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Lung Transplantation Does Not Impact on Daily Physical Activity Despite Substantial Improvements in Respiratory Function and Exercise Capacity
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The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
Purpose: Enterally feeding patients on extracorporeal membrane oxygenation (ECMO) is challenging due to haemodynamic instability, feed intolerance and interruptions. Risk of malnutrition is high thus optimal nutrition is required pre-transplantation. We assessed feed delivery and tolerance over 7days of ECMO as bridge to lung or heart-lung transplant (LTx). Methods: Patients admitted for ECMO as bridge to LTx from July 2011-Oct 2015 were retrospectively identified. Nutritional goals were calculated based on European guidelines. Enteral nutrition (EN) recorded for feeding days 3, 5 and 7 were compared with goal rate for energy/protein. Other parameters included day EN was initiated and first day 80% goal rate was met for energy/ protein. Tolerance was assessed by monitoring bowels, incidence of vomiting, large (> 250mls) gastric residual volume (GRVs) as set by local policy. Results: 16 patients were identified requiring ECMO as bridge to LTx (n= 15) and Heart-lung Transplant (n= 1). Ratio of female to male was 10:6 respectively and mean age was 29.3±8.2years. Indication for LTx included cystic fibrosis (n= 12), pulmonary hypertension (n= 2), bronchiectasis (n= 1) and emphysema (n= 1). Mean duration on ECMO was 15.8±13.2days. On average EN was commenced within 2.3±1.3 days and 80% of goal rate achieved by 5.2±2.1 days. However 80% goal rate was not sustained as by day7 % goal rate achieved was 62% energy and 73% protein. Bowels were first opened on day 5±3.1, Three experienced vomiting and 4 had GRV > 250mls after day 5. Two Patients went onto have TPN after day7 prior to LTx. Conclusion: Patients who undergo ECMO as bridge to LTx are not achieving adequate nutritional support in the first 7 days. Feeding is initiated within 72 hours however beyond 5 days disruptions to feeding occur due to tolerance leading to underfeeding. Potential improvements could include prophylactic Naso-Jejunal feeding and aggressive use of laxatives to open bowels sooner.
Mean % goal rate met for energy and protein over 7 days Day
N
Mean Energy (% SD)
Mean Protein (% SD)
3 5 7
16 16 14
32±31.8 80±21.1 62±36.6
23±25.1 85±28.1 68±27.3
1( 13) Lung Transplantation Does Not Impact on Daily Physical Activity Despite Substantial Improvements in Respiratory Function and Exercise Capacity J.R. Walsh ,1 D.C. Chambers,1 S.T. Yerkovich,1 P.M. Hopkins,1 N.R. Morris.2 1Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; 2School of Rehabilitation Sciences and Griffith Health Institute, Griffith University, Gold Coast, Australia. Purpose: Physical activity is an emerging functional performance measure in people with chronic respiratory disease. However, there is little evidence evaluating physical activity post lung transplantation (LTx). Study aims: To describe the changes in physical activity post-LTx when compared to preLTx levels, and to determine any relationship between physical activity level (PAL) and demographic, respiratory function or exercise capacity measures. Methods: A prospective observational design was used. Participants in a single institution were assessed pre- and twelve months post-LTx. PAL was defined as total energy expenditure in twenty-four hours/basal metabolic rate. PAL, mean minutes/day being physically active (> 1.69 metabolic equivalents (METs)), and minutes/day performing moderate activity (> 3.0 METs) were measured using the SenseWear multi-sensor device. Demographics, forced expiratory volume in one second (FEV1%), six minute walk distance (6MWD), and quadriceps strength corrected for body weight (QS%) were also assessed. Results: 24 participants (14 males), mean (SD) age 52.0 ± 12.5 years were studied. Mean FEV1% increased by 56.7 ± 29.9% (p< 0.001) and 6MWD increased by 195 ± 121m (p< 0.001) 12 months after transplant, but QS% did not improve (-3.8 ± 38.0%, p< 0.101). Mean PAL at 12 months (1.49 ± 0.31) was not significantly different to pre-LTx (1.44 ± 0.34, p= 0.353). Mean time physically active had increased by 58 ± 132 minutes/day (p= 0.024) but there was no significant difference in time performing moderate activity (p= 0.247). Post-LTx, PAL was correlated with 6MWD (r= 0.574, p= 0.003), and QS%
(r= 0.531, p= 0.008) but not FEV1% (r= -0.163, p= 0.446), age (r= -0.310, p= 0.150), or pre-LTx PAL (r= 0.258, p= 0.235). However, ∆PAL was not correlated to age (r= 0.168, p= 0.443), ∆FEV1% (r= -0.036, p= 0.872), ∆6MWD (r= 0.340, p= 0.112) or ∆QS% (r= 0.228, p= 0.296). Conclusion: Despite substantial improvements in respiratory function and exercise capacity post lung transplantation, recipients’ physical activity does not change significantly from pre-transplant levels. Exercise capacity and quadriceps strength appear important determinants of post-transplant PAL. However, the factors influencing change in PAL from pre to post-transplant have not been identified. 1( 14) Incidence of Vocal Cord Palsy and Aspiration Status in the Lung Transplant Population Z. Meszarich ,1 N. Patel,1 A. Reed,2 A. Simon.3 1Speech and Language Therapy, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; 2Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; 3Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom. Purpose: Vocal cord paralysis (VCP) is a known postoperative complication following lung transplantation (LTx). There is a paucity of literature regarding the incidence and impact on swallowing function. It is well documented that newly transplanted lungs are immunosuppressed and highly susceptible to aspiration induced pulmonary injury. The purpose of this study is to evaluate the incidence of VCP and the presence of associated dysphagia in this cohort. Methods: Between January 2009 and August 2015 a total of 337 lung transplants were performed at Harefield Hospital (HH). Of the 337, 78 were referred to speech and language therapy (SLT) post LTx. A retrospective study of this group was completed. Indication for assessment of vocal cord status was the presence of dysphonia and weak cough persisting post extubation. VCP was identified either using nasendoscopy (n= 11), on awake bronchoscopy (n= 5) or assumed based on voice quality (n= 2 declined objective assessment). Of the 78, 23% (n= 18) were identified with VCP. Results: 61% (11/18) of patients identified with VCP underwent fibreoptic endoscopic evaluation of swallowing (FEES) and/or videofluoroscopy (VFS) having presented with clinical signs of aspiration on bedside assessment. 28% (5/18) patients reported no concerns with their swallowing and showed no signs of dysphagia on bedside assessment despite confirmed presence of VCP. There was therefore no clinical indication to conduct further swallowing assessment.11% (2/18) patients were not able to undergo FEES or VFS due to poor cognition. 82% (9/11) of patients who underwent a VFS aspirated silently on thin fluids. 18% (2/11) of those who underwent VFS presented with normal oropharyngeal stage swallows. Conclusion: Almost one quarter of LTx patients presented with VCP and a high incidence of silent aspiration was found in this population. This study supports the introduction of routine post- operative instrumental swallow assessment for all patients identified with VCP post LTx.
patient demographics Total number of patients referred Total number of VCP, n (%) Indication for LTx n (%) Gender, n (%) Total number instrumental ax,n (%) Silent aspirators identified, n (%)
78 18 (23%) CF= 10 (53%) M= 9 (53%) 11 (61%) 9 (82%)
1( 15) A Multi-Centre Study on the Effects of Iyengar Yoga on Health Related Quality of Life in Patients with Pulmonary Arterial Hypertension M.V. Thakrar ,1 D.S. Helmersen,1 N. Hirani,1 K. Jackson,2 D.C. Lien,2 M.J. Santana.3 1Department of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada; 2Alberta Lung Transplant Program, University of Alberta, Edmonton, AB, Canada; 3Department of Medicine, W21C, University of Calgary, Calgary, AB, Canada.
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
Purpose: Enterally feeding patients on extracorporeal membrane oxygenation (ECMO) is challenging due to haemodynamic instability, feed intolerance and interruptions. Risk of malnutrition is high thus optimal nutrition is required pre-transplantation. We assessed feed delivery and tolerance over 7days of ECMO as bridge to lung or heart-lung transplant (LTx). Methods: Patients admitted for ECMO as bridge to LTx from July 2011-Oct 2015 were retrospectively identified. Nutritional goals were calculated based on European guidelines. Enteral nutrition (EN) recorded for feeding days 3, 5 and 7 were compared with goal rate for energy/protein. Other parameters included day EN was initiated and first day 80% goal rate was met for energy/ protein. Tolerance was assessed by monitoring bowels, incidence of vomiting, large (> 250mls) gastric residual volume (GRVs) as set by local policy. Results: 16 patients were identified requiring ECMO as bridge to LTx (n= 15) and Heart-lung Transplant (n= 1). Ratio of female to male was 10:6 respectively and mean age was 29.3±8.2years. Indication for LTx included cystic fibrosis (n= 12), pulmonary hypertension (n= 2), bronchiectasis (n= 1) and emphysema (n= 1). Mean duration on ECMO was 15.8±13.2days. On average EN was commenced within 2.3±1.3 days and 80% of goal rate achieved by 5.2±2.1 days. However 80% goal rate was not sustained as by day7 % goal rate achieved was 62% energy and 73% protein. Bowels were first opened on day 5±3.1, Three experienced vomiting and 4 had GRV > 250mls after day 5. Two Patients went onto have TPN after day7 prior to LTx. Conclusion: Patients who undergo ECMO as bridge to LTx are not achieving adequate nutritional support in the first 7 days. Feeding is initiated within 72 hours however beyond 5 days disruptions to feeding occur due to tolerance leading to underfeeding. Potential improvements could include prophylactic Naso-Jejunal feeding and aggressive use of laxatives to open bowels sooner.
Mean % goal rate met for energy and protein over 7 days Day
N
Mean Energy (% SD)
Mean Protein (% SD)
3 5 7
16 16 14
32±31.8 80±21.1 62±36.6
23±25.1 85±28.1 68±27.3
1( 13) Lung Transplantation Does Not Impact on Daily Physical Activity Despite Substantial Improvements in Respiratory Function and Exercise Capacity J.R. Walsh ,1 D.C. Chambers,1 S.T. Yerkovich,1 P.M. Hopkins,1 N.R. Morris.2 1Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; 2School of Rehabilitation Sciences and Griffith Health Institute, Griffith University, Gold Coast, Australia. Purpose: Physical activity is an emerging functional performance measure in people with chronic respiratory disease. However, there is little evidence evaluating physical activity post lung transplantation (LTx). Study aims: To describe the changes in physical activity post-LTx when compared to preLTx levels, and to determine any relationship between physical activity level (PAL) and demographic, respiratory function or exercise capacity measures. Methods: A prospective observational design was used. Participants in a single institution were assessed pre- and twelve months post-LTx. PAL was defined as total energy expenditure in twenty-four hours/basal metabolic rate. PAL, mean minutes/day being physically active (> 1.69 metabolic equivalents (METs)), and minutes/day performing moderate activity (> 3.0 METs) were measured using the SenseWear multi-sensor device. Demographics, forced expiratory volume in one second (FEV1%), six minute walk distance (6MWD), and quadriceps strength corrected for body weight (QS%) were also assessed. Results: 24 participants (14 males), mean (SD) age 52.0 ± 12.5 years were studied. Mean FEV1% increased by 56.7 ± 29.9% (p< 0.001) and 6MWD increased by 195 ± 121m (p< 0.001) 12 months after transplant, but QS% did not improve (-3.8 ± 38.0%, p< 0.101). Mean PAL at 12 months (1.49 ± 0.31) was not significantly different to pre-LTx (1.44 ± 0.34, p= 0.353). Mean time physically active had increased by 58 ± 132 minutes/day (p= 0.024) but there was no significant difference in time performing moderate activity (p= 0.247). Post-LTx, PAL was correlated with 6MWD (r= 0.574, p= 0.003), and QS%
(r= 0.531, p= 0.008) but not FEV1% (r= -0.163, p= 0.446), age (r= -0.310, p= 0.150), or pre-LTx PAL (r= 0.258, p= 0.235). However, ∆PAL was not correlated to age (r= 0.168, p= 0.443), ∆FEV1% (r= -0.036, p= 0.872), ∆6MWD (r= 0.340, p= 0.112) or ∆QS% (r= 0.228, p= 0.296). Conclusion: Despite substantial improvements in respiratory function and exercise capacity post lung transplantation, recipients’ physical activity does not change significantly from pre-transplant levels. Exercise capacity and quadriceps strength appear important determinants of post-transplant PAL. However, the factors influencing change in PAL from pre to post-transplant have not been identified. 1( 14) Incidence of Vocal Cord Palsy and Aspiration Status in the Lung Transplant Population Z. Meszarich ,1 N. Patel,1 A. Reed,2 A. Simon.3 1Speech and Language Therapy, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; 2Transplant Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; 3Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom. Purpose: Vocal cord paralysis (VCP) is a known postoperative complication following lung transplantation (LTx). There is a paucity of literature regarding the incidence and impact on swallowing function. It is well documented that newly transplanted lungs are immunosuppressed and highly susceptible to aspiration induced pulmonary injury. The purpose of this study is to evaluate the incidence of VCP and the presence of associated dysphagia in this cohort. Methods: Between January 2009 and August 2015 a total of 337 lung transplants were performed at Harefield Hospital (HH). Of the 337, 78 were referred to speech and language therapy (SLT) post LTx. A retrospective study of this group was completed. Indication for assessment of vocal cord status was the presence of dysphonia and weak cough persisting post extubation. VCP was identified either using nasendoscopy (n= 11), on awake bronchoscopy (n= 5) or assumed based on voice quality (n= 2 declined objective assessment). Of the 78, 23% (n= 18) were identified with VCP. Results: 61% (11/18) of patients identified with VCP underwent fibreoptic endoscopic evaluation of swallowing (FEES) and/or videofluoroscopy (VFS) having presented with clinical signs of aspiration on bedside assessment. 28% (5/18) patients reported no concerns with their swallowing and showed no signs of dysphagia on bedside assessment despite confirmed presence of VCP. There was therefore no clinical indication to conduct further swallowing assessment.11% (2/18) patients were not able to undergo FEES or VFS due to poor cognition. 82% (9/11) of patients who underwent a VFS aspirated silently on thin fluids. 18% (2/11) of those who underwent VFS presented with normal oropharyngeal stage swallows. Conclusion: Almost one quarter of LTx patients presented with VCP and a high incidence of silent aspiration was found in this population. This study supports the introduction of routine post- operative instrumental swallow assessment for all patients identified with VCP post LTx.
patient demographics Total number of patients referred Total number of VCP, n (%) Indication for LTx n (%) Gender, n (%) Total number instrumental ax,n (%) Silent aspirators identified, n (%)
78 18 (23%) CF= 10 (53%) M= 9 (53%) 11 (61%) 9 (82%)
1( 15) A Multi-Centre Study on the Effects of Iyengar Yoga on Health Related Quality of Life in Patients with Pulmonary Arterial Hypertension M.V. Thakrar ,1 D.S. Helmersen,1 N. Hirani,1 K. Jackson,2 D.C. Lien,2 M.J. Santana.3 1Department of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada; 2Alberta Lung Transplant Program, University of Alberta, Edmonton, AB, Canada; 3Department of Medicine, W21C, University of Calgary, Calgary, AB, Canada.