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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 159-161

A case study: Effectiveness of preoperative pulmonary rehabilitation program in liver transplantation patient


1 Department of Pulmonary Medicine, Pulmonary Rehabilitation Unit, PSG Hospitals, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
2 Department of Pulmonary Medicine, PSG Hospitals, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
3 Department of Allied Health Sciences, Sri Ramachandra Institute of Higher Education and Research (DU), Chennai, Tamil Nadu, India

Date of Submission28-Dec-2019
Date of Acceptance15-Mar-2020
Date of Web Publication06-Jul-2020

Correspondence Address:
Mr. Manivel Arumugam
Senior Physiotherapy (Grade II), Department of Pulmonary Medicine, Pulmonary Rehabilitation Unit, PSG Hospitals, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_75_19

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  Abstract 


A 56-year-old male patient suffering from multiple conditions of decompensated chronic liver disease, alcohol-related cirrhosis of liver stage of CHILD-B, model for end-stage liver disease-11, and portal hypertension and admitted for liver transplantation in a specialty hospital was reported in this study. Previously, the patient was hospitalized for several times for hepatic encephalopathy. Preoperative evaluation was done by a pulmonologist for cardiorespiratory fitness. The patient was examined with high-resolution computed tomography chest and the functional capacity evaluation by 6-min walk test. The reports showed that the patient is not fit for surgery due to interstitial lung disorder, significant desaturation, noticeable dyspnea, and limited functional walk capacity, and hence, he was referred for cardiorespiratory fitness to the unit of pulmonary rehabilitation program for 12 weeks.

Keywords: 6-min walk test, liver transplantation, physical activity, pulmonary rehabilitation


How to cite this article:
Arumugam M, Rajagopal S, Govindharaj P. A case study: Effectiveness of preoperative pulmonary rehabilitation program in liver transplantation patient. Indian J Transplant 2020;14:159-61

How to cite this URL:
Arumugam M, Rajagopal S, Govindharaj P. A case study: Effectiveness of preoperative pulmonary rehabilitation program in liver transplantation patient. Indian J Transplant [serial online] 2020 [cited 2020 Aug 6];14:159-61. Available from: http://www.ijtonline.in/text.asp?2020/14/2/159/289055




  Introduction Top


Liver transplantation is an operation that replaces the patient's diseased liver with a whole or partial healthy liver from another person who may be alive or cadaveric. Liver transplantation is a viable treatment option for end-stage liver diseases such as decompensated chronic liver disease. Prerehabilitation is essential in case of organ transplant patients due to their chronic illness, and the range of physical recovery is highly variable based on the progression of their disease; the administration of prerehabilitation influences in improving aerobic capacity,[1],[2] encourages independence, improves physical conditioning and exercise tolerance,[3] improves emotional well-being, and reduces the postoperative complications [4] and days of hospitalization. Since respiratory disorders are common and have a significant impact on postoperative outcome in patients undergoing liver transplant, a careful preoperative assessment is of paramount importance.

Here, we report the outcomes of pulmonary rehabilitation (PR) program in a case of liver transplantation who listed and waiting for transplantation.


  Case Report Top


A 56-year-old male patient suffering from multiple conditions of decompensated chronic liver disease, alcohol-related cirrhosis of liver stage of CHILD-B, model for end-stage liver disease-11, and portal hypertension and admitted for liver transplantation in a specialty hospital, Coimbatore. Previously, the patient was hospitalized for several times for hepatic encephalopathy. Preoperative evaluation was done by a pulmonologist for cardiorespiratory fitness. The patient was examined with high-resolution computed tomography chest and functional capacity evaluation with 6-min walk test (6 MWT). The reports revealed interstitial lung disorder-usual interstitial pneumonia pattern with peripheral interlobular septal thickening with adjacent ground-glass opacities and few tiny cysts in both lower lobes and right middle lobe and left lingular lobe. 6 MWT report showed significant desaturation (95%–88%), noticeable dyspnea, and limited functional walk capacity. When compared with normal range (300 m [59.8%]), the patient was not fit for surgery and hence was referred to the PR unit for 12 weeks PR program to get cardiorespiratory fitness.

Pulmonary rehabilitation program

The patient was admitted for PR program after obtaining informed consent. Baseline assessment was done for the patient and collected demographic profile, followed by 6 MWT, activity questionnaire's (functional independence measure [FIM score-self-care domain], and physical activity index [PAI]). The PR program [5] consists of exercise training (flexibility training, endurance training, strength training, airway clearance technique, and breathing retraining), educational support (about his condition, program, nutrition, advantages, and guidance to family members), psychological counseling, and nutritional intervention if needed. The detailed PR program is explained in [Table 1].
Table 1: Protocol of pulmonary rehabilitation program

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The patient underwent PR program, twice weekly up to 3 months, along with the patient was advised to home care exercise, regular walking, breathing exercises, resistance exercises with the use of simple object such as water bottles and sandbags. Periodically, every month, the patient was consulted with gastroenterologist and pulmonologist for prognosis of his condition. Blood investigations and arterial blood gas analysis were monitored to observe the liver and lung functions. In addition, he underwent regular counseling about transplantation and diet.

Outcome measures and results

The outcome measures were taken according to the patient condition and complaints; in this patient, we took 6-min walk distance,[6] with cardiopulmonary parameters (arterial oxygen saturation [SpO2], heart rate and height, weight, and body mass index), PAI which includes poor to high active category, FIM score, self-care domain which includes eating, grooming, bathing, dressing-upper and lower body and toileting (scoring starts with 1– total assistance to 7 – complete independence). The measurements were taken before initial rehabilitation session, after 1 month, and after completion of 3-month program.

The post-PR program results showed substantial changes in functional walk capacity from 59.2% to 97.66% of prediction distance and FIM score level changes from moderate assistance level to modified independence in self-care activities. PAI was changed from sedentary to very good active healthy. Other parameters such as SpO2 and peak heart rate showed significant changes from the baseline. The details of outcomes are shown in [Table 2].
Table 2: Results and outcomes

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  Discussion Top


Chronic liver disease is one of the leading causes of mortality and morbidity in the worldwide adult population. Liver transplant is the gold standard therapy for end-stage liver disease, and many patients are on the waiting list for a transplant. Since liver transplantation is a high-risk surgery and respiratory dysfunction is common and affects prognosis, the precise identification of pulmonary disorders is of great importance.[7]

In this case study report, the outcome measures showed the significant changes in functional walk capacity, PAI, and FIM score (self-care domain). On completion of PR program, the patient underwent liver transplantation surgery and was doing well post surgery. In liver transplantation, the pre-PR program effectively enhances the better quality of life, less stay in intensive care unit, easier in weaning process, initiating early mobilization, and promoting self-care activities of daily livings independently. Pre-PR program should be initiated for all solid organ transplantation for better outcomes and also to reduce morbidity and mortality in transplantation patients. The authors hope, may be this study outcomes will help the rehabilitation practitioners to understand the important of pre-PR program in transplantation surgery in the Indian setups.

Initiation of early PR program will result in better outcomes and promote better quality of life in liver transplantation patients, will reduce the mortality and morbidity, and will reduce the hospitalization period. PR program will enhance the patients to fit for earlier transplantation surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
van den Berg-Emons RJ, van Ginneken BT, Nooijen CF, Metselaar HJ, Tilanus HW, Kazemier G, et al. Fatigue after liver transplantation: Effects of a rehabilitation program including exercise training and physical activity counseling. Phys Ther 2014;94:857-65.  Back to cited text no. 1
    
2.
Kothari AN, Yau RM, Blackwell RH, Schaidle-Blackburn C, Markossian T, Zapf MA, et al. Inpatient rehabilitation after liver transplantation decreases risk and severity of 30-day readmissions. J Am Coll Surg 2016;223:164-7100.  Back to cited text no. 2
    
3.
Cortazzo MH, Helkowski W, Pippin B, Boninger ML, Zafonte R. Acute inpatient rehabilitation of 55 patients after liver transplantation. Am J Phys Med Rehabil 2005;84:880-4.  Back to cited text no. 3
    
4.
Tuel SM, Meythaler JM, Cross LL. Inpatient comprehensive rehabilitation after liver transplantation. Am J Phys Med Rehabil 1991;70:242-5.  Back to cited text no. 4
    
5.
Senduran M, Yurdalan U. Physiotherapy in liver transplantation. In: Abdeldayem H, Allam N, editors. Liver transplantation – Technical issues and complications. Rijeka, Croatia: Intech; 2012. p. 445-4. Available from: https://www.intechopen.com/books/liver-transplantation-technical-issues-and-complications/physiotherapy-in-liver-transplantation. [Last accessed on 2020 Mar 11].  Back to cited text no. 5
    
6.
Palaniappan Ramanathan R, Chandrasekaran B. Reference equations for 6-min walk test in healthy Indian subjects (25-80 years). Lung India 2014;31:35-8.  Back to cited text no. 6
    
7.
Bozbas SS, Eyuboglu F. Evaluation of liver transplant candidates: A pulmonary perspective. Ann Thorac Med 2011;6:109-14.  Back to cited text no. 7
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    Tables

  [Table 1], [Table 2]



 

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