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Muelas-Gómez L, Martínez-Gimeno L, Escudero-Gómez C, Atin Arratibel MÁ, Cebrià i Iranzo MA, Solís-Muñoz M. [Efficacy of Physiotherapy Interventions on the Respiratory Musculature Through Respiratory Training Techniques in Post-operative Lung Transplant Recipients: Systematic Review]. OPEN RESPIRATORY ARCHIVES 2024; 6:100288. [PMID: 38274199 PMCID: PMC10809207 DOI: 10.1016/j.opresp.2023.100288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/09/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Respiratory muscles are a limiter of exercise capacity in lung transplant patients. It is necessary to know the effectiveness of specific respiratory muscle training techniques carried out in the management of adult lung transplant patients in the postoperative period. Methodology A systematic review of clinical trials was carried out, which included adult lung transplant patients undergoing post-transplant respiratory training. A search was carried out in the databases PubMed/Medline, EMBASE, Scopus, Web of Science, Cochrane Library between January 2012 and September 2023, using the terms: "breathing exercise", "respiratory muscle training", "inspiratory muscle training", "respiratory exercise", "pulmonary rehabilitation", "lung rehabilitation"; in combination with "lung transplantation", "lung transplant", "posttransplant lung". No language limit. Results Eleven trials were included with a total of 639 patients analyzed. Most training programs begin upon hospital discharge (more than one month post-transplant), few do so early (Intensive Care Unit). The duration varies from 1-12 months post-transplant. The interventions were based on aerobic training and peripheral muscle strength. Some of them included breathing exercises and chest expansions. The most used outcome variable was submaximal exercise capacity measured with the 6-minute walk test. Conclusions Training the respiratory muscles of the adult transplant patient favors the improvement of exercise capacity and quality of life. Aerobic training, as well as strength training of the rest of the peripheral muscles, contribute to the improvement of respiratory muscles.
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Affiliation(s)
- Laura Muelas-Gómez
- Unidad de Rehabilitación Respiratoria, Servicio de Rehabilitación y Medicina Física, Hospital Universitario Puerta de Hierro Majadahonda, Grupo de Investigación en Enfermería y Cuidados de Salud, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Majadahonda, Madrid, España
| | - Lara Martínez-Gimeno
- Fundación San Juan de Dios, Departamento de Ciencias de la Salud, Escuela de Enfermería y Fisioterapia San Juan de Dios, Universidad Pontificia Comillas, Madrid, España
| | - Cristina Escudero-Gómez
- Servicio de Biblioteca, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España
| | - María Ángeles Atin Arratibel
- Departamento de Radiología, Rehabilitación y Fisioterapia, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, España
| | - Maria Angels Cebrià i Iranzo
- Departamento de Fisioterapia, Facultad de Fisioterapia, Universidad de Valencia. Servicio de Medicina Física y Rehabilitación, Hospital La Fe de Valencia. Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, España
| | - Montserrat Solís-Muñoz
- Unidad de Investigación, Desarrollo e Innovación en Cuidados de Salud, Hospital Universitario Puerta de Hierro Majadahonda, Grupo de Investigación en Enfermería y Cuidados de Salud, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Majadahonda, Madrid, España
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Orthostatic Hypotension and Concurrent Autonomic Dysfunction: A Novel Complication of Lung Transplantation. J Transplant 2022; 2022:3308939. [PMID: 35282328 PMCID: PMC8913146 DOI: 10.1155/2022/3308939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/06/2022] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background Persistent orthostatic hypotension (OH) is a lesser-known complication of lung transplantation (LTx). In this retrospective case series, we describe the clinical manifestations, complications, and treatment of persistent OH in 13 LTx recipients. Methods We identified LTx recipients who underwent transplantation between March 1, 2018, and March 31, 2020, with persistent symptomatic OH and retrospectively queried the records for clinical information. Results Thirteen patients were included in the analysis, 9 (69%) had underlying pulmonary fibrosis, and 12 (92%) were male. The median age, height, and body mass index at LTx were 68 years, 70 inches, and 27 kg/m2, respectively. Six (46%) patients were deceased at the time of chart abstraction with a median (IQR) posttransplant survival of 12.6 months (6, 21); the 7 remaining living patients were a median of 19.6 months (18, 32) posttransplant. Signs and symptoms of OH developed a median of 60 (7, 75) days after transplant. Patients were treated with pharmacological agents and underwent extensive physical therapy. Most patients required inpatient rehabilitation (n = 10, 77%), and patients commonly developed comorbid conditions including weight loss, renal insufficiency with eGFR <50 (n = 13, 100%), gastroparesis (n = 7, 54%), and tachycardia-bradycardia syndrome (n = 2, 15%). Falls were common (n = 10, 77%). The incidence of OH in LTx recipients at our center during the study period was 5.6% (13/234). Conclusions Persistent OH is a lesser-known complication of LTx that impacts posttransplant rehabilitation and may lead to comorbidities and shortened survival. In addition, most LTx recipients with OH at our center were tall, thin men with underlying pulmonary fibrosis, which may offer an opportunity to instate pretransplant OH screening of at-risk patients.
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Abstract
The rehabilitation needs of individuals undergoing thoracic surgery are changing, especially as surgical management is increasingly being offered to patients who are at risk of developing functional limitations during and after hospital discharge. In the past rehabilitative management of these patients was frequently limited to specific respiratory physiotherapy interventions in the immediate postoperative setting with the aim to prevent postoperative pulmonary complications. In the past two decades, this focus has shifted toward pulmonary rehabilitation interventions that aim to improve functional status of individuals, both in the pre- and (longer-term) postoperative period. While there is increased interest in (p)rehabilitation interventions the majority of thoracic surgery patients are however currently on their own with respect to progression of their exercise and physical activity regimens after they have been discharged from hospital. There are also no formal guidelines supporting the referral of these patients to outpatient rehabilitation programs. The current evidence regarding rehabilitation interventions initiated before, during, and after the hospitalization period will be briefly reviewed with special focus on patients undergoing surgery for lung cancer treatment and patients undergoing lung transplantation. More research will be necessary in the coming years to modify or change clinical rehabilitation practice beyond the acute admission phase in patients undergoing thoracic surgery. Tele rehabilitation or web-based activity counseling programs might also be interesting emerging alternatives in the (long-term) postoperative rehabilitative treatment of these patients.
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Affiliation(s)
- Daniel Langer
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Respiratory Diseases, UZ Leuven, BREATHE Department CHROMETA, KU Leuven, Leuven, Belgium
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Braccioni F, Bottigliengo D, Ermolao A, Schiavon M, Loy M, Marchi MR, Gregori D, Rea F, Vianello A. Dyspnea, effort and muscle pain during exercise in lung transplant recipients: an analysis of their association with cardiopulmonary function parameters using machine learning. Respir Res 2020; 21:267. [PMID: 33059678 PMCID: PMC7559436 DOI: 10.1186/s12931-020-01535-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/05/2020] [Indexed: 01/05/2023] Open
Abstract
Background Despite improvement in lung function, most lung transplant (LTx) recipients show an unexpectedly reduced exercise capacity that could be explained by persisting peripheral muscle dysfunction of multifactorial origin. We analyzed the course of symptoms, including dyspnea, muscle effort and muscle pain and its relation with cardiac and pulmonary function parameters during an incremental exercise testing. Methods Twenty-four bilateral LTx recipients were evaluated in an observational cross-sectional study. Recruited patients underwent incremental cardio-pulmonary exercise testing (CPET). Arterial blood gases at rest and peak exercise were measured. Dyspnea, muscle effort and muscle pain were scored according to the Borg modified scale. Potential associations between the severity of symptoms and exercise testing parameters were analyzed using a Forest-Tree Machine Learning approach, which accomplishes for a ratio between number of observations and number of screened variables less than unit. Results Dyspnea score was significantly associated with maximum power output (WR, watts), and minute ventilation (VE, L/min) at peak exercise. In a controlled subgroup analysis, dyspnea score was a limiting symptom only in LTx recipients who reached the higher levels of WR (≥ 101 watts) and VE (≥ 53 L/min). Muscle effort score was significantly associated with breathing reserve as percent of maximal voluntary ventilation (BR%MVV). The lower the BR%MVV at peak exercise (< 32) the higher the muscle effort perception. Muscle pain score was significantly associated with VO2 peak, arterial [HCO3−] at rest, and VE/VCO2 slope. In a subgroup analysis, muscle pain was the limiting symptom in LTx recipients with a lower VO2 peak (< 15 mL/Kg/min) and a higher VE/VCO2 slope (≥ 32). Conclusions The majority of our LTx recipients reported peripheral limitation as the prevalent reason for exercise termination. Muscle pain at peak exercise was strictly associated with basal and exercise-induced metabolic altered pathways. The onset of dyspnea (breathing effort) was associated with the intensity of ventilatory response to meet metabolic demands for increasing WR. Our study suggests that only an accurate assessment of symptoms combined with cardio-pulmonary parameters allows a correct interpretation of exercise limitation and a tailored exercise prescription. The role and mechanisms of muscle pain during exercise in LTx recipients requires further investigations.
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Affiliation(s)
- Fausto Braccioni
- Division of Respiratory Pathophysiology, Department of Cardio-Thoracic, Vascular and Public Health Sciences, University Hospital of Padova, Padova, Italy.
| | - Daniele Bottigliengo
- Division of Biostatistics, Epidemiology and Public Health, Department of Cardio-Thoracic, Vascular and Public Health Sciences, University Hospital of Padova, Padova, Italy
| | - Andrea Ermolao
- Division of Sport and Exercise Medicine, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Marco Schiavon
- Division of Thoracic Surgery, Department of Cardio-Thoracic, Vascular and Public Health Sciences, University Hospital of Padova, Padova, Italy
| | - Monica Loy
- Division of Thoracic Surgery, Department of Cardio-Thoracic, Vascular and Public Health Sciences, University Hospital of Padova, Padova, Italy
| | - Maria Rita Marchi
- Division of Respiratory Pathophysiology, Department of Cardio-Thoracic, Vascular and Public Health Sciences, University Hospital of Padova, Padova, Italy
| | - Dario Gregori
- Division of Biostatistics, Epidemiology and Public Health, Department of Cardio-Thoracic, Vascular and Public Health Sciences, University Hospital of Padova, Padova, Italy
| | - Federico Rea
- Division of Thoracic Surgery, Department of Cardio-Thoracic, Vascular and Public Health Sciences, University Hospital of Padova, Padova, Italy
| | - Andrea Vianello
- Division of Respiratory Pathophysiology, Department of Cardio-Thoracic, Vascular and Public Health Sciences, University Hospital of Padova, Padova, Italy
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Abstract
PURPOSE Pulmonary rehabilitation (PR) is advocated in the pre- and post-lung transplantation (LTx) periods. However, there is limited literature on the benefit of PR post-LTx. The aim of this study was to investigate the efficacy of an outpatient, multidisciplinary, comprehensive PR program in bilateral LTx recipients in the early period after LTx. METHOD Twenty-three LTx recipients were referred to the PR center. Change in incremental and endurance shuttle walk tests, hand and quadriceps strength, respiratory muscle strength (maximum inspiratory/expiratory pressure), dyspnea (Medical Research Council score), quality of life (St George's Respiratory Questionnaire, Chronic Respiratory Questionnaire), and psychological status (Hospital Anxiety Depression Scale) were compared pre- and post-PR. RESULTS Seventeen of 23 (74%) recipients completed PR, comprising 15 male and 2 female patients whose median age was 51 yr. The initiation of the program was 75 ± 15 d after LTx. The incremental shuttle walk test distance was predicted as 23% before PR and it increased to 36% after PR (P < .001); the endurance shuttle walk test distance also increased (P < .01). Significant improvement was seen in upper and lower extremity strength, and St George's Respiratory Questionnaire and Chronic Respiratory Questionnaire scores and Hospital Anxiety Depression Scale scores reflected less anxiety and depressive symptoms. Furthermore, body mass and fat-free mass indices, maximum inspiratory pressure, and maximum expiratory pressure improved significantly. There was no significant change in forced expiratory volume in the first second of expiration, forced vital capacity, or Medical Research Council scores. CONCLUSION This study demonstrated that patients who attended PR within 3 mo of bilateral LTx showed improvements in exercise capacity, respiratory muscle strength, quality of life, body composition, and psychological status.
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Spiesshoefer J, Henke C, Kabitz HJ, Nofer JR, Mohr M, Evers G, Strecker JK, Brix T, Randerath WJ, Herkenrath S, Schmidt LH, Boentert M. Respiratory Muscle and Lung Function in Lung Allograft Recipients: Association with Exercise Intolerance. Respiration 2020; 99:398-408. [PMID: 32403109 DOI: 10.1159/000507264] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/15/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In lung transplant recipients (LTRs), restrictive ventilation disorder may be present due to respiratory muscle dysfunction that may reduce exercise capacity. This might be mediated by pro-inflammatory cytokines such as tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). OBJECTIVE We investigated lung respiratory muscle function as well as circulating pro-inflammatory cytokines and exercise capacity in LTRs. METHODS Fifteen LTRs (6 female, age 56 ± 14 years, 63 ± 45 months post-transplantation) and 15 healthy controls matched for age, sex, and body mass index underwent spirometry, measurement of mouth occlusion pressures, diaphragm ultrasound, and recording of twitch transdiaphragmatic (twPdi) and gastric pressures (twPgas) following magnetic stimulation of the phrenic nerves and the lower thoracic nerve roots. Exercise capacity was quantified using the 6-min walking distance (6MWD). Plasma IL-6 and TNF-α were measured using enzyme-linked immunosorbent assays. RESULTS Compared with controls, patients had lower values for forced vital capacity (FVC; 81 ± 30 vs.109 ± 18% predicted, p = 0.01), maximum expiratory pressure (100 ± 21 vs.127 ± 17 cm H2O, p = 0.04), diaphragm thickening ratio (2.2 ± 0.4 vs. 3.0 ± 1.1, p = 0.01), and twPdi (10.4 ± 3.5 vs. 17.6 ± 6.7 cm H2O, p = 0.01). In LTRs, elevation of TNF-α was related to lung function (13 ± 3 vs. 11 ± 2 pg/mL in patients with FVC ≤80 vs. >80% predicted; p < 0.05), and lung function (forced expiratory volume after 1 s) was closely associated with diaphragm thickening ratio (r = 0.81; p < 0.01) and 6MWD (r = 0.63; p = 0.02). CONCLUSION There is marked restrictive ventilation disorder and respiratory muscle weakness in LTRs, especially inspiratory muscle weakness with diaphragm dysfunction. Lung function impairment relates to elevated levels of circulating TNF-α and diaphragm dysfunction and is associated with exercise intolerance.
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Affiliation(s)
- Jens Spiesshoefer
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany, .,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy,
| | - Carolin Henke
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Hans Joachim Kabitz
- Department of Pneumology, Cardiology and Intensive Care Medicine, Klinikum Konstanz, Konstanz, Germany
| | - Jerzy Roch Nofer
- Center for Laboratory Medicine, University Hospital Münster, University of Münster, Münster, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mohr
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, Münster, Germany
| | - Georg Evers
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, Münster, Germany
| | | | - Tobias Brix
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Winfried Johannes Randerath
- Bethanien Hospital gGmbH, Solingen, Germany.,Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Simon Herkenrath
- Bethanien Hospital gGmbH, Solingen, Germany.,Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Lars Henning Schmidt
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Münster, Münster, Germany
| | - Matthias Boentert
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
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Cebrià I Iranzo MÀ, Vos R, Verleden GM, Gosselink R, Langer D. Evolution of Functional Exercise Capacity in Lung Transplant Patients With and Without Bronchiolitis Obliterans Syndrome: A Longitudinal Case-Control Study. Arch Bronconeumol 2018; 55:239-245. [PMID: 30595421 DOI: 10.1016/j.arbres.2018.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Bronchiolitis Obliterans Syndrome (BOS) is a debilitating disease with limited treatment options that threatens both the quality of life and long-term survival of lung transplant (LTx) recipients. This retrospective longitudinal case-control study was performed to compare the long-term functional evolution of LTx recipients with and without BOS. METHODS Twenty-four LTx recipients with BOS (BOS=Cases) and 24 without BOS (NON-BOS=Controls) were selected and individually matched according to age, gender, diagnosis and LTx characteristics. Measurements of 6-minute walking distance (6MWD), symptoms of dyspnea (BORG CR-10 scale), and comprehensive pulmonary function testing were performed before LTx and at annual follow-up assessments after LTx. RESULTS Peak FEV1 after LTx was similar in both groups [FEV1 (% predicted) 101±25 vs. 101±31, p=0.96] and BOS diagnosis in cases was established 3.6±2.5 years after LTx. At the final follow-up assessment (6.5±3.2 years after LTx) FEV1 (% predicted) was 86±34 in NON-BOS vs. 44±17 in BOS (p<0.001). Evolution of 6MWD was different between groups (group by time interaction: p=0.002). Borg dyspnea scores were also significantly different between groups at the final evaluation (NON-BOS 3.3±1.7 vs. BOS 5.0±2.2; p=0.024). CONCLUSIONS We observed gradual reductions in functional exercise capacity and increasing symptoms of dyspnea in patients who developed BOS after LTx. As such, prospective studies seem warranted to explore whether rehabilitative interventions might be useful to improve symptoms and slow down deterioration of exercise capacity in these patients from the onset of BOS.
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Affiliation(s)
- Maria À Cebrià I Iranzo
- Department of Physiotherapy, University of Valencia and Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Robin Vos
- Respiratory Division, Lung Transplantation Unit, University Hospitals Leuven and Department of Clinical and Experimental Medicine, KU Leuven, Belgium
| | - Geert M Verleden
- Respiratory Division, Lung Transplantation Unit, University Hospitals Leuven and Department of Clinical and Experimental Medicine, KU Leuven, Belgium
| | - Rik Gosselink
- Respiratory Division, Respiratory Rehabilitation Unit, University Hospitals Leuven and Department of Rehabilitation Sciences, KU Leuven, Belgium
| | - Daniel Langer
- Respiratory Division, Respiratory Rehabilitation Unit, University Hospitals Leuven and Department of Rehabilitation Sciences, KU Leuven, Belgium.
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Acute and 6-Month Outcomes in Recipients of Lung Transplantation Following Lower Extremity Strength Training: Pilot Study. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2018. [DOI: 10.1097/jat.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gustaw T, Schoo E, Barbalinardo C, Rodrigues N, Zameni Y, Motta VN, Mathur S, Janaudis-Ferreira T. Physical activity in solid organ transplant recipients: Participation, predictors, barriers, and facilitators. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12929] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Tanya Gustaw
- Department of Physical Therapy; Faculty of Medicine; University of Toronto; Toronto ON Canada
| | - Emma Schoo
- Department of Physical Therapy; Faculty of Medicine; University of Toronto; Toronto ON Canada
| | - Colleen Barbalinardo
- Department of Physical Therapy; Faculty of Medicine; University of Toronto; Toronto ON Canada
| | - Nicole Rodrigues
- Department of Physical Therapy; Faculty of Medicine; University of Toronto; Toronto ON Canada
| | - Yalda Zameni
- Department of Physical Therapy; Faculty of Medicine; University of Toronto; Toronto ON Canada
| | | | - Sunita Mathur
- Department of Physical Therapy; Faculty of Medicine; University of Toronto; Toronto ON Canada
- Canadian National Transplant Research Program; Edmonton AB Canada
| | - Tania Janaudis-Ferreira
- Canadian National Transplant Research Program; Edmonton AB Canada
- School of Physical and Occupational Therapy; Faculty of Medicine; McGill University; Montreal QC Canada
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11
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12
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Abstract
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.
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Affiliation(s)
- Daniel Langer
- Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, and Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
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Rochester CL, Fairburn C, Crouch RH. Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease. Clin Chest Med 2014; 35:369-89. [PMID: 24874132 DOI: 10.1016/j.ccm.2014.02.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Carolyn L Rochester
- Section of Pulmonary, Critical Care and Sleep, Yale University School of Medicine, 333 Cedar Street, Building LCI-105, New Haven, CT 06520, USA.
| | - Carl Fairburn
- Duke Cardiopulmonary Rehabilitation, Duke University School of Medicine, 1821 Hillandale Road, Suite 25B, Durham, NC 27705, USA
| | - Rebecca H Crouch
- Duke Cardiopulmonary Rehabilitation, Duke University School of Medicine, 1821 Hillandale Road, Suite 25B, Durham, NC 27705, USA
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Sarcopenia in lung transplantation: a systematic review. J Heart Lung Transplant 2014; 33:1203-12. [PMID: 25044057 DOI: 10.1016/j.healun.2014.06.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 05/06/2014] [Accepted: 06/04/2014] [Indexed: 12/23/2022] Open
Abstract
Lung transplant candidates and recipients have significant impairments in skeletal muscle mass, strength and function--individual measures of sarcopenia. Skeletal muscle dysfunction has been observed in the pre-transplant and post-transplant period and could have an important effect on transplant outcomes. A systematic review was performed to characterize the techniques used to study sarcopenia and assess the level of impairment throughout the transplant process. Electronic databases were searched (inception to July 2013) for prospective studies measuring at least 1 element of sarcopenia (muscle mass, strength, or function) in lung transplant patients. Eighteen studies were included, and study quality was assessed using the Downs and Black scale. A variety of measurements were used to evaluate sarcopenia in 694 lung transplant patients. Muscle mass in 7 studies was assessed using bioelectrical impedance (n = 4), computed tomography or magnetic resonance imaging (n = 2), or skin folds (n = 1), and was significantly reduced. Quadriceps strength was examined in 14 studies with computerized dynamometer (n = 10) and hand-held dynamometer (n = 4). Quadriceps strength was reduced in the pre-transplant period (mean range, 49%-86% predicted; n = 455 patients), further reduced immediately after transplant (51%-72%, n = 126), and improved beyond 3 months after transplant (58%-101%, n = 164). Only 2 studies measured lower extremity function (sit-to-stand test). A multitude of measurement techniques have been used to assess individual measures of sarcopenia, with reduced muscle mass and quadriceps strength observed in the pre-transplant and post-transplant period. Further standardization of measurement techniques is needed to assess the clinical effect of sarcopenia in lung transplantation.
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Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WDC, Pitta F, Sewell L, Raskin J, Bourbeau J, Crouch R, Franssen FME, Casaburi R, Vercoulen JH, Vogiatzis I, Gosselink R, Clini EM, Effing TW, Maltais F, van der Palen J, Troosters T, Janssen DJA, Collins E, Garcia-Aymerich J, Brooks D, Fahy BF, Puhan MA, Hoogendoorn M, Garrod R, Schols AMWJ, Carlin B, Benzo R, Meek P, Morgan M, Rutten-van Mölken MPMH, Ries AL, Make B, Goldstein RS, Dowson CA, Brozek JL, Donner CF, Wouters EFM. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188:e13-64. [PMID: 24127811 DOI: 10.1164/rccm.201309-1634st] [Citation(s) in RCA: 2107] [Impact Index Per Article: 191.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope. PURPOSE The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field. METHODS A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members. RESULTS An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed. CONCLUSIONS The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.
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Walsh JR, Chambers DC, Davis RJ, Morris NR, Seale HE, Yerkovich ST, Hopkins PMA. Impaired exercise capacity after lung transplantation is related to delayed recovery of muscle strength. Clin Transplant 2013; 27:E504-11. [PMID: 23815281 DOI: 10.1111/ctr.12163] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2013] [Indexed: 12/24/2022]
Abstract
Lung transplant recipients report reduced exercise capacity despite satisfactory graft function. We analysed changes in lung function, six-min walk distance (6MWD), and quadriceps strength in the first 26-wk post-transplant and examined what factors predict 6MWD recovery. All lung transplant recipients at a single institution between June 2007 and January 2011 were considered for inclusion. Lung function, 6MWD, and quadriceps strength corrected for body weight (QS%) were recorded pre- and two-, six-, 13-, and 26-wk post-transplant. Fifty recipients, of mean (± SD) age 42 (± 13) yr, were studied. Mean FEV1 % and 6MWD improved from 26.4% to 88.9% and from 397 to 549 m at 26 wk, respectively (both p < 0.001). QS% declined in the first two wk but had improved to above pre-transplant levels by 26 wk (p = 0.027). On multivariate analysis (n = 35), lower pre-transplant exercise capacity and greater recovery in muscle strength explained most of the improvement in exercise capacity. Delayed recovery of exercise capacity after lung transplantation is unrelated to delay in improvement in graft function, but occurs secondary to the slow recovery of muscle strength. Our findings show that additional controlled trials are needed to better understand the influence of exercise rehabilitation on improvement in exercise capacity post-transplantation.
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Affiliation(s)
- James R Walsh
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Qld, Australia.
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17
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Langer D, Burtin C, Schepers L, Ivanova A, Verleden G, Decramer M, Troosters T, Gosselink R. Exercise training after lung transplantation improves participation in daily activity: a randomized controlled trial. Am J Transplant 2012; 12:1584-92. [PMID: 22390625 DOI: 10.1111/j.1600-6143.2012.04000.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The effects of exercise training after lung transplantation have not been studied in a randomized controlled trial so far. We investigated whether 3 months of supervised training, initiated immediately after hospital discharge, improve functional recovery and cardiovascular morbidity of patients up to 1 year after lung transplantation. Patients older than 40 years, who experienced an uncomplicated postoperative period, were eligible for this single blind, parallel group study. Sealed envelopes were used to randomly allocate patients to 3 months of exercise training (n = 21) or a control intervention (n = 19). Minutes of daily walking time (primary outcome), physical fitness, quality of life and cardiovascular morbidity were compared between groups adjusting for baseline assessments in a mixed models analysis. After 1 year daily walking time in the treated patients (n = 18) was 85 ± 27 min and in the control group (n = 16) 54 ± 30 min (adjusted difference 26 min [95%CI 8-45 min, p = 0.006]). Quadriceps force (p = 0.001), 6-minute walking distance (p = 0.002) and self-reported physical functioning (p = 0.039) were significantly higher in the intervention group. Average 24 h ambulatory blood pressures were significantly lower in the treated patients (p ≤ 0.01). Based on these results patients should be strongly encouraged to participate in an exercise training intervention after lung transplantation.
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Affiliation(s)
- D Langer
- Faculty of Kinesiology and Rehabilitation Sciences, KULeuven, Tervuursevest, Heverlee, Belgium
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18
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Estenne M, Fessler HE, DeCamp MM. Lung transplantation and lung volume reduction surgery. Compr Physiol 2011; 1:1437-71. [PMID: 23733648 DOI: 10.1002/cphy.c100044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Since the publication of the last edition of the Handbook of Physiology, lung transplantation has become widely available, via specialized centers, for a variety of end-stage lung diseases. Lung volume reduction surgery, a procedure for emphysema first conceptualized in the 1950s, electrified the pulmonary medicine community when it was rediscovered in the 1990s. In parallel with their technical and clinical refinement, extensive investigation has explored the unique physiology of these procedures. In the case of lung transplantation, relevant issues include the discrepant mechanical function of the donor lungs and recipient thorax, the effects of surgical denervation, acute and chronic rejection, respiratory, chest wall, and limb muscle function, and response to exercise. For lung volume reduction surgery, there have been new insights into the counterintuitive observation that lung function in severe emphysema can be improved by resecting the most diseased portions of the lungs. For both procedures, insights from physiology have fed back to clinicians to refine patient selection and to scientists to design clinical trials. This section will first provide an overview of the clinical aspects of these procedures, including patient selection, surgical techniques, complications, and outcomes. It then reviews the extensive data on lung and muscle function following transplantation and its complications. Finally, it reviews the insights from the last 15 years on the mechanisms whereby removal of lung from an emphysema patient can improve the function of the lung left behind.
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Affiliation(s)
- Marc Estenne
- Chest Service and Thoracic Transplantation Unit, Erasme University Hospital, Brussels, Belgium
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19
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Benefits of home-based endurance training in lung transplant recipients. Respir Physiol Neurobiol 2011; 177:189-98. [PMID: 21333761 DOI: 10.1016/j.resp.2011.02.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 02/11/2011] [Accepted: 02/11/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND To investigate the effect of home-based exercise training on exercise tolerance, muscle function and quality of life in lung transplant recipients (LTR). METHODS Twelve LTR and 7 age-matched healthy subjects underwent exercise training (ET, 12-wk, 3×/wk, 40 min). Peak aerobic capacity VO2peak, endurance time (T(end)), minute ventilation (VE) quadriceps strength, percentage of type I fiber (%Ifb), fiber diameters and chronic respiratory questionnaire were assessed before and after ET. A positive response to ET was defined as an improvement in T(end) at least comparable to the mean change observed in healthy subjects. RESULTS Training significantly improved T(end) (+12 ± 11 min), isowatt during exercise (-5.5 ± 2.6L/min), muscle strength (+4.6 ± 2.6 kg) and dyspnea score (+0.6 ± 0.9) in LTR (p < 0.05), leading to recovery of T(end) and muscle strength up to healthy subjects' values. In responders (n = 6), VO2peak, %Ifb and fatigue score were improved after training (p < 0.05). Non-responders had lower %Ifb and greater delay between surgery and the beginning of the study than responders (56 [21-106] vs. 8 [2-59] months respectively, p = 0.03). CONCLUSIONS Home-based ET was effective to improve exercise tolerance, muscle strength and quality of life in LTR but more successful in patients with moderate muscle dysfunction and in the first years after transplantation. Multicenter and controlled-studies are needed to confirm the benefits and optimal modalities of home training in LTR.
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Wickerson L, Mathur S, Brooks D. Exercise training after lung transplantation: a systematic review. J Heart Lung Transplant 2010; 29:497-503. [PMID: 20133160 DOI: 10.1016/j.healun.2009.12.008] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 11/20/2009] [Accepted: 12/07/2009] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Lung transplant recipients experience persistent impairments in exercise capacity and skeletal muscle function despite a vast improvement in lung function after transplantation. Exercise training may be beneficial in improving exercise capacity in lung transplant recipients. A systematic review was undertaken to examine the evidence for exercise training on functional outcomes in lung transplant recipients. METHODS Studies were identified by searching electronic databases and scanning reference lists. Only randomized controlled trials, controlled trials, and prospective cohorts were included in the review. Seven studies met the inclusion criteria. Study quality was assessed using the Physiotherapy Evidence Database, Jadad, and Downs scales. RESULTS The overall quality of studies was fair to moderate in assessing the effect of exercise training on maximal and functional exercise capacity, skeletal muscle function, and lumbar bone mineral density. Every study reported significant improvements in these outcomes. Some studies lacked randomization and/or a control group, so it was not possible to separate the effects of training with the natural recovery process after lung transplantation. CONCLUSION Some evidence was found to support that a period of structured exercise training could improve maximal and functional exercise capacity, skeletal muscle strength, and lumbar bone mineral density in lung transplant recipients. Further studies are needed to determine the potential for exercise training to optimize these functional outcomes and to develop optimal guidelines for exercise prescription in the lung transplant population.
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Affiliation(s)
- Lisa Wickerson
- Department of Rehabilitation Services, University Health Network, Toronto, Ontario, Canada
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21
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Review series: Rehabilitation in non COPD: Mechanisms of exercise limitation and pulmonary rehabilitation for patients with pulmonary fibrosis/restrictive lung disease. Chron Respir Dis 2009; 7:47-60. [DOI: 10.1177/1479972309348654] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The standard of care in the treatment of chronic lung disease includes pulmonary rehabilitation (PR). While evidence of the effectiveness of PR in chronic obstructive lung disease (COPD) is robust, that for pulmonary fibrosis and other non-fibrotic restrictive lung diseases is less extensive. However, PR has been shown to improve functional exercise capacity and health-related quality of life in non-COPD patients, primarily those with interstitial lung diseases. This review examines mechanisms of exercise limitation in non-COPD patients and discusses how they might affect both the application of and outcome measures of PR. We also review the assessment of exercise performance, dyspnea, and quality of life as well as special protocols, safety considerations, and special techniques in PR as applied to patients with pulmonary fibrosis or restrictive lung disease. At present, there are no evidence-based guidelines for PR in non-COPD patients whereas PR is firmly recommended in COPD management. More research is needed to strengthen the evidence for the use of PR in non-COPD patients. Meanwhile, the available data, summarized in this review, support the inclusion of PR in the management of all patients with chronic lung disease including pulmonary fibrosis and restrictive lung disease.
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22
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Bossenbroek L, ten Hacken NHT, van der Bij W, Verschuuren EAM, Koëter GH, de Greef MHG. Cross-sectional assessment of daily physical activity in chronic obstructive pulmonary disease lung transplant patients. J Heart Lung Transplant 2009; 28:149-55. [PMID: 19201340 DOI: 10.1016/j.healun.2008.11.905] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Revised: 06/19/2008] [Accepted: 11/18/2008] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Information about daily physical activity of chronic obstructive pulmonary disease (COPD) lung transplant patients is relevant for evaluation of the functional recovery of physical capacity after lung transplantation. The objective of this study was to cross-sectionally assess daily physical activity, pulmonary function, physical fitness, fear of physical activity and motivation to exercise in COPD patients who were lung transplant candidates and lung transplant recipients. METHODS Fifteen COPD lung transplant candidates (5 men and 10 women, mean age 53 years, forced expiratory volume in 1 second [FEV(1)] 20% predicted) and 47 recipients (18 men and 29 women, mean age 55 years, FEV(1) 93% predicted, 39 bilateral and 8 unilateral transplants) were enrolled in this observational study. Daily physical activity was measured using a pedometer (Digiwalker SW-200) and the Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH). Physical fitness was measured by the sit-to-stand test and the arm curl test. Fear of physical activity and motivation to exercise were measured by the Tampa Scale for Kinesiophobia-Dutch version Questionnaire and the Exercise Self-Regulation Questionnaire. RESULTS Mean (+/-SD) number of steps per day in lung transplant recipients was higher compared with transplant candidates: 6,642 (+/-2,886) and 1,407 (+/-1,166), respectively (p < 0.05). Number of steps per day correlated significantly with FEV(1) (r = 0.32, p = 0.03) and lower body strength (r = 0.45, p = 0.002) in lung transplant recipients. There was no significant difference in daily physical activity, physical fitness, fear and motivation between bi- and unilateral transplant recipients. CONCLUSION Our data suggest that lung transplantation improves daily physical activity, lower body strength and FEV(1).
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Affiliation(s)
- Linda Bossenbroek
- Department of Pulmonology, University Medical Center Groningen, Groningen, The Netherlands.
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23
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Langer D, Gosselink R, Pitta F, Burtin C, Verleden G, Dupont L, Decramer M, Troosters T. Physical activity in daily life 1 year after lung transplantation. J Heart Lung Transplant 2009; 28:572-8. [PMID: 19481017 DOI: 10.1016/j.healun.2009.03.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Revised: 03/04/2009] [Accepted: 03/06/2009] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Reduced physical fitness has been reported to occur after lung transplantation. Pre- and post-transplant factors, including an inactive lifestyle, have been proposed as possible causes. However, daily physical activity has not been objectively assessed so far in lung recipients. The purpose of this study was to objectively measure daily physical activity in lung recipients. METHODS Twenty-two clinically stable patients with single (n = 7) and bilateral lung grafts (n = 15) underwent measurements of physical activity with activity monitors at least 12 months after surgery. Results were compared with findings from 22 healthy, age- and gender-matched control subjects. RESULTS Substantial and statistically significant differences in daily activity were observed. Steps, standing time and moderate-intensity activity of lung recipients were reduced by 42%, 29% and 66%, respectively, relative to controls. Daily sedentary time was increased by 30%. Daily steps correlated with self-reported physical functioning (r = 0.81), 6-minute walk distance (r = 0.68), quadriceps force (r = 0.66) and maximum workload (r = 0.63). CONCLUSIONS This study has shown for the first time that daily activity is substantially reduced after lung transplantation and related to measures of physical fitness and health-related quality of life. Future studies need to examine whether physical activity can be modified to improve functional recovery after lung transplantation.
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Affiliation(s)
- Daniel Langer
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, Leuven, Belgium
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Estenne M. Effect of lung transplant and volume reduction surgery on respiratory muscle function. J Appl Physiol (1985) 2009; 107:977-86. [PMID: 19359607 DOI: 10.1152/japplphysiol.91620.2008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lung transplantation and lung volume reduction surgery have opened a new therapeutic era for patients with advanced emphysema. In addition to providing impressive clinical benefits, they have helped us better understand how the chest wall and respiratory muscles adapt to chronic hyperinflation. This article reviews the effects of these procedures on respiratory muscle and chest wall function. Inspiratory (including diaphragm) and expiratory muscle strength are often close to normal after unilateral and bilateral transplantation, although some patients have marked weakness. After bilateral transplantation for emphysema, graft volume is normal at full inflation but remains greater than normal at end expiration, which results from structural changes in the chest wall. In contrast, patients with unilateral transplantation have a reduction in graft volume at full inflation. The mediastinum is displaced toward the graft at end expiration, which reduces the surface area of the diaphragm on the transplanted side, and it moves toward the native lung during tidal and full inspiration and toward the graft during tidal and forced expiration. Lung volume reduction produces an increase in contractility, length and surface area of the diaphragm, and increases its contribution to tidal volume; at the same time, neural drive to the muscle and respiratory load are reduced, such that diaphragm neuromechanical coupling is improved. Diaphragm configuration and rib cage dimensions are only minimally affected by the procedure. Single-lung transplantation and lung volume reduction favorably impact on the disadvantageous size interaction by which the lungs are functionally restricted by the chest wall in emphysema.
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Affiliation(s)
- Marc Estenne
- Chest Service, Erasme University Hospital, Brussels School of Medicine, B-1070 Brussels, Belgium.
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25
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Assessment of Pulmonary Artery Systolic Pressures by Stress Doppler Echocardiography After Bilateral Lung Transplantation. J Heart Lung Transplant 2008; 27:66-71. [DOI: 10.1016/j.healun.2007.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 07/24/2007] [Accepted: 09/24/2007] [Indexed: 11/19/2022] Open
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26
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Limiting Factors of Exercise Performance 1 Year After Lung Transplantation. J Heart Lung Transplant 2006; 25:1310-6. [DOI: 10.1016/j.healun.2006.08.008] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Revised: 07/06/2006] [Accepted: 08/20/2006] [Indexed: 11/19/2022] Open
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Ratnovsky A, Elad D, Izbicki G, Kramer MR. Mechanics of Respiratory Muscles in Single-Lung Transplant Recipients. Respiration 2006; 73:642-50. [PMID: 16612048 DOI: 10.1159/000092671] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2005] [Accepted: 12/19/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emphysema and pulmonary fibrosis force the patients to breathe at an abnormal lung volume, which alters the lengths of the respiratory muscles and thereby their work capability is reduced. After single-lung transplantation, muscle function is restored on the side of the transplant but it may be asymmetric to that on the side of the native diseased lung. OBJECTIVE Investigating the hypothesis that single-lung transplantation induces mechanical asymmetry of the respiratory muscles on the two sides. METHODS Simultaneously noninvasive measurements of inspiratory and expiratory mouth pressure, airflow rate and electromyography signals from the sternomastoid, external intercostal, rectus abdominis and external oblique muscles were acquired during different breathing maneuvers. The study group included 10 single-lung transplant recipients (5 with pulmonary fibrosis and 5 with emphysema) and 10 healthy controls. RESULTS Analysis of the finding shows a significant lower global strength of the respiratory muscles of single-lung transplant recipients compared to that of healthy subjects. No significant difference in the EMG signals of respiratory muscles was found either between the different groups or between the sides of the transplant and the native lung in the patient groups. Both single-lung transplant recipients and healthy subjects demonstrated high EMG activity of the inspiratory muscles during inspiration at different breathing efforts. CONCLUSION Patients after single-lung transplantation have lower respiratory muscle strength than healthy subjects, but apparently normal electrical activity. The lower global respiratory muscle strength emphasizes the importance of their rehabilitation before and after single-lung transplantation.
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Affiliation(s)
- Anat Ratnovsky
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel.
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28
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Guerrero K, Wuyam B, Mezin P, Vivodtzev I, Vendelin M, Borel JC, Hacini R, Chavanon O, Imbeaud S, Saks V, Pison C. Functional coupling of adenine nucleotide translocase and mitochondrial creatine kinase is enhanced after exercise training in lung transplant skeletal muscle. Am J Physiol Regul Integr Comp Physiol 2005; 289:R1144-54. [PMID: 16020522 DOI: 10.1152/ajpregu.00229.2005] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Mechanisms responsible for limitation of exercise capacity in lung transplant recipients (LR) and benefits gained by exercise training were studied. Mitochondrial respiration parameters, energy transfer, and cell structure were assessed in vastus lateralis biopsies using the permeabilized fiber technique with histochemical and morphometric measurements. Twelve male controls (C) and 12 LR performed exercise training over 12 wk. Before exercise training, there were strong correlations between exercise capacity (maximal O2 consumption and endurance time at 70% maximal power output) and cellular events, as assessed by percentage of type I fibers and apparent Km for exogenous ADP. Anticalcineurins were not involved in LR exercise limitation, since there were no differences in maximal mitochondrial rate of respiration before exercise training and no abnormalities in respiratory chain complexes compared with C. Training resulted in a significant increase in physiological parameters both at the cellular (apparent Km for exogenous ADP and stimulating effect of creatine) and integrated (maximal O2 consumption, power output at ventilatory threshold, maximal power output, and endurance time at 70% maximal power output) levels in LR and C. After the training period, improvements in maximal O2 consumption and in maximal mitochondrial rate of respiration were noted, as well as changes in endurance time and percentage of type I fibers. Because there were no changes in diameters and fiber types, baseline alteration of apparent Km for exogenous ADP and its improvement after training might be related to changes within the intracellular energetic units. After the training period, intracellular energetic units exhibited a higher control of mitochondrial respiration by creatine linked to a more efficient functional coupling adenine nucleotide translocase-mitochondrial creatine kinase, resulting in better exercise performances in C and LR.
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Affiliation(s)
- Karen Guerrero
- Laboratoire de Bioénergétique Fondamentale et Appliquée, Institut National de la Santé et de la Recherche Médicale E221, Université Joseph Fourier, Grenoble, France
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White AC, Terrin N, Miller KB, Ryan HF. Impaired Respiratory and Skeletal Muscle Strength in Patients Prior to Hematopoietic Stem-Cell Transplantation. Chest 2005; 128:145-52. [PMID: 16002928 DOI: 10.1378/chest.128.1.145] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The primary aim was to determine if respiratory and skeletal muscle strength and submaximal exercise capacity were reduced in subjects prior to sibling- or unrelated-donor hematopoietic stem-cell transplantation (HSCT). DESIGN Prospective observational study. SETTING Tufts-New England Medical Center, a tertiary referral center in Boston, MA. PATIENTS All patients (n = 56) undergoing either sibling- or unrelated-donor HSCT from January 1, 2002, to December 31, 2002. MEASUREMENTS Demographic data, chemotherapy burden, pulmonary function tests (PFTs), maximal inspiratory muscle strength (PImax), maximal expiratory muscle strength (PEmax), dominant hand grip strength (GS), 6-min walk test (6MWT), and survival as of May 21, 2004. RESULTS PImax was reduced to < 80% predicted in 42% of subjects and to < 60% predicted in 18% of subjects. PEmax was reduced to < 80% predicted in 89% of subjects and to < 60% of predicted in 80% of subjects. A significant correlation was observed between PImax and PEmax (r = 0.65, p < 0.0001). GS was reduced to < 80% predicted in 39% of subjects and < 60% predicted in 15% of subjects. The 6MWT was reduced to < 80% predicted in 58% of subjects and to < 60% predicted in 9.6% of subjects. Diffusing capacity of the lung for carbon monoxide (Dlco) was the only PFT that was significantly correlated with 6MWT distance (r = 0.44, p = 0.015). The mean calculated load of chemotherapy was 14.8 +/- 16.5 U (+/- SD). The mean time elapsed from date of hematologic diagnosis to date of HSCT was 874 +/- 1,109 days. The median survival of the cohort was 374 days (95% confidence interval, 177 to 665 days). Respiratory or skeletal muscle strength, 6MWT distance, or calculated burden of chemotherapy did not predict survival. CONCLUSIONS Respiratory and skeletal muscle strength and submaximal exercise capacity are reduced in a significant percentage of patients prior to undergoing HSCT. These observations may help explain musculoskeletal weakness that has been reported in the posttransplant period.
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Affiliation(s)
- Alexander C White
- Pulmonary, Critical Care and Sleep Division, New England Medical Center, NEMC #369, 750 Washington St, Boston, MA 02111, USA.
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Pinet C, Scillia P, Cassart M, Lamotte M, Knoop C, Mélot C, Estenne M. Preferential reduction of quadriceps over respiratory muscle strength and bulk after lung transplantation for cystic fibrosis. Thorax 2004; 59:783-9. [PMID: 15333856 PMCID: PMC1747142 DOI: 10.1136/thx.2004.021766] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND In the absence of complications, recipients of lung transplants for cystic fibrosis have normal pulmonary function but the impact of the procedure on the strength and bulk of respiratory and limb muscles has not been studied. METHODS Twelve stable patients who had undergone lung transplantation for cystic fibrosis 48 months earlier (range 8-95) and 12 normal subjects matched for age, height, and sex were studied. The following parameters were measured: standard lung function, peak oxygen uptake by cycle ergometry, diaphragm surface area by computed tomographic (CT) scanning, diaphragm and abdominal muscle thickness by ultrasonography, twitch transdiaphragmatic and gastric pressures, quadriceps isokinetic strength, and quadriceps cross section by CT scanning, and lean body mass. Diaphragm mass was computed from diaphragm surface area and thickness. RESULTS Twitch transdiaphragmatic and gastric pressures, diaphragm mass, and abdominal muscle thickness were similar in the two groups but quadriceps strength and cross section were decreased by nearly 30% in the patients. Patients had preserved quadriceps strength per unit cross section but reduced quadriceps cross section per unit lean body mass. The cumulative dose of corticosteroids was an independent predictor of quadriceps atrophy. Peak oxygen uptake showed positive correlations with quadriceps strength and cross section in the two groups, but peak oxygen uptake per unit quadriceps strength or cross section was reduced in the patient group. CONCLUSIONS The diaphragm and abdominal muscles have preserved strength and bulk in patients transplanted for cystic fibrosis but the quadriceps is weak due to muscle atrophy. This atrophy is caused in part by corticosteroid therapy and correlates with the reduction in exercise capacity.
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Affiliation(s)
- C Pinet
- Department of Chest Medicine, Erasme University Hospital, Brussels, Belgium
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31
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Bowdish ME, Arcasoy SM, Wilt JS, Conte JV, Davis RD, Garrity ER, Hertz ML, Orens JB, Rosengard BR, Barr ML. Surrogate markers and risk factors for chronic lung allograft dysfunction. Am J Transplant 2004; 4:1171-8. [PMID: 15196078 DOI: 10.1111/j.1600-6143.2004.00483.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Obliterative bronchiolitis (OB) is the histologic correlate of chronic allograft dysfunction in pulmonary transplantation. The histologic diagnosis of OB is challenging, therefore a physiologic definition, bronchiolitis obliterans syndrome (BOS) based on pulmonary function tests has been used as a surrogate marker for OB for the last decade. BOS has proven to be the best available surrogate marker for OB and is predictive of the ultimate endpoints of graft and patient survival. Multiple other clinical markers have been reported and proposed as alternates for or complements to BOS grade, but all need further evaluation and validation in large, prospective clinical trials. Lastly, given the early occurrence and high incidence of chronic allograft dysfunction, the easily measurable endpoint of BOS grade, and our lack of understanding of ways to prevent or alter the course of BOS, lung transplant recipients represent an ideal population for clinical trials targeting prevention and treatment of chronic allograft dysfunction.
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McKenna MJ, Fraser SF, Li JL, Wang XN, Carey MF, Side EA, Morton J, Snell GI, Kjeldsen K, Williams TJ. Impaired muscle Ca2+ and K+ regulation contribute to poor exercise performance post-lung transplantation. J Appl Physiol (1985) 2003; 95:1606-16. [PMID: 12807900 DOI: 10.1152/japplphysiol.01175.2002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lung transplant recipients (LTx) exhibit marked peripheral limitations to exercise. We investigated whether skeletal muscle Ca2+ and K+ regulation might be abnormal in eight LTx and eight healthy controls. Peak oxygen consumption and arterialized venous plasma [K+] (where brackets denote concentration) were measured during incremental exercise. Vastus lateralis muscle was biopsied at rest and analyzed for sarcoplasmic reticulum Ca2+ release, Ca2+ uptake, and Ca2+-ATPase activity rates; fiber composition; Na+-K+-ATPase (K+-stimulated 3-O-methylfluorescein phosphatase) activity and content ([3H]ouabain binding sites); as well as for [H+] and H+-buffering capacity. Peak oxygen consumption was 47% less in LTx (P < 0.05). LTx had lower Ca2+ release (34%), Ca2+ uptake (31%), and Ca2+-ATPase activity (25%) than controls (P < 0.05), despite their higher type II fiber proportion (LTx, 75.0 +/- 5.8%; controls, 43.5 +/- 2.1%). Muscle [H+] was elevated in LTx (P < 0.01), but buffering capacity was similar to controls. Muscle 3-O-methylfluorescein phosphatase activity was 31% higher in LTx (P < 0.05), but [3H]ouabain binding content did not differ significantly. However, during exercise, the rise in plasma [K+]-to-work ratio was 2.6-fold greater in LTx (P < 0.05), indicating impaired K+ regulation. Thus grossly subnormal muscle calcium regulation, with impaired potassium regulation, may contribute to poor muscular performance in LTx.
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Affiliation(s)
- Michael J McKenna
- School of Human Movement, Recreation and Performance (FO22 Victoria Univ. of Technology, P.O. Box 14428, MCMC, Melbourne, Melbourne, Victoria 8001, Australia.
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Abstract
The act of breathing depends on coordinated activity of the respiratory muscles to generate subatmospheric pressure. This action is compromised by disease states affecting anatomical sites ranging from the cerebral cortex to the alveolar sac. Weakness of the respiratory muscles can dominate the clinical manifestations in the later stages of several primary neurologic and neuromuscular disorders in a manner unique to each disease state. Structural abnormalities of the thoracic cage, such as scoliosis or flail chest, interfere with the action of the respiratory muscles-again in a manner unique to each disease state. The hyperinflation that accompanies diseases of the airways interferes with the ability of the respiratory muscles to generate subatmospheric pressure and it increases the load on the respiratory muscles. Impaired respiratory muscle function is the most severe consequence of several newly described syndromes affecting critically ill patients. Research on the respiratory muscles embraces techniques of molecular biology, integrative physiology, and controlled clinical trials. A detailed understanding of disease states affecting the respiratory muscles is necessary for every physician who practices pulmonary medicine or critical care medicine.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Edward Hines, Jr. VA Hospital, 111 N. 5th Avenue and Roosevelt Road, Hines, IL 60141, USA.
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Van Der Woude BT, Kropmans TJB, Douma KW, Van Der Bij W, Ouwens JP, Koeter GH, Van Der Schans CP. Peripheral muscle force and exercise capacity in lung transplant candidates. Int J Rehabil Res 2002; 25:351-5. [PMID: 12451312 DOI: 10.1097/00004356-200212000-00014] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- B T Van Der Woude
- Department of Rehabilitation, University Hospital Groningen, The Netherlands.
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Estenne M, Maurer JR, Boehler A, Egan JJ, Frost A, Hertz M, Mallory GB, Snell GI, Yousem S. Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria. J Heart Lung Transplant 2002; 21:297-310. [PMID: 11897517 DOI: 10.1016/s1053-2498(02)00398-4] [Citation(s) in RCA: 949] [Impact Index Per Article: 43.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Affiliation(s)
- D L DeMeo
- Lung Transplant Program, Pulmonary and Critical Care Unit, Bigelow 808, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Abstract
Lung transplantation has become a viable treatment option for patients with end-stage lung disease. Donor selection and organ allocation must follow specific guidelines. Single, bilateral, and living-donor lobar transplantation have all been performed successfully for a variety of diseases. Complications include reimplantation response and airway complications. Rejection may occur in the hyperacute, acute, or chronic settings and requires judicious management with immunosuppression. Infection and malignancy remain potential complications of the commitment to lifelong systemic immunosuppression. Survival statistics have remained encouraging and continue to improve with experience. Improved exercise tolerance and quality of life have been demonstrated in the years following transplantation. Remaining obstacles include limited donor organ availability, long-term graft function, and patient survival. However, ongoing advances in immune tolerance and standardized training of physicians in the care of transplant patients should carry lung transplant forward in the twenty-first century.
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Affiliation(s)
- D L DeMeo
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114, USA.
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