Active Rehabilitation and Physical Therapy During Extracorporeal Membrane Oxygenation While Awaiting Lung Transplantation

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1 Active Rehabilitation and Physical Therapy During Extracorporeal Membrane Oxygenation While Awaiting Lung Transplantation David A Turner MD 1, David Zaas MD MBA 2, Kyle J Rehder MD 1, W Lee Williford RRT 3, Shu Lin MD PhD 4, R Duane Davis MD 4, Ira M Cheifetz MD FCCM FAARC 1,3 Pediatric Critical Care Medicine 1, Pulmonary, Allergy, and Critical Care Medicine 2, Respiratory Care Services 3, Cardiovascular and Thoracic Surgery 4 Duke University Medical Center Duke Children s Hospital Durham, North Carolina, USA Abstract 294

2 *U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients 2009 Annual Report Lung Transplantation Lung transplantation is an important therapeutic option for many severe respiratory diseases associated with a high mortality. Indications for Lung Transplantation Diagnosis 2008 Transplants (%)* Idiopathic Pulmonary Fibrosis 33.5 Emphysema/COPD 28.6 Cystic Fibrosis 13.7 Alpha 1 Antitrypsin Deficiency 2.9 Idiopathic Pulmonary Arterial 1.8 Hypertension Congenital Disease 0.3 *U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients 2009 Annual Report

3 ECMO and Lung Transplantation Patients with end-stage respiratory disease are at a high risk for critical illness, thus limiting their transplant candidacy. Extracorporeal membrane oxygenation (ECMO) may be necessary as a bridge to transplantation in the most critically ill of these patients who become refractory to maximal conventional therapies. Poor outcomes have been reported with ECMO as a pre-operative bridge to lung transplantation.

4 ECMO and Lung Transplantation Underlying muscle strength and deconditioning likely contribute to low survival rates in patients transplanted from ECMO. To ameliorate the negative effects of pre-transplant deconditioning, our multidisciplinary team developed a strategy to actively rehabilitate patients while using ECMO as a bridge to transplantation.

5 Methods In our Pediatric Intensive Care Unit, we initiated an ambulatory ECMO program for an adolescent with end-stage cystic fibrosis and respiratory failure. The clinical care team determined that ECMO was necessary to allow for pre-transplant rehabilitation. Program development was initiated by a multidisciplinary team including pediatric intensivists, lung transplant pulmonologists, respiratory therapists, ECMO specialists, nurses, occupational therapists, and physical therapists.

6 Patients and Main Results We describe two patients (ages 17 and 24 years) with refractory respiratory failure due to end-stage cystic fibrosis who had previously been denied lung transplantation at their referring centers. Each patient: was cannulated for venovenous (VV) ECMO with a double lumen internal jugular venous cannula (Avalon Labs; Rancho Domingo, CA). underwent rehabilitation while on VV ECMO awaiting transplant. received tracheostomy to facilitate weaning of sedation and mechanical ventilation within 24 hours of ECMO cannulation. ambulated while on ECMO within 1 week. underwent successful bilateral sequential lung transplantation and was subsequently decannulated from ECMO within hours. was discharged from the ICU less than one week post-transplant. was discharged home without the need for transition to a rehabilitation facility (at 31 and 32 days post-transplant).

7 Ambulation while on ECMO

8 Discussion In the setting of lung transplantation, deconditioning may be an important cause of both morbidity and mortality. Pre-transplant conditioning may be improved via rehabilitation and active conditioning in critically ill patients on ECMO. A potential mechanism to enhance the mobility of ECMO patients is single vessel internal jugular vein cannulation. To actively rehabilitate and ambulate patients being treated with ECMO, substantial planning is required by a dedicated multidisciplinary team (including physicians, nurses, respiratory therapists, ECMO specialists, physical therapists, and occupational therapists).

9 Conclusions Ambulation on ECMO can be safe in critically ill patients awaiting lung transplantation. Pre- and post-operative morbidity and mortality may be decreased when ambulatory ECMO is used as a bridge to lung transplantation. Rehabilitation and re-conditioning on ECMO may decrease ICU length of stay following lung transplantation. This innovative approach to ambulation and activity on ECMO has potential implications for the management of all critically ill ECMO patients. Future investigation is needed to further assess the impact of increased activity and active physical therapy on the morbidity and mortality of ECMO patients.

10 References Organ Procurement and Transplant Network. Accessed December 12, Jackson A, Cropper J, Pye R, Junius F, Malouf M, Glanville A. Use of extracorporeal membrane oxygenation as a bridge to primary lung transplant: 3 consecutive, successful cases and a review of the literature. J Heart Lung Transplant 2008, 27(3): Nosotti M, Rosso L, Palleschi A, Lissoni A, Crotti S, Marenghi C, Colombo C, Costantini D, Santambrogio L: Bridge to lung transplantation by venovenous extracorporeal membrane oxygenation: a lesson learned on the first four cases. Transplant Proc, 42(4): Olsson KM, Simon A, Strueber M, Hadem J, Wiesner O, Gottlieb J, Fuehner T, Fischer S, Warnecke G, Kuhn C et al: Case report: extracorporeal membrane oxygenation in nonintubated patients as bridge to lung transplantation. Am J Transplant, 10(9):

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