Pulmonary rehabilitation in lung transplant candidates. J Heart Lung Transplant. 2013;32:626-632. [PMID: 23701852 DOI: 10.1016/j.healun.2013.04.002]

Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review

OBJECTIVES

The aim of this systematic review of randomised controlled trials (RCTs), and quasi-experimental and retrospective studies is to investigate the effects of pulmonary rehabilitation (PR) in patients with advanced chronic disease on the waiting list for lung transplantation.

SETTING

PR performed for inpatient or outpatient lung transplant candidates.

INTERVENTION

PR programme including aerobic exercise training and/or resistance exercise training.

PRIMARY AND SECONDARY OUTCOMES

Quality of life and exercise capacity (primary outcomes). Survival rate after transplant surgery; pulmonary function; respiratory muscle strength; psychological aspects; upper and lower extremity muscle strength and adverse effects (secondary outcomes). Two review authors independently selected the studies, assessed study quality and extracted data. Studies in any language were included.

RESULTS

This was a systematic review and studies were searched on the Cochrane Library, MEDLINE, EMBASE, CINAHL and PEDro. Experimental and retrospective studies evaluating the effects of PR in candidates for lung transplantation (>18 years old) with any lung diseases were included. 2 RCTs, and two quasi-experimental and two retrospectives studies, involving 1305 participants were included in the review. 5 studies included an enhancement reported in quality of life using the Short Form 36 questionnaire and showed improvements in some domains. All studies included exercise capacity evaluated through 6 min walk test and in five of them, there were improvements in this outcome after PR. Owing to the different characteristics of the studies, it was not possible to perform a meta-analysis.

CONCLUSIONS

Studies included in this review showed that PR is an effective treatment option for patients on the waiting list for lung transplantation and can improve quality of life and exercise capacity in those patients. Although individual studies reported positive effects of PR, this review shows that there is a need for more studies of a high methodological quality addressing PR effects in lung transplant candidates.

TRIAL REGISTRATION NUMBER

PROSPERO CDR42015025110.

Comprehensive Care of the Lung Transplant Patient

Lung transplantation has evolved into a life-saving treatment with improved quality of life for patients with end-stage respiratory failure unresponsive to other medical or surgical interventions. With improving survival rates, the number of lung transplant recipients with preexisting and posttransplant comorbidities that require attention continues to increase. A partnership between transplant and nontransplant care providers is necessary to deliver comprehensive and optimal care for transplant candidates and recipients. The goals of this partnership include timely referral and assistance with transplant evaluation, optimization of comorbidities and preparation for transplantation, management of common posttransplant medical comorbidities, immunization, screening for malignancy, and counseling for a healthy lifestyle to maximize the likelihood of a good outcome. We aim to provide an outline of the main aspects of the care of candidates for and recipients of lung transplants for nontransplant physicians and other care providers.

Physical rehabilitation for lung transplant candidates and recipients: An evidence-informed clinical approach

Physical rehabilitation of lung transplant candidates and recipients plays an important in optimizing physical function prior to transplant and facilitating recovery of function post-transplant. As medical and surgical interventions in lung transplantation have evolved over time, there has been a demographic shift of individuals undergoing lung transplantation including older individuals, those with multiple co-morbidites, and candidates with respiratory failure requiring bridging to transplantation. These changes have an impact on the rehabilitation needs of lung transplant candidates and recipients. This review provides a practical approach to rehabilitation based on research and clinical practice at our transplant centre. It focuses on functional assessment and exercise prescription during an uncomplicated and complicated clinical course in the pre-transplant, early and late post-transplant periods. The target audience includes clinicians involved in pre- and post-transplant patient care and rehabilitation researchers.

How to minimise ventilator-induced lung injury in transplanted lungs: The role of protective ventilation and other strategies

Lung transplantation is the treatment of choice for end-stage pulmonary diseases. In order to avoid or reduce pulmonary and systemic complications, mechanical ventilator settings have an important role in each stage of lung transplantation. In this respect, the use of mechanical ventilation with a tidal volume of 6 to 8 ml  kg(-1) predicted body weight, positive end-expiratory pressure of 6 to 8 cmH2O and a plateau pressure lower than 30 cmH2O has been suggested for the donor during surgery, and for the recipient both during and after surgery. For the present review, we systematically searched the PubMed database for articles published from 2000 to 2014 using the following keywords: lung transplantation, protective mechanical ventilation, lung donor, extracorporeal membrane oxygenation, recruitment manoeuvres, extracorporeal CO2 removal and noninvasive ventilation.

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline

Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non-invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence-based physiotherapy care to people with CF in Australia and New Zealand.

New perspectives on management of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive parenchymal lung disease characterized by a median survival of 3-5 years following diagnosis. The diagnosis is based on clinical, radiological and histopathological evaluation. Therefore, a multidisciplinary team is needed to reach the correct diagnosis. For a long time, supportive care and lung transplantation in selected cases, have been considered the only possible treatments for IPF. In the last decade many studies have investigated IPF pathogenesis, leading to an improved knowledge of the mechanisms underlying the disease and to the approval of two new drugs for IPF treatment (pirfenidone and nintedanib). The therapeutic approach of IPF cannot be limited to the administration of antifibrotic drugs, but it is necessary for improving the quality of life of patients and for facilitating, as far as possible, the performance of normal daily activities and relationships. IPF patients are also afflicted by disease-related complications such as gastroesophageal reflux, pulmonary hypertension, acute exacerbations and an increased risk of developing lung cancer. The clinician who treats IPF patients, should also treat these possible complications to slow disease progression, thus maintaining the possibility of a pulmonary transplantation.

Effects of Recipient Age and Diagnosis on Health-related Quality-of-Life Benefit of Lung Transplantation

RATIONALE

The average age of lung transplant recipients is increasing, and the mix of recipient indications for transplantation is changing.

OBJECTIVES

To determine whether the health-related quality-of-life (HRQL) benefit of lung transplantation differs by recipient age and diagnosis.

METHODS

In this prospective cohort study, we obtained serial HRQL measurements in adults with advanced lung disease who subsequently underwent lung transplantation (2004-2012). HRQL assessments included the St. George's Respiratory Questionnaire, 36-Item Short-Form Health Survey (SF-36), EQ-5D, Standard Gamble, and Visual Analog Scale for current health. We used linear mixed effects models for associations between age or diagnosis and changes in HRQL with transplantation. To address potential survivorship bias, we fitted Markov models to the distribution of discrete post-transplant health states (HRQL better than pretransplant, not better, or dead) and estimated quality-adjusted life-years post-transplant.

MEASUREMENTS AND MAIN RESULTS

A total of 430 subjects were listed, 387 were transplanted, and 326 provided both pretransplant and post-transplant data. Transplantation conferred large improvements in all HRQL measures: St. George's change of -47 units (95% confidence interval, -48 to -44), 36-Item Short-Form Health Survey physical component summary score of 17.7 (16.5-18.9), EQ-5D of 0.27 (0.24-0.30), Standard Gamble of 0.48 (0.44-0.51), and Visual Analog of 44 (42-47). Age was not associated with meaningful differences in the HRQL benefits of transplantation. There was less HRQL benefit in interstitial lung disease than in cystic fibrosis.

CONCLUSIONS

Lung transplantation confers large HRQL benefits, which vary by recipient diagnosis, but do not differ substantially in older recipients.

Lung transplantation in chronic obstructive pulmonary disease: patient selection and special considerations

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity. Lung transplantation is one of the few treatments available for end-stage COPD with the potential to improve survival and quality of life. The selection of candidates and timing of listing present challenges, as COPD tends to progress fairly slowly, and survival after lung transplantation remains limited. Though the natural course of COPD is difficult to predict, the use of assessments of functional status and multivariable indices such as the BODE index can help identify which patients with COPD are at increased risk for mortality, and hence which are more likely to benefit from lung transplantation. Patients with COPD can undergo either single or bilateral lung transplantation. Although many studies suggest better long-term survival with bilateral lung transplant, especially in younger patients, this continues to be debated, and definitive recommendations about this cannot be made. Patients may be more susceptible to particular complications of transplant for COPD, including native lung hyperinflation, and development of lung cancer.

Predictors of success for pulmonary rehabilitation in patients awaiting lung transplantation

BACKGROUND

Numerous studies have shown the effectiveness of comprehensive pulmonary rehabilitation (PR) programs in chronic obstructive pulmonary disease (COPD). At present, it is uncertain whether PR is also effective in the management of patients with various diseases awaiting lung transplantation (LTx).

METHODS

In a retrospective clinical preanalysis and postanalysis, we investigated the effects of a 5-week inpatient PR in LTx candidates. We compared data of patients with COPD, α-1-antitrypsin deficiency, interstitial lung disease, or cystic fibrosis before and after PR with regard to exercise capacity (6-min walking distance [6MWD]) and health-related quality of life (HRQL; SF36). Multivariate stepwise regression analysis was performed to detect predictors of PR outcome.

RESULTS

Eight hundred eleven data sets from consecutive patients referred to our PR center before LTx could be analysed (COPD, 360; α-1-antitrypsin deficiency, 127; interstitial lung disease, 195; cystic fibrosis, 69; other, 60). After PR 6MWD increased by 56 ± 58 m (P < 0.001), the physical summary component of SF36 (0-100) improved by 1.9 ± 8.5 points (P < 0.001), the mental summary component of SF36 by 8.7 ± 13.5 points (P < 0.001). Stepwise regression analysis yielded no relevant predictors of success or nonsuccess of PR with regard to age, sex, disease, body mass index, 6MWD, and HRQL on admission.

CONCLUSION

Short-term comprehensive PR can significantly improve exercise capacity and HRQL in LTx candidates to a clinically relevant extent independent of the underlying lung disease. No relevant predictor influencing PR outcome could be detected. Further research is needed to evaluate the relevance of PR before LTx and its impact on clinical outcome after transplantation.

Skeletal muscle atrophy in advanced interstitial lung disease

BACKGROUND AND OBJECTIVE

A limited number of studies examine skeletal muscle dysfunction in individuals with interstitial lung disease (ILD). We compared upper and lower limb muscle size and strength in individuals with advanced ILD with healthy controls. Second, the relationships of muscle size to muscle strength and function were explored.

METHODS

Individuals with advanced ILD listed for lung transplant and healthy control subjects were studied. B-mode ultrasound was performed to assess cross-sectional area (CSA) of rectus femoris and thickness of gastrocnemius and soleus and biceps brachii. Subjects performed isometric muscle strength testing, Short Physical Performance Battery, Timed Up and Go, and Unsupported Upper Limb Exercise Test.

RESULTS

Twenty-six individuals with advanced ILD (61 ± 8 years; 73% males; forced vital capacity: 2 ± 0.8 L, 49 ± 13% predicted; diffusing capacity of carbon monoxide: 9.3 ± 4 mL/min/mm Hg, 51 ± 20% predicted) and 12 healthy age and gender-matched controls (56 ± 9.5 years; 50% males) were included. Compared with controls, people with ILD had a smaller CSA of rectus femoris (7.6 ± 2.1 vs 9.4 ± 2.4 cm(2) ; P = 0.03) and lower strength of knee extensors (119 ± 35 vs 147 ± 39 Nm; P = 0.02) and plantarflexors (37 ± 19 vs 50 ± 15 Nm; P = 0.02), but not of biceps. Individuals with ILD also had impaired performance on all functional tests (P < 0.02). Moderate correlations were found between rectus femoris CSA and knee extensor strength (r = 0.63; P < 0.01) and biceps thickness and elbow flexor strength (r = 0.78; P < 0.01) in the ILD group.

CONCLUSIONS

Individuals with advanced ILD presented with lower limb muscle atrophy and weakness. Future studies should evaluate the effectiveness of exercise training on muscle function in advanced ILD.

Factors affecting discharge destination following lung transplantation

BACKGROUND

Lung transplant (LT) recipients requiring additional care may be referred to inpatient rehabilitation prior to discharge home. This study seeks to describe discharge destinations following LT, compare the characteristics of patients discharged to different destinations, and identify the predictors of discharge destination.

METHODS

Retrospective study of 243 LT recipients who survived to hospital discharge between 2006 and 2009. LT recipients were compared based on discharge destination on data pertaining to demographics, clinical characteristics, and healthcare utilization.

RESULTS

Of the 243 recipients, 197 (81%) were discharged home, 42 (17%) to inpatient rehabilitation, and 4 (2%) to other medical facilities. Age, pulmonary diagnosis, most recent six-minute walk distance (6 MWD) prior to transplant, pre-transplant mechanical ventilation, priority listing status, pre- and post-transplant intensive care unit length of stay (ICU LOS), post-transplant LOS, total LOS, and participation in pre-transplant rehabilitation were statistically different between patients that were discharged home versus inpatient rehabilitation. Age, most recent 6 MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were found to be independent predictors of discharge destination.

CONCLUSION

Clinical factors can help identify patients more likely to require inpatient rehabilitation. Identification of these factors has the potential to facilitate early discharge planning and optimize continuity of care.

Rehabilitation in Patients before and after Lung Transplantation

Lung transplantation is an established treatment for patients with end-stage lung disease. It has been observed that despite near-normal lung function, exercise intolerance and reductions in quality of life (QOL) often persist up to years after transplantation. Several modifiable pre- and posttransplant factors are known to contribute to these persisting impairments. Physiological changes associated with severe and chronic lung disease, limb muscle dysfunction, inactivity/deconditioning, and nutritional depletion can affect exercise capacity and physical functioning in candidates for lung transplantation. After transplantation, extended hospital and intensive care unit stay, prolonged sedentary time, persisting inactivity, immunosuppressant medications and episodes of organ rejection may all impact lung recipients' recovery. Available evidence will be reviewed and content will be proposed (both evidence and experience based) for rehabilitation interventions prior to transplantation, during hospitalization after transplantation, and in both the immediate (≤12 months after hospital discharge) and long-term (>12 months after hospital discharge) posttransplant phase. Outpatient rehabilitation programs including supervised exercise training have been shown to be effective in improving limb muscle dysfunction, exercise capacity, and QOL both before and after transplantation if offered appropriately. Unmet research needs included the absence of sufficiently powered randomized controlled trials measuring the effects of rehabilitation interventions on crucial long-term outcomes such as sustained improvements in QOL, participation in daily activity, survival, incidence of morbidities and cost-effectiveness. Remotely monitored (telehealth) home-based exercise or pedometer-based walking interventions might be interesting alternatives to supervised outpatient rehabilitation interventions in the long-term posttransplant phase and warrant further investigation.

Lung transplantation: a treatment option in end-stage lung disease

BACKGROUND

Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list.

METHOD

We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO).

RESULTS

The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%).

CONCLUSION

Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.

Physical activity levels early after lung transplantation

BACKGROUND

Little is known of the early changes in physical activity after lung transplantation.

OBJECTIVES

The purposes of this study were: (1) to describe physical activity levels in patients up to 6 months following lung transplantation and (2) to explore predictors of the change in physical activity in that population.

DESIGN

This was a prospective cohort study.

METHODS

Physical activity (daily steps and time spent in moderate-intensity activity) was measured using an accelerometer before and after transplantation (at hospital discharge, 3 months, and 6 months). Additional functional measurements included submaximal exercise capacity (measured with the 6-Minute Walk Test), quadriceps muscle torque, and health-related quality of life (measured with the Medical Outcomes Study 36-Item Short-Form Health Survey 36 [SF-36] and the St George's Respiratory Questionnaire).

RESULTS

Thirty-six lung transplant recipients (18 men, 18 women; mean age=49 years, SD=14) completed posttransplant measurements. Before transplant, daily steps were less than a third of the general population. By 3 months posttransplant, the largest improvement in physical activity had occurred, and level of daily steps reached 55% of the general population. The change in daily steps (pretransplant to 3 months posttransplant) was inversely correlated with pretransplant 6-minute walk distance (r=-.48, P=.007), daily steps (r=-.36, P=.05), and SF-36 physical functioning (SF-36 PF) score (r=-.59, P=.0005). The SF-36 PF was a significant predictor of the change in physical activity, accounting for 35% of the variation in change in daily steps.

LIMITATIONS

Only individuals who were ambulatory prior to transplant and discharged from the hospital in less than 3 months were included in the study.

CONCLUSIONS

Physical activity levels improve following lung transplantation, particularly in individuals with low self-reported physical functioning. However, the majority of lung transplant recipients remain sedentary between 3 to 6 months following transplant. The role of exercise training, education, and counseling in further improving physical activity levels in lung transplant recipients should be further explored.

Meeting report: consensus recommendations for a research agenda in exercise in solid organ transplantation

With improved survival rates in solid organ transplantation there has been an increased focus on long-term outcomes following transplant, including physical function, health-related quality-of-life and cardiovascular mortality. Exercise training has the potential to affect these outcomes, however, research on the optimal timing, type, dose of exercise, mode of delivery and relevant outcomes is limited. This article provides a summary of a 2-day meeting held in April 2013 (Toronto, Canada) in which a multi-disciplinary group of clinicians, researchers, administrators and patient representatives engaged in knowledge exchange and discussion of key issues in exercise in solid organ transplant (SOT). The outcomes from the meeting were the development of top research priorities and a research agenda for exercise in SOT, which included the need for larger scale, multi-center intervention studies, development of standardized outcomes for physical function and surrogate measures for clinical trials, examining novel modes of exercise delivery and novel outcomes from exercise training studies such as immunity, infection, cognition and economic outcomes. The development and dissemination of "expert consensus guidelines," synthesizing both the best available evidence and expert opinion was prioritized as a key step toward improving program delivery.

Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease

Pulmonary rehabilitation (PR) is an important therapeutic intervention that should no longer be considered suitable only for patients with chronic obstructive pulmonary disease (COPD). A strong rationale exists for providing PR to persons with a broad range of respiratory disorders other than COPD. Evidence shows that PR for these patients is feasible, safe and effective. A disease-relevant approach should be undertaken, based on individual patients' needs. Further research is needed to better understand the optimal program content, duration and outcomes measures, to enable diverse patients to achieve maximal benefits of PR.