care before and after

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186

ILung transplantation is a growing surgicaloption for patients with end-stage lung and

pulmonary vascular diseases. After

completing an extensive evaluation and

meeting the selection criteria, patients are

listed for either single or

bilateralsequential lung transplantation.

Immediate postoperative managementrequires detailed attention to fluid

management, monitoring for infection,

reperfusion injury, pulmonary hygiene, and

pain management.Length of stay depends

on the patients condition before transplant

and postoperative complications.

Discharge from the hospital can be as

early as 7 days after transplantation.

Newer immunosuppressive medications

offer more options for treating and

preventing rejection. Advanced practice

nurses, such as coordinators, case

managers, nurse practitioners, and clinical

nurse specialists, are uniquely positioned

to play key roles in coordinating the care of

transplant patients across settings and

both before and after the transplant

procedure.The perioperative needs of lung

transplant patients and the impact of this

complex procedure on the recipients and

familys quality of life merit furtherinvestigation by clinicians and researchers.

(KEYWORDS: lung transplantation, quality

of life, perioperative care, transplant nurse

coordinator, immunosuppressive

medications)

AACN Clinical Issues

Volume 12, Number 2, pp. 186201

2001, AACN

Lung transplantation provides a last-resorttherapy for selected individuals who haveend-stage respiratory disease, a life ex-pectancy of 3 years or less, and an unaccept-able quality of life (QOL).1 The end-stagerespiratory conditions may be the result ofunderlying diseases that can be classified un-der four major categories: suppurative (e.g.,

cystic fibrosis), obstructive (e.g., emphy-sema), restrictive (e.g., pulmonary fibrosis),and vascular (e.g., pulmonary hypertension).This article presents a brief historic overviewof lung transplantation, describes care be-fore and after lung transplant, and identifiesnursing diagnoses2 that may be applicablefor each stage of care. In addition, researchon the quality of life of lung transplant pa-tients is summarized, and implications forpractice and research are discussed.

The first lung transplant procedure wasperformed in 1963, and the patient survivedonly 18 days.3 It was not until after improve-ments in immunosuppressive medications(e.g., introduction of cyclosporine) and surgi-cal techniques were achieved in the early1980s that the number of lung transplant pro-

Care Before and AfterLung Transplant andQuality of Life ResearchDorothy M. Lanuza, PhD, RN, FAAN,* and Mary A. McCabe, MS, RN

From *Niehoff School of Nursing, Loyola Universityof Chicago, and Nursing Department & Lung Trans-plant Program, Foster G. McGaw Hospital, Loyola Uni-

versity Medical Center, Maywood, Illinois.

Reprint requests to: Dorothy M. Lanuza, PhD, RN,FAAN, Niehoff School of Nursing, Loyola UniversityMedical Center, Building 105, Room 2859, 2160 S. First

Avenue, Maywood, IL 60153.


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Vol. 12, No. 2 May 2001 LUNG TRANSPLANT CARE 187

cedures increased markedly. Between 1988and 1999, more than 7,033 transplant proce-dures were performed.4Advances in surgicaltechniques, organ preservation methods, and

immunosuppressive medications have led tosignificant improvements in lung transplantpatients survival rates that average approxi-mately 76%, 58%, and 44% for 1, 3, and 5years after transplant, respectively.58

The early lung transplant procedures wereprimarily heartlung transplants (HLTs),which involved transplantation of a donorheart and both lungs, or double-lung trans-plants (DLTs), which involved transplantationof both donor lungs en block with a single

tracheal anastomosis. The volume for HLTand DLT procedures peaked in 1989 becauseof improvements in surgical techniques andthe development of new surgical procedures.Currently, most lung transplantations are ei-ther bilateralsequential lung transplants(BSLTs) or single-lung transplants (SLTs). TheBSLT procedure involves two bronchial anas-tamoses and was shown to decrease the inci-dence of airway ischemia and bronchial com-plications associated with older surgicaltechniques (e.g., DLT using tracheal anasta-moses).3 The BSLT procedure involves trans-planting two donor lungs sequentially. First,one of the recipients native lungs is removed,followed immediately by transplantation of adonor lung; then the other native lung is ex-planted and the second donor lung is im-planted. Each donor lung is anastomosed tothe main stem bronchus.9 The SLT procedureis performed when the transplant team deter-

mines that one lung would be sufficient toprovide the patient satisfactory pulmonaryfunction.10 The SLT involves the replacementof one of the patients native lungs with adonor lung. It is used for patients with alltypes of lung disease, except septic lung dis-eases, such as cystic fibrosis and bronchiecta-sis.1 A bilateral lung transplantation is indi-cated for cystic fibrosis and bronchiectasispatients to avoid the risk of overwhelming in-fection that would occur if one of the recipi-

ents septic lungs were left in place.

Care Before Transplant

When patients with end-stage respiratoryconditions are referred to transplant centers,

they undergo a thorough evaluation to de-termine whether they meet the selection cri-teria for lung transplantation (see Table 1).While the evaluation workup may vary from

center to center, usually a complete historyand physical examination, laboratory tests,and diagnostic procedures (especially of theheart, kidney, and lungs) are performed. Inaddition, a social worker or psychologist in-terviews the patient to assess the patientspsychological, social (e.g., patients supportsystem), and financial status. When the ini-tial evaluations are completed, a multidisci-plinary team (e.g., lung transplant surgeon,lung transplant pulmonary physician, trans-

plant nurse coordinator, social worker, anddietician) meets to consider the findings anddetermine whether the patient qualifies as acandidate for lung transplantation.

If the selection criteria are successfullymet, than the patients name is added to thetransplant waiting list and the individual be-comes a lung transplant candidate. Since thedemand for donor lungs far exceeds the sup-ply, the waiting time for a suitable donor or-gan is increasing. As of September 1998, themedian waiting time for candidates 18 to 64years of age was 619 days.7 This prolongedwaiting time currently results in a mortalityrate of 11% before transplant.7

During the waiting period before the trans-plant, the goal is to provide the patient withoptimal treatment for the underlying respira-tory disease and any co-morbid medical con-ditions. If indicated, psychosocial conditionsalso should be addressed during this period.

Anxiety and depression often are associatedwith end-stage respiratory conditions, such aschronic obstructive pulmonary disease(COPD).1116 Since the period before the trans-plant is laden with uncertainty and concernsabout the future, it is not surprising that lungtransplant candidates may experience anxietyand depression during this time. In one study,21% of the lung transplant candidates (n= 57)developed a psychiatric disorder (e.g., an ad-justment problem with anxious mood) while

awaiting lung transplantation.17 Thus, care be-fore transplant is aimed at treating the psy-chophysiological symptoms and complica-tions of the patients underlying respiratorycondition and existing co-morbidities. Refer-rals are made to psychologists, social workers,other health professionals, and community re-


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188 LANUZA AND MCCABE AACN Clinical Issues

sources, as necessary. In addition, the lungtransplant candidate is encouraged to strive toachieve optimal nutritional and physical activ-ity status within the limitations of his or hercondition. Nursing diagnoses approved by theNorth American Nursing Diagnosis Associa-tion (NANDA) for lung transplant patients inthe pretransplant period are listed in Table 2.

Nutrition

Nutrition can significantly impact immedi-ate postoperative morbidity and mortality.

Malnutrition can increase the patients riskof developing airway infection through itsadverse effect on the immune system.18,19

Poor nutrition can also unfavorably affectrespiratory muscle function by reducing di-aphragmatic muscle mass and strength.20,21

Thus, achieving an optimal nutritional sta-tus before transplant is considered criticalto obtain a successful outcome after trans-plantation. In fact, a patient may be takenoff the transplant waiting list and deniedconsideration for transplantation if his orher nutritional status does not meet the

TABLE 1 International Guidelines for Selectionof Lung Transplant Candidates22

Selection Criteria

Patient has a diagnosis of end-stage chronic respiratory diseaseunresponsive to available medical or surgical treatment, declining function,and limited survival.

Age: approximately 55 years for heartlung transplants; approximately 65years for single lung transplant, and approximately 60 years for bilateral lungtransplants.

Has no dysfunction of other major organs besides the lung (e.g., renaldysfunction with creatinine clearance 50 mg/mL/min)

Is not infected with human immunodeficiency virus

Has no active malignancy within the past 2 years with the exception of basalcell and squamous cell carcinoma of the skin

Does not have hepatitis B antigen positivity

Does not have hepatitis C with biopsy-proven liver disease

Has no progressive neuromuscular disease

Relative Contraindications to Transplant Selection (candidates need to beconsidered on an individual basis)

Medical condition without end-organ damage (e.g., hypertension, diabetesmellitus)

Symptomatic osteoporosis

Severe musculoskeletal disease affecting the thorax (e.g., kyphoscoliosis)

Nutritional states 70% or 130% ideal body weight

Not free of substance addiction (i.e., tobacco, street drugs, alcohol, etc.) forat least 6 months

Poorly controlled major psychoaffective disorder

Inability to comply with complex medical regimen or documented history ofnoncompliance

Requires invasive ventilation

Systemic disease (e.g., collagen vascular processes and diabetes mellitus)

Colonization with fungi or atypical mycobacteria

Note: The following are notconsidered contraindications for transplant:

Active infection with systemic symptoms (e.g., Mycobacterium tuberculosis)

Current use of corticosteroids, however, must attempt to discontinue thesedrugs or at least reduce the prednisolone or prednisone dosage to20 mg/day64


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transplant criteria. While the range mayvary among transplant centers, many pro-grams require lung transplant candidates toweigh between 70% and 130% of their idealbody weight (IBW) before they are eligiblefor transplantation.22 Therefore, a thoroughnutritional assessment is part of the lungtransplantation evaluation process. The ini-tial assessment includes the determinationof the patients nutritional history, anthro-pometric measurements, biochemical mark-ers of nutritional status, as well as currentand overall nutritional status. At the conclu-sion of this assessment, the dietitians rec-

ommendations and goals are reviewed withthe patient, and target dates are set for at-taining these goals. Subsequent assess-ments are conducted thereafter to evaluatethe patients progress toward reaching thenutritional goals. For candidates who weighless than 70% of IBW, nutritional interven-tions may include the placement of a feed-ing tube and a daily infusion of enteralfeedings, as well as requiring the patient torecord weekly weights and keep a daily nu-

tritional log. For those candidates weighinggreater than 130% of IBW, a weight-lossprogram with a goal to achieve weight lossof approximately 1 to 2 pounds per week isdiscussed. A target weight loss or gain mustbe achieved before the candidate will belisted for transplantation.

Rehabilitation

Pulmonary rehabilitation has been shown toprolong survival in patients with COPD.23

Thus, rehabilitation is started before trans-plantation to improve the transplant candi-dates overall physical condition, maximizeactivity tolerance, improve endurance, anddecrease co-morbidities (e.g., obesity). Opti-mizing physical and emotional health throughexercise also is thought to increase the poten-tial for a positive outcome after transplanta-tion.24 Although exercise programs do notnecessarily change lung function, researchfindings indicate they improve patients abili-ties to carry out activities of daily living andincrease their endurance.24 The duration andintensity of the exercise vary, depending onthe patients severity of illness and motiva-tion.24 Typically, a patient participates in a su-pervised exercise program three to five timesa week, focusing on large muscle groups. Inaddition, portions of the exercise program arecontinued at home. The lung transplant can-didates participation provides an indication

of motivation, as well as the likelihood thathe or she will participate in a rehabilitationprogram after transplantation.

Patient/Family Education

In addition to nutrition and physical therapyassessments before a transplant, a compre-

TABLE 2 Nursing Diagnoses for Lung TransplantPatients in Pretransplant Period*2

Risk for anxiety related to: threat of change in health status, role function, eco-

nomic status

Risk for impaired social interaction related to: impaired communication, im-paired physical mobility

Powerlessness related to: lifestyle of helplessness

Risk for inef

fective family coping: compromise related to inadequate or incorrectinformation or understanding by primary person; temporary family disorganiza-tion and role changes; other situational crises

Impaired gas exchange related to: underlying respiratory disease or condition

Activity intolerance related to: generalized deconditioning, dyspnea, poor oxy-genation, etc.

Altered nutrition related to: inability to ingest, digest, or absorb nutrients; insuffi-

cient or excessive nutritional intake related to metabolic needs

Risk for activity intolerance related to: general weakness, sedentary lifestyle, im-balance between oxygen supply/demand, deconditioned status

Self-Care deficit related to: physical impaired mobility

*Approved by the North American Nursing Diagnosis Association.


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hensive teaching session is conducted forthe candidate and his or her significantother(s). During this educational session,many topics are addressed (Table 3). Theoral presentation and discussion are rein-forced with written patient education materi-als. In addition to patient teaching, the im-portance of strong family/social support

systems also is stressed. Therefore, lungtransplant candidates and the members oftheir support system are invited to attendand participate in group support meetings.At our institution, three support meetings areheld each month; however, the frequencyand format for support meetings vary at eachtransplant center.

Early Management

After Transplant

As indicated earlier, before the recipient fi-nally undergoes lung transplantation, he/shemay experience multiple admissions for theprocedure. It is not uncommon for trans-plant surgery to be cancelled after a patientis admitted to the hospital because the surgi-cal team may determine that the donor lungsare unsuitable due to irreversible damage orpoor function (e.g., multiple lung contu-

sions, aspiration, or pneumonia).After patients undergo lung transplanta-

tion, they are usually transferred from theoperating room to a private room in a surgi-cal intensive care unit. Much of their imme-diate postoperative care is similar to othercardiothoracic surgical patients. The lung

transplant recipients require close monitor-ing of their overall fluid status throughouttheir hospitalization. The initial fluid assess-ment is done every 15 minutes along withcontinuous blood pressure monitoring, oxy-gen saturation monitoring, and heart rateand rhythm monitoring. The recipient mayor may not have a pulmonary artery catheter

in place, but he/she will have intravenousaccess via a large bore catheter that providesa route for the administration of fluid, bloodproducts, and vasopressors, as needed. AFoley catheter will be in place so that hourlyurine output can be determined, with thegoal of keeping urine output at 30 mL/houror more. Electrolytes will be monitoreddaily. The SLT recipient will have either aright or left posterolateral thoracotomy inci-sion with two chest tubes on the side of the

transplanted lung. The BSLT recipient willhave an anterio-transverse thoracoster-notomy with four chest tubes inserted, twoon the left and two on the right side of thechest. The chest tubes will be connected to20-cm water suction and monitored every 15minutes for type and amount of drainage. Ifthe chest drainage exceeds 100 mL/hr afterthe first 2 to 3 hours and is primarily san-guineous in nature, the surgeon is notifiedand the patients blood loss is closely moni-tored to determine whether the chest shouldbe explored for bleeding. Table 4 lists nurs-ing diagnoses for lung transplant patients inthe postoperative period.

Patients will be intubated and receive vol-ume-controlled ventilation after the trans-plant procedure. The length of time patients

TABLE 3 Topics Addressed During Teaching Sessions forLung Transplant Candidates and Their Families

The procedure the candidate will follow when notified of the possibility that a

suitable donor organ is available

The possibility that the candidate will experience multiple admissions for poten-tial transplantation before suitable donor lungs are found

Potential and expected surgical and medical complications associated withlung transplantation

The post transplant medications that are commonly used, including their names,dosages, administration frequency, and common side effects

Expected hospital length of stay; the usual out-patient follow-up schedule; thefrequency of scheduled transbronchial bronchoscopy and biopsies

The potential need for in-patient rehabilitation and home care


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remain intubated may vary among patients;however, attempts will be made to extubateall patients as soon as possible to preventbarotrauma. Barotrauma, which is caused byover-distension of alveoli with excessive ven-tilatory volume or pressures, can affect alltransplant patients but is more likely to de-velop in patients with COPD who undergoSLT (i.e., the COPD patients native lung isespecially vulnerable to barotrauma).25 Oncethe patient is successfully extubated, aggres-sive pulmonary hygiene is very important.The patient will need to actively participatein coughing and deep breathing to facilitateairway clearance and prevent atelectasis andpneumonia. These exercises will assist thepatient in expectorating secretions and spu-tum, which are often thick and tenacious.Adequate pain management is essential if thepatient is to fully engage in these activities.

Epidural catheters or patient-controlled anal-gesia are frequently used to manage earlypostoperative pain. If pain or narcotic man-agement is still needed after hospital dis-charge, the patient is referred to an outpa-tient pain management program.

Length of Stay

The length of hospitalization is influenced bythe patients overall condition before the

transplant, underlying lung disease, cardiacfunction, nutritional status, age, type of trans-plant (SLT or BSLT), rehabilitation potential,perioperative complications, and supportsystems. An uncomplicated lung transplantrecipient can be discharged from the hospitalas early as 7 days after transplantation. The

current trend of earlier hospital dischargeprotects the immunocompromised transplantrecipient from the risk of nosocomial infec-tions. An earlier hospital discharge alsomeans that the costs related to the patientslung transplantation will be decreased.

Preparation for Discharge

To discharge patients early and provide con-tinuity of care, a thorough, multidisciplinarydischarge plan needs to be in place. For theplan to be successful, it is imperative to in-clude the patient and family in the planningprocess. Good communication and coordina-tion among the hospital transplant team,home healthcare agency, home intravenousprovider, durable medical equipment agency,and the lung transplant recipient and his orher supporters are fundamental to the success

of the plan. The anticipated date of dischargeshould be discussed with the patient and thepatients supporters within the first 36 hoursafter the transplant procedure. This advancednotification will allow the healthcare team tomake the necessary arrangements for the pa-tients discharge and give the patient andmembers of his or her support system time toadjust to the idea of the patient going home.In addition, it provides the patients care-giver(s) time to make the necessary changes

in their work schedules.An evaluation and a treatment plan for

the patient are developed within 48 hours ofthe transplant procedure. Preparing the pa-tient for discharge includes providing in-structions about all postoperative medica-tions that the patient will be taking at home

TABLE 4 Nursing Diagnoses for Lung Transplant Patients inthe Postoperative Period2

Risk for fluid volume imbalance related to: transplant surgical procedure

Risk for fluid volume deficit related to: massive blood loss

Risk for electroly

te imbalance related to: surgical procedure, altered fluid balance

Potential for infection related to: surgical procedure, decrease respiratory ciliarysaction, inadequate secondary defenses, chronic disease, invasive procedures

Ineffective airway clearance of retained secretions related to: slowing ofmucocilliary clearance

Pain related to: surgical and diagnostic procedures, coughing and deep breathing

Knowledge deficit related to: lack of recall, information misinterpretation, cogni-tive limits


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and the spirometry device the patient willuse to monitor pulmonary function. In addi-tion, the patients ability to monitor his or

her blood pressure, temperature, and weightand to identify signs and symptoms that maybe indicative of an infection or rejection (seeTable 5) is reviewed. The recipient also is as-sessed to determine whether physical, occu-pational, or other skilled services will beneeded after discharge from the hospital.

The patients insurance case manager willneed to be informed of the anticipated dateof discharge as soon as possible. The inpa-tient transplant nurse coordinator (TNC)

communicates with the insurance case man-ager to identify the appropriate home careagency, outpatient pharmacy, durable med-ical equipment, and intravenous provider. Tofind a home care agency that can meet theneeds of the patient, it may be necessary forthe TNC to seek a vendor not listed as a pre-ferred provider of the patients insurancecompany. When this occurs, a letter of med-ical necessity may be required from the trans-plant center to support the referral. To ensuresuccess with obtaining all prescribed medica-tions, early communication with an outpa-tient pharmacy is essential, because many ofthe newer medications (e.g., mycophenolatemofetil [Cellcept, Roche Laboratories, Nutley,NJ] and sirolimus [Rapamune, Wyeth-AyerstLaboratories, Philadelphia, PA]) are not typi-

cally kept in stock at most pharmacies. Usu-ally, pharmacies, including major chains, re-quire a 24-hour notice to place orders withtheir suppliers. During state, federal, or other

recognized holidays, additional time may beneeded to fill the order.

Transplant Nurse Coordinators

The patients TNC plays a key role in coordi-nating the patients care among the many dis-ciplines and healthcare providers. The role ofthe TNC varies among transplant centers.One TNC may be responsible for coordinat-ing patient care for all phases of the trans-

plantation, or the role may include two TNCswith responsibilities divided by inpatient ver-sus outpatient or status before versus aftertransplantation. In any case, the TNC main-tains close communication between the pa-tient and the home care agency by way ofdaily telephone calls to the recipient andtelephone calls from the visiting home carenurse. The TNC ensures that the lung trans-plant recipient, significant others, and home

care nurse understand the process for obtain-ing 24-hour access to the hospital transplantteam. The TNC is also responsible for review-ing laboratory results with the physician andnotifying the patient of laboratory and/orbronchoscopy results. The TNC also coordi-nates the home care intravenous treatmentthat is prescribed if the laboratory tests orbronchoscopy results warrant intervention.

Long-Term ManagementAfter Transplant

Home Care Nurse

Home care visits are part of the follow-upprotocol of our institution, but this practicemay vary among transplant centers. Thehome care nurse usually makes the initialhome visit to the patient within 24 hours of apatients discharge from the hospital. The

nurse conducts a standard patient and homeassessment. In addition, a thorough pul-monary and cardiac assessment is performedand the surgical wound, chest tube site(s),and intravenous site are inspected. Thenurse evaluates the patients fluid balance,pain status, understanding of medications, as

TABLE 5 Signs and SymptomsSuggestive of Infectionor Acute Rejection AfterLung Transplant

Low grade fever41

Decrease in FEV1 10%41

Arterial blood gas values that indicatehypoxemia41 or decreased oxygen saturation63

Cough1, 41

Dyspnea1, 41

Presence of rales or wheezes41

Change in chest x-ray41

Reduced exercise tolerance41

New or increased fatigue63

Pleuritic chest pain

New or increased productive sputum

FEV1=forced expiratory volume in 1 second.


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well as the patients and significant othersability to correctly measure blood pressure,temperature, and weight and to use the re-mote spirometer to measure pulmonary

function. If small children are in the home,an inspection of where the medications willbe stored also is done to ensure that the pa-tients medications are kept safely out ofreach. Blood samples for laboratory testsmay need to be obtained within the first 72hours of discharge. The laboratory tests mayinclude a basic metabolic panel, magnesiumlevel, complete blood count, and a troughtacrolimus or cyclosporine level. Whentrough blood levels are needed, the timing

of the nursing visit is important because theblood sample will need to be obtained atleast 30 to 60 minutes before the regularlyscheduled morning immunosuppressivemedication dose. The home care nurse visitsthe patient at least once, or as often asneeded, until the patient is seen in the clinicby the transplant physician approximately 3to 4 days after discharge. The frequency ofsubsequent home care visits is determined atthat clinic visit.

Risks for Infection and Rejection

During the first 6 months after transplant,the greatest threat to survival is infection,especially bacterial, but also cytomegalo-virus (CMV) infections.26,27 Patients withproven CMV pneumonitis were reported tobe three times more likely to develop oblit-erative bronchiolitis than those who are

CMV negative.28

Obliterative bronchiolitis isconsidered the most significant, long-termlung transplant complication, and the pri-mary determinant of long-term survival.29

Frequent, severe episodes of acute rejectionare considered among the most importantrisk factors that lead to the development ofobliterative bronchiolitis; however, airwayischemia and CMV disease may also play arole.26,30 When obliterative bronchiolitis isdetected early, it is more responsive to aug-

mented immunosuppression medications.30Thus, the aims of treatment after transplan-tation are to prevent or provide early treat-ment for infection and rejection episodesand treat existing co-morbid medical condi-tions and symptoms. In addition, it is im-portant for healthcare workers to promote

the transplant recipients treatment adher-ence, participation in physical rehabilita-tion, achievement of a good nutritional sta-tus, and a satisfactory QOL.

Self-Monitoring and Treatment Adherence

To prevent infection and rejection episodes,the patient must assume the responsibilityfor carefully adhering to his or her trans-plant treatment regimen. It is crucial thatthe patient understands the importance oftaking immunosuppressive medications asprescribed and discussing with the physi-cian or nurses any difficulties they have ad-

hering to the treatment regimen. Failure totake immunosuppressive medications canbe life threatening. In addition, other drugsare prescribed to prevent or treat infections(e.g., antiviral, anti-fungal, antibiotics) andto treat pre-existing or new co-morbid med-ical conditions after transplantation (e.g.,diabetes, hypertension). It is also criticalthat the patient and his or her significantother appreciate the need for regular, con-sistent, self-care monitoring (e.g., spirome-try, blood pressure, temperature, and heartrate measurements), exercise, and good nu-trition. The patient needs to be instructed tonotify the physician of changes in the pat-terns and trends of the physiological mea-surements, problems with excessive weightgain or loss, and new, bothersome symp-toms. Table 6 lists nursing diagnoses forlong-term lung transplant patients.

Physical Activity

Physical activity is very important aftertransplantation. The aggressive rehabilita-tion program that was initiated before trans-plantation needs to be continued aftertransplantation until optimal recovery hasbeen achieved. If the rehabilitation programis in a different setting, it is important forthe physical therapist to try to determinewhat type of pulmonary rehabilitation pro-

gram the lung transplant recipient partici-pated in before transplantation and how therecipient responded to activity while in theacute care setting. An exercise programconsisting of at least 30 minutes of continu-ous exercise four or five times a week isthen developed for the patient, as toler-


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ated.31 Limiting factors to exercise changeafter transplantation. It is no longer pul-monary, but rather peripheral factors, suchas abnormal neuromuscular function andmuscular deconditioning, that limit exercise

performance.3234

Improvement in exercisecapacity may continue throughout the firstyear after transplantation; however, usuallythe greatest improvement is manifestedwithin the first 3 months.35,36And yet, stud-ies of lung transplant recipients aerobicand peak exercise capabilities in the firstyear were reported to be considerably lessthan untrained controls, but sufficient to al-low moderate levels of work, exercise, anda comfortable lifestyle.32,37 Most transplant

recipients undergo pulmonary rehabilita-tion within the first 3 months of their trans-plant. Recently, the effects of aerobic en-durance training beyond the first 3 monthsafter transplantation were investigated andthe findings showed increases in the lungtransplant recipients exercise capacity.38

Further studies are needed to determinewhether longer periods of training wouldresult in additional improvements.

Nutrition

Good nutrition is encouraged after trans-plantation, but it is not usually as serious aconcern as it is before transplantation. If thelung transplant recipient is considered un-dernourished, it may be necessary to initi-

ate enteral feedings, which may continuefor 6 to 8 weeks after transplantation or un-til nutritional stability is attained. In con-trast, the recipient may experience weightgain after transplantation without an in-

crease in their caloric intake before trans-plantation. This could be due to the markeddecrease in the patients work of breathingthat decreases the need for the amount ofcalories before transplantation. Or, it couldbe that weight gain or loss after transplanta-tion may be due, in part, to the excessivehunger or anorexia side effects of certainimmunosuppressive medications. Strategiesfor achieving optimal nutritional status andweight management should be developed

for lung transplant recipients as needed.

Immunosuppressive Medications

Many of the symptoms experienced by pa-tients after transplantation are thought to bedue to the side effects of their immunosup-pressive medications. The following sectionbriefly discusses the current and new im-munosuppressive and antiviral medicationsprescribed to prevent organ rejection.

Advances in the development of immuno-suppressive medications have played a keyrole in improving survival rates. These med-ications can be divided into the followingcategories: corticosteroids, calcineurin in-hibitors, antimetabolites, and monoclonal

TABLE 6 Nursing Diagnoses for Long-TermPost-Lung Transplant Patients2

Risk for body image changes related to: psychosocial, biophysical,

cognitive/perceptual, illness, illness treatment, surgery

Altered protection related to: immunosuppressive therapy

Noncompliance related to: knowledge deficit, health beliefs, client value system

Risk for opportunistic infection related to: abnormal immune function blood pro-files, immunosuppressive medications

Impaired health maintenance related to: long-term treatment after transplanta-tion, diet, signs of rejection, use of medications

Ineffective family coping: compromise related to inadequate or incorrect infor-mation or understanding by primary person; temporary family disorganizationand role changes; other situational crises

Risk for activity intolerance related to: deconditioned status

Altered nutrition related to: inability to ingest, digest, or absorb nutrients; insuf-ficient or excessive nutritional intake related to metabolic needs


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and polyclonal antibodies (Table 7). Theseagents are prescribed in several differentcombinations to achieve a rejection-freestate. The combination of these therapies is

as much an art as it is a science. The drugregimen varies based on the type of rejectionthe recipient experiences, whether drug tol-erance develops, and the recipients re-sponse to alternate therapies. Although eachtransplant center follows center-specific pro-tocols for initiating and adjusting immuno-suppressive regimens, most centers followsimilar guidelines as outlined in this article.Examples of triple maintenance immunosup-pressive medications regimens are shown in

Table 7.

Steroids

Corticosteroids (anti-inflammatory steroids)have been a mainstay in transplantation toaugment immunosuppression by inhibitingthe production of T-cell lymphokines.39,40

Methylprednisolone (Pharmacia and Upjohn,Inc., Peapack, NJ) and prednisone are usedboth intraoperatively and after transplanta-tion (see Table 7). The intraoperative dose ofmethylprednisolone is given after the anas-tomosis of the first bronchus. It is also indi-cated as treatment for acute rejection diag-nosed either clinically or by tissue biopsy.Prednisone (Table 7) is initiated on the sec-ond postoperative day (if the patient is ableto take oral medications) and given every 12hours, then gradually reduced to daily at thetime of discharge. There are many potential

side effects associated with this drug (Table7), and patients need to be informed aboutwhat to expect. Since the side effects areusually dose-dependent, as the dose de-creases so should the side effects.

Calcineurin Inhibitors

Cyclosporine (CSA) and tacrolimus (FK506,Prograf) are examples of immunosuppres-sant medications that prevent organ rejection

by inhibiting calcineurin activity and thus in-terfering with the function of interleukin-2(IL-2) (Table 7). Cyclosporine blunts the acti-vation of lymphocytes and inhibits the pro-duction and release of IL-2.39,41 Tacrolimus, afungal macrolide, has an action similar toCSA, in that it also impairs T lymphocyte ac-

tivation and proliferation by connecting to T-cellbinding proteins, preventing the synthe-sis of IL-239,41 and inhibiting cell-mediatedimmunity.42 Tacrolimus has been shown to

significantly decrease the incidence of acuterejection41 and may be more effective thanCSA in some instances.

Hausen and Morris42 report that the stan-dard triple-drug immunosuppressive regi-men (CSA, azathioprine, and prednisone)has failed to prevent acute and chronic rejec-tion episodes in many lung transplant recipi-ents, resulting in incidence rates that arehigher for lung transplant recipients than forany other solid organ transplant group. Cur-

rently, there is an increasing trend to replaceCSA with tacrolimus because the latter drugproduces significant reductions in acute andchronic rejection episodes and decreases theincidence of infection. Although researchhas shown that the survival rates did not dif-fer significantly between lung transplant re-cipients receiving CSA or tacrolimus, the de-velopment of obliterative bronchiolitis wassignificantly (P= 0.025) less in the tacrolimusgroup.43,44

Antimetabolites

Antimetabolites (see Table 7) such as aza-thioprine (Imuran), methotrexate (BarrLaboratories, Inc., Pomona, NY), and my-cophenolate mofetil (Cellcept) promoteimmunosuppression by interfering withDNA and RNA synthesis, which results inthe inhibition of the proliferation of both T

and B lymphocytes.39 In the past, azathio-prine, which may cause liver dysfunction,was the most frequently used antimetabo-lite. More recently, there is a growing inter-est in mycophenolate mofetil, which is re-ported to decrease the risk of first rejectionby 50% and have only minor toxicity.39

Monoclonal Antibodies

Monoclonal antibodies, including muro-

manab-CD3 (Orthocolne OKT 3, OrthoBiotech, Inc., Raritan, NJ), basiliximab(Simulect, Novartis, Summit, NJ), da-clizumab (Zenapax, Roche Laboratories,Nutley, NJ), and sirolimus (Rapamune) arerelatively new medications, and they areused at some transplant centers as induc-


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12/16


TABLE7

T

ripleImmunosuppressive

Therapy(Continued)

Drug

Dose*

CommonAdverseEffects

DrugInteractions

Azathioprine

Do

seisthesameintravenouslyAlo

pecia,myelosuppression(e.g.,

leukopenia,anemia

Whengivenwithallopurinola

marked

(Imuran)

ororally22.5mg/kg/day

thrombocytopenia),hepatotoxicity,

infection,gastrointestinal

reductioninazothioprinedo

seage

disturbance(nausea,vomiting,d

iarrhea),malignancy

isneeded.

Mayleadtoanemiaand

leukopeniawhengivenwith

ACE

OR

inhibitors;synergisticwitho

therbone

marrowsuppressants.

Mycophenolate

250mgtwicedaily.

Ac

ne,anxiety,artrhythmias,abdom

inalpain,

bodyweightchanges

Noclinicallysignificantinterac

tions.

mofetil

Increasethedose

confusion,cough,

depression,dyspnea,edema,electrolyte

Ifrenalimpairmentispresentand/or

(Cellcept)

by250mgtwicedaily

imbalance,elevatedcreatinine,depression,

fever,nausea,

ifpatientisoneitheracycloviror

every3daysuntilagoal

vomiting,constipation,

diarrhea,

hepatotoxicity,

hyperlipidemia,

gancyclovir,

thedrugconce

ntrations

of10001500mgtwice

hyperglycemia,

hypertension,

hy

potension,

infection,

insomnia,

ofmycophenolatemofetilandthese

dailyisreached.

muscleweakness,myelosuppression(e.g.,

leukopenia,anemia),

drugsmayincrease.

Avoiddrugs

nephrotoxicity,neurotoxicity(trem

ors,seizures,

headache,),skin

(e.g.,cholestyramine)whichinterfere

changes,pain

withenterohepaticcirulation

and

antacidswithmagnesiumand

aluminum

hydroxidewhichmay

decrease

absorption.

ACE=angiotensin-con

vertingenzyme.

*Drugdoselungtransp

lantprotocolusedatLoyolaUniversityMedicalCenter,Maywood,

Illinois.

Doserangemayvaryacrosstransplantcenters.

Sources:Pirschetal.3

9anddruginsertinformationfrom

the

following:Cyclosporine(Neoral,San

dimmune),Novartis,

Summit,

NJ,

1998;Tacrolimus(FK506,

Prograf),

Fujis

awa,

Deerfield,

IL,

1998;Azathioprine(Imuran),FaroPharmaceuticals,

Inc.,

Bedminster,NJ,

2000;Prednisone,R

oxaneLaboratories,

Columbus,

OH,

2000;Mycophenolatemofetil(Cellcept),

RocheLab-

oratories,

Nutley,NJ,1

999.

Boldsymptomsaresy

mptomsmostfrequentlyreported.


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tion therapy and also to treat refractorychronic rejection of transplanted organs. In-duction therapy, an additional step that istaken to prevent organ rejection, involves

the administration of non-maintenance im-munosuppressive medication for a specificnumber of doses, with the first dose givenbefore implantation. Monoclonal antibodiesprevent rejection of transplanted organsand promote immunosuppression by inter-fering with antigen recognition and withthe IL-2 receptor alpha chain of activatedT lymphocytes.39Although sirolimus is clas-sified as a macrolide antibiotic, it has astructure similar to tacrolimus but its mode

of action is different.39,45 When sirolimuswas given with CSA, phase II clinical trialsshowed that the addition of sirolimus led toa decrease in acute rejection rates from 40%to less than 10%.45

Polyclonal Antibodies

Antithymocyte globulins, which are derivedfrom either equine (ATGAM, Pharmacia andUpjohn) or rabbit (Thymoglobulin, Sang-Stat, Fremont, CA) sources, are polyclonalantibodies. These medications are usedprophylactically to delay the first onset ofacute rejection and for the reversal of acuterejection. They produce a decrease in Tlymphocytes through the interaction of anti-bodies with antigens.39

Quality of Life

As the preceding discussion indicates, it isclear that lung transplantation is effective inimproving survival in certain patients withend-stage respiratory disease.4Yet, there isvery little information on the impact of thisprocedure on the quality of the recipientslife and function.

A review of QOL studies (19882000)4658

conducted on lung transplant candidates andrecipients indicates that lung transplant recip-

ients generally report a significantly betterQOL than lung transplant candidates.59 How-ever, only seven of the QOL studies used alongitudinal design,4749,53,55,58,60 following thesame subjects prospectively from before toafter transplantation. In one50 of the threestudies50,53,61 that examined symptoms of

lung transplant patients, shortness of breath(SOB) with activity was reported to be a fre-quently occurring and distressing symptomby one third of the 48 subjects. Since some

patients may not anticipate that some respira-tory symptoms, such as SOB with activity,may still exist after transplantation, thesefindings need to be shared with them. It isvery likely that the SOB with activity and ex-ercise after transplantation limitations are dueprimarily to general deconditioning ratherthan to centrally impaired respiratory func-tion.34When the symptoms of the total sam-ple were examined, general muscle weak-ness, fatigue, changed facial and bodily

appearance, overeating, and hirsutism alsowere reported to be frequently occurring anddistressing symptoms.

Lung transplant patients are a heteroge-neous group. Subgroup differences (i.e.,gender, underlying diagnosis, type oftransplant procedure) in mortality rates4

and symptom experiences have been re-ported.50,62 Yet, only one62 of the threestudies that examined symptoms of lungtransplant patients reported subgroupfindings. While many symptoms werecommon across the subgroups, in generalfemale lung transplant recipients reportedmore symptoms to be frequently occur-ring and distressing than males (e.g.,changed facial appearance, excessive hairgrowth, tremors, and heart palpitations).Men, on the other hand, reported moredistress associated with sexual problems.Patients who underwent SLT reported

more symptom frequency and distress(e.g., SOB with activity, bruising, fever)than those who underwent BSLT proce-dures. Finally, patients with conditionsother than cystic fibrosis as their underly-ing respiratory condition reported morefrequently occurring and distressingsymptoms (e.g., SOB with activity, muscleweakness, fatigue). Virtually all the re-ported symptoms may be related to theside effects associated with the immuno-

suppressive medications (Table 7).62A review of the QOL lung transplant liter-

ature indicates that many conceptual andmethodological limitations exist that makecomparison of findings across studies diffi-cult and weaken the credibility of some ofthe studies findings (e.g., the lack of a com-


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mon definition of QOL4648,50,53,5557 the greatvariety of instruments used to measureQOL, etc.).59 In addition, only three studiesexamined the symptom experiences of lung

transplant recipients50,53,61

and just a fewstudies included physiological vari-ables.53,54,60 Knowledge of the symptom ex-periences of lung transplant recipients isnecessary to provide the patients and theirfamilies a clear understanding of the poten-tial risks and benefits associated with thetransplant procedure and the patients life-long follow-up care. Furthermore, to teachpatients what to expect during and aftertransplantation, we need to learn about the

experiences, concerns, and symptoms oflung transplant candidates and recipients.The lung transplant population is heteroge-neous, and this must be taken into consider-ation when planning patient care. For exam-ple, subgroup differences (i.e., according tounderlying respiratory diagnosis, gender,and type of transplant procedure) werefound for symptoms,62 and, thus, there is aneed to individualize symptom managementstrategies to meet the needs of the individ-ual patient.

Summary

In summary, the development and imple-mentation of care management strategiesrequire basic knowledge about the needsand treatment requirements of lung trans-plant patients before and after transplanta-

tion in both the hospital and home settings.Advanced practice nurses (e.g., clinicalnurse specialists, TNCs, nurse practitioners)are uniquely positioned to play a key roleon the health team in coordinating the careof transplant patients across settings, bothbefore and after the transplant procedure.Identification of potential nursing diagnosesthat may develop during the various stagesof the transplant process can guide patientcare. Providing thorough patient and family

teaching so that the patient and members oftheir support system understand and areable to do what is required as part of thepatients treatment and monitoring regimenis crucial to achieving positive transplantoutcomes. After discharge from the hospi-tal, follow-up care management will require

excellent communication and coordinationamong the healthcare teams and with thelung transplant patient and family to besuccessful. Although research has shown

that transplant recipients report a higherQOL and better functional status than can-didates, the number of studies that havebeen conducted on this patient populationare very few and mostly cross-sectional. Ad-ditional prospective, longitudinal researchis needed that further examines the needsand concerns of these patients and the im-pact of the transplant procedure on theireveryday lives.

Acknowledgments

The authors thank Gabriella A. Farcas for hercomputer assistance in the preparation ofthis article.

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care before and after

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