily at home to monitor for possible rejection. Emphasis is put on adequate rest for the patients at night. The protocol is carried out for 2 weeks following transplantation, after which the patient is treated according to our standard Respiratory Therapy Consult Service protocol. Should the patient remain in the ICU for longer that 2 weeks, the protocol is followed for 72 hours before converting to the standard RTCS protocol. Since the initiation of our protocol, there have been 90 lung transplants performed at CCF (57 singles, 29 doubles, 4 en-bloc) with an overall survival rate of 61%. The major complications have been rejection (90% having at least 1 episode of rejection) and infection (30% on bronchoscopy). Anecdotally ,as provided by the case manager for the lung transplant nursing unit and the primary respiratory therapist working in this unit (Marianne Potts), there were no instances of a lung transplant patient treated by our protocol returning to the ICU because of inappropriate or insufficient respiratory care. In view of the increase in numbers of patients undergoing lung transplantation (272 from 1983 - 1989 to 2529 from 1992 - 1994) a more detailed study of the appropriate respiratory care for this patient population seems warranted.