Česky
Where are lung transplants performed in the Czech Republic and when did you start working with lung transplant patients at the Rehabilitation Hospital Beroun? For which lung diseases are transplants performed?
Lung transplants are performed in the Czech Republic only in III. Surgical Clinic of Motol University Hospital. Here, a team of experts under the leadership of the head of the clinic, Prof. Robert Lischke, who is a pupil of Prof. Pavel Pafko, performs these operations. It was Prof. Pafko who performed the first lung transplantation in the Czech Republic in 1997 and thus started the lung transplantation programme in the Czech Republic. We were approached by the Surgical Clinic of the Motol University Hospital with an offer of cooperation in the field of rehabilitation of patients after lung transplantation, but no other department in the Czech Republic was systematically involved in the rehabilitation of these patients. I admit that it was a challenge for us. We accepted the offer to cooperate and after several meetings of representatives of both departments and specification of all key aspects of cooperation we started to accept patients indicated for complex rehabilitation after lung transplantation to the Rehabilitation Centre. As far as I know, our centre is the only rehabilitation centre in the Czech Republic dedicated to the rehabilitation of these patients.
How are patients selected for lung transplantation, who decides?
Lung transplantation is usually proposed by the pneumologist who treats the patient. Patients undergo a series of examinations, the results of which are carefully evaluated by a team involving several specialists. For example, patients are examined by a dentist or interviewed by a psychologist. In addition to the purely medical parameters, the patient's willingness to cooperate actively over the long term is also taken into account, including in terms of pre-operative and especially post-operative rehabilitation. The selected patient then undergoes an informational interview, where he/she meets the entire transplant team (lung surgeon, pulmonologist, anaesthesiologist, psychologist and sometimes other specialists are present) and after the assessment of all the results of ancillary examinations, the patient is placed on a waiting list. From this point on, the patient waits to be contacted by the transplant team doctor that a suitable donor, i.e. a suitable lung, has been found. The waiting time for a new organ can be up to 2 years. The main criteria for selecting a suitable organ is the match in blood type between donor and recipient and the size of the organ.
What is the care of these patients after the actual transplant? How often are checks carried out and which tests are performed?
After the actual transplantation, the patient's stay in the ICU is necessary, where the patient remains connected to a ventilator for several hours to days in artificial sleep, and when the transplanted lung appears to be functioning properly, the patient is taken off the ventilator. Rehabilitation also takes place in the ARO from the very beginning. After one or two weeks in the ARO, the patient is then transferred back to the transplant ward, where rehabilitation continues, the doses of the necessary drugs are adjusted and the patient learns how to breathe properly. Then, approximately one month after surgery, a lung biopsy is performed. This takes a sample of lung tissue and examines it microscopically to rule out acute "rejection" (or healing - destruction) of the transplanted lung. If the biopsy goes well, then the patient can be discharged home. After discharge, the patient is monitored on an outpatient basis, with regular blood laboratory parameters, spirometry and lung x-rays. Checks are weekly for the first 2 months after surgery, every 2-4 weeks for six months after surgery, then monthly until the end of the first year, and then once every 2-3 months thereafter. During this time, 3 more follow-up biopsies are performed, especially if "rejection" is suspected. The patient must follow a strict regimen and attention must be paid to symptoms that could indicate an incipient infection, which could put the patient at serious risk. If, for example, there is an increase in temperature, or general fatigue or muscle and joint pain, then the patient must contact the transplant team immediately.
What medicines do these patients take?
The mainstay of pharmacological treatment is so-called immunosuppressants, i.e. drugs that weaken the immune system, which is necessary after transplantation to minimise the risk of 'rejection'. However, this makes the patient more susceptible to infections. Immunosuppressive drugs must be taken continuously after transplantation and usually a triple combination of these immunosuppressive drugs is given, and the patient must be advised that this treatment may have various side effects. Corticosteroids are also given, which act in several ways but also immunosuppressive, but this therapy also has side effects. Depending on the situation, antibiotics, antifungals or antivirals may also be given prophylactically.
Are any regimens necessary for these patients before transplantation?
Already during the period of waiting for the transplant, the patient needs to keep himself in good condition and maintain good muscle strength. Therefore, regular conditioning exercises are essential. It is also important to prevent the development of excess weight. If the patient is overweight, then weight reduction should be required. However, for example, in cystic fibrosis patients who are malnourished, a high-energy diet is required. Rehabilitation becomes especially important after the transplantation itself, both in the early postoperative period and later. Patients are admitted to the RNB Rehabilitation Centre after lung transplantation if their condition stabilises and on the recommendation of the attending pulmonologist, who is a member of the transplant team. We always respect the pneumologist's recommendations regarding regimen measures or intensity of exercise. During the stay in our Rehabilitation Centre, the patient usually undergoes weekly check-ups with a pneumologist at Motol Hospital. In addition, an internal consultant from our internal medicine department regularly visits these patients during their stay in the centre.
How is the rehabilitation of transplanted patients carried out, what rehabilitation procedures are used?
Rehabilitation of lung transplant patients starts very soon after the operation. Immediately after surgery in the ARO and then it continues after transfer in the standard ward of the surgical clinic and subsequently in our Rehabilitation Center. It is necessary to pay sufficient attention to the process of gradual verticalization of the patient after lung transplantation. This should be done in the early postoperative phase (preferably already in ARO), especially after the patient is no longer ventilator dependent. Sitting with the lower limbs lowered from the bed is practiced, eventually the patient is put in a chair. Leg cushion stimulation is also performed in preparation for standing and walking. If the patient's condition and physical condition allow, then training in high gait is started. The spectrum of rehabilitation procedures is adapted to the patient's current state of health and the time since transplantation. The basis of the rehabilitation programme is respiratory physiotherapy, using reflex breathing as well as an active cycle of breathing techniques consisting of controlled breathing, forceful exhalation techniques and exercises to increase chest flexibility. Autogenic drainage is also used, which aims to loosen mucus in the lower airways and move it into the upper airways. Autogenic drainage uses different patient positions and manual contact of the therapist with the patient's chest. Techniques using expiration against resistance are also included to help dilate the airway. This is the so-called PEP (or "positive expiratory presure") breathing system, which helps to remove secretions from the airways and aerate the peripheral areas of the lungs. For this purpose, for example, the Acapella device is also used in patients after lung transplantation, which increases and decreases expiratory resistance during exhalation, thus creating oscillations that facilitate mucus mobilisation and expectoration. Inhalation therapy is also an integral part of respiratory physiotherapy, which the patient carries out later at home and promotes easier and faster mucus removal. In patients after lung transplantation, so-called soft and mobilisation techniques are used as standard (taking into account postoperative evolution), with the aim of modifying the elasticity of the soft tissues of the chest and restoring their mobility. The techniques are aimed at relaxing the muscle fascia as well as the muscles themselves, whose increased tension could cause breathing difficulties. The care of the surgical scar is very important, and it is particularly important that its aforementioned mobility is preserved.
As part of the rehabilitation of these patients, do you also focus on improving physical fitness and include any strengthening elements?
Yes, since a certain period of time, therapeutic physical education methods are also included in the rehabilitation programme to promote increased muscle strength. It is also important to improve the patient's independence in activities of daily living. Later on, if the post-operative development is satisfactory and the patient's health is stabilised, aerobic training such as walking or riding a treadmill is started. This training should not cause shortness of breath or a reduction in oxygen saturation below 90 %. Gradually, strength training, such as exercises using the body's own weight or exercises with dumbbells or elastic stretches, should also be started. Endurance training is also important, depending on the patient's ability. For example, pedalling on a treadmill, walking or running on a moving sidewalk, etc. are suitable.
Are you able to provide all the rehabilitation procedures you have mentioned so far in your Rehabilitation Centre? And how do these patients work together in rehabilitation from your point of view?
Yes, in the Rehabilitation Centre of our Beroun hospital the physiotherapists use all the above mentioned procedures. The other staff is also sufficiently familiar with the needs of lung transplant patients. This makes the care of lung transplant patients really comprehensive. Our experience has shown us that lung transplant patients are disciplined, adhere to regimens and cooperate well during rehabilitation.
Lung transplantation is a major step and a challenging surgical procedure that has numerous risks. Therefore, this procedure is only undertaken when all available conservative treatment options have been exhausted. Bilateral lung transplantation is most commonly performed for the following basic diagnoses: chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, primary arterial pulmonary hypertension, lymphangiomyomatosis and cystic fibrosis. Unilateral lung transplantation is currently rarely performed.
