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Pre- and Postoperative Pulmonary Rehabilitation for a COPD Patient Undergoing Bilateral Lung Transplant

Case Editor - Judd Flesch

Reviewed By Pulmonary Rehabilitation Assembly

Submitted by

Rebecca H. Crouch, PT, DPT, MS, CCS, FAACVPR

Director of Pulmonary Rehabilitation

Duke University Medical Center

Durham, NC

Brian Tiep, MD

Medical Director, Pulmonary Rehabilitation

City of Hope National Medical Center

Duarte, CA

Submit your comments to the author(s).

History

A 56-year-old man with severe COPD is listed for lung transplantation. He is a disabled brick mason who lives alone. He is hypercapnic and oxygen dependent: 3 L/min via nasal cannula at rest, 4 L/min with exercise and 2 L/min during sleep with bilevel PAP. He recently stopped smoking via ALA “Freedom From Smoking” administered by a pulmonary rehabilitation instructor. He has hypertension that is controlled with medication. His goals are to return to community activities, resume household chores and to become oxygen independent. The patient’s greatest physical difficulties are walking inclines, functioning in hot weather, showering and vacuuming. The patient reports intermittent cervical stiffness with his worse pain level at 5/10. Medications include diltiazem, aspirin, inhaled formoterol, furosemide, inhaled levalbuterol, inhaled mometasone, omeprazole, lisinopril and inhaled tiotropium.

This patient underwent preoperative pulmonary rehabilitation (12/20/07 – 02/05/08). Bilateral lung transplant was performed on 7/5/08. Postoperative pulmonary rehabilitation started 17 days after surgery (07/22/08 – 09/15/08).

Physical Exam

Rehabilitation physical evaluation: height: 6 ft., weight: 190 lbs. Diminished breath sounds are present throughout all lung fields. His joint range of motion is within normal limits and hamstring length is 80 degrees bilaterally. His strength is 4/5 throughout. His postural characteristics are a barrel chest with elevated shoulders. He demonstrates a fair diaphragmatic and good lateral costal expansion and a pursed lips breathing pattern while supine with supplemental verbal and tactile cues. In the sitting and standing positions, he demonstrates accessory respiratory muscle use of bilateral sternocleidomastoid, upper trapezii and scalene muscles. His gait is slow and steady.

Lab

Preoperative Data

Prerehabilitation   (Pretransplant)

Arterial Blood Gas:   (12/06/07)

FIO2 30%
pH 7.38
PCO2 72 mm Hg
PO2 53 mm Hg
Base Excess 14 mM/L
Bicarbonate 43 mM/L
CO2 Total 45 mM/L
Hemoglobin 14.2 g/dl
%O2 Hemoglobin 87.7 %
%CO Hemoglobin 1.8 %

Pulmonary Function Tests (PFT):  (12/06/07)

    Reference Best Predicted
FVC Liters 5.13 2.27 44 %
FEV1 Liters 4.02 0.48 12 %
FEV/FVC % 78 21  
FEF 25-75% L/sec 3.74 0.13 4 %
PEF L/sec 9.23 2.09 23 %
MVV L/min 152 14 9 %

6-Minute Walk Test:  (12/20/07)

  Prewalk Postwalk
Heart Rate 118 bpm 136 bpm
Blood Pressure 116/86 mm Hg 186/90 mm Hg
Oxygen Saturation 98% 93%
Oxygen 2 lpm 4 lpm

Rate of Perceived Exertion:

   
Breathing 0/10 8/10

Effort

0/10 6/10
Distance (feet)   1300
Number of rest stops   0
Ambulatory assistive device  

4-wheeled rolling walker

Postrehabilitation (Pretransplant)

Following 25 Sessions of Pulmonary Rehabilitation

6-Minute Walk Test:  (2/05/08)

  Prewalk Postwalk
Heart Rate 115 bpm 141 bpm
Oxygen Saturation 98% 94%
Oxygen 4 lpm 8 lpm

Rate of Perceived Exertion:

   
Breathing 0/10 8/10

Effort

0/10 8/10
Distance (feet)   1400
Number of rest stops   0
Ambulatory assistive device  

4-wheeled rolling walker

Postoperative Data

Arterial Blood Gas:   25 days after surgery  (7/30/08)

Patient Temperature 37.0
FIO2 21%
pH, Blood 7.36
PCO2 56 mm Hg
PO2 64 mm Hg
Base Excess 5 mM/L
Bicarbonate 32 mM/L
PCO2 Total 33 mM/L
Hemoglobin 12.7 g/dl
%O2 Hemoglobin 92.5 %
%CO Hemoglobin 1.4 %

Pulmonary Function Tests (PFT):  46 days after surgery  (8/20/08)

    Reference Best % Predicted
FVC Liters 5.11 3.29 64
FEV1 Liters 4.00 2.76 69
FEV/FVC % 78 84  
FEF 25-75% L/sec 3.70 3.44 93
PEF L/sec 9.20 7.90 86
MVV L/min 151 111 74

Pulmonary Function Tests (PFT):      1 year after surgery  (7/06/09)

    Reference Best % Predicted
FVC Liters 5.11 4.27 83
FEV1 Liters 4.00 3.48 87
FEV/FVC % 78 82  
FEF 25-75% L/sec 3.70 4.14 112
PEF L/sec 9.20 9.04 98
MVV L/min 151 142 94

Prerehabilitation (Posttransplant)

6-Minute Walk Test:  (7/22/08)

  Prewalk Postwalk
Heart Rate 100 bpm 118 bpm
Oxygen Saturation 98% 98%
Oxygen 0 0

Rate of Perceived Exertion:

   
Breathing 0/10 0/10

Effort

0/10 3/10
Distance (feet)   1500
Number of rest stops   0
Ambulatory assistive device  

4-wheeled walker

Following 23 Pulmonary Rehabilitation Sessions

Postrehabilitation (Posttransplant)

6-Minute Walk Test:  (9/15/08)

  Prewalk Postwalk
Heart Rate 108 bpm 118 bpm
Oxygen Saturation 98% 97%
Oxygen 0 0

Rate of Perceived Exertion:

   
Breathing 0/10 5/10

Effort

0/10 6/10
Distance (feet)   1600
Number of rest stops   0
Ambulatory assistive device  

none

Question 1

The preoperative role of pulmonary rehabilitation in lung transplant is which of the following:

References

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