1997 OPEN FORUM Abstracts
What Do I Need To Know about the Lung Transplant Patient?
Patricia Ann Doorley, MS, RRT, Tuesday, December 9, 1997.
The first human lung transplant was performed in 1963, but a new era in the performance of this surgical intervention began in 1981 with the introduction of new surgical techniques and cyclosporine. To date over 3000 lung transplants have been performed in the U.S. and Europe and the 5 year survival rate following transplantation is approximately 60%.
Lung transplantation is considered a potential surgical intervention for individuals suffering from a wide range of pulmonary disease entities. Individuals with obstructive lung disease comprise approximately 60% of the candidate pool with the remaining 40% comprised of individuals with restrictive lung disease (20%), cystic fibrosis (10%) and pulmonary hypertension (10%). There is, however, a limited supply of donors and only 20-25% of donor candidates actually are acceptable. As a result the waiting time for candidates for lung transplantation - the time from placement on the transplant list to the performance of the surgical procedure - averages 12 to 18 months. This long wait period is associated with a 20% waiting list mortality rate.
The general indications for candidates to be considered for lung transplantation are few. They include: (1) candidate life expectancy of 18 - 24 month, (2) exhaustion of all medical interventions, and (3) candidate ability to comply with a complex medical regimen following the surgery. Similarly, the absolute contraindications for consideration for lung transplantation at most centers are also few. This list includes: (1) current smoking, (2) presence of malignancy, (3) sepsis, (4) unresolved psychosocial dysfunction, and (5) severe extrapulmonary disease. Additionally, there are well-established PFT and ABG requirements that must be met by candidates based on their underlying disease process and their need for single or double lung transplantation.
The lung transplant patient population provides a unique opportunity for respiratory care practitioners as their management, both pre- and post-operatively, requires extensive use of respiratory care services. Once the candidate is identified for transplantation, the candidate's care management generally becomes the responsibility of a "transplant" coordinator. This individual is responsible for assuring the patient remains as healthy as possible while waiting for donor organ(s) to become available, as well as coordinating their care following transplantation. Developing a pulmonary rehabilitation regimen for both the pre- and post- operative phases of the patient's care is an essential component of the coordinator's role and absolutely necessary for a positive outcome.
In the immediate post operative period the patient's primary respiratory care needs are management of his/her airway and mechanical ventilation. This period is typically associated with complex clinical presentation that may require an extensive care plan. Though the immediate post operative course can be complex, the success of the surgical procedure and a positive long term outcome for the patient are more greatly influenced by the quality of the pulmonary hygiene program provided following extubation. The lung transplant patient population is particularly prone to the development of atelectasis, retained secretions, and infection. They greatly benefit from a vigorous pulmonary hygiene program performed by practitioners that can assess and evaluate the effectiveness of the therapeutic interventions, while adjusting the regimen to meet the ever-changing clinical needs of the patient. Focused attention on coughing and deep breathing techniques, proper positioning, pain management, and nutrition greatly influence the length of stay and clinical outcomes for this patient population.
AARC 50th Anniversary, December 6 - 9, 1997, New Orleans, Louisiana.