The Lung Transplant Program at the University of Iowa Hospitals and Clinics (UIHC) is almost 8 years old! There have been 110 lung transplants performed in that time. Many of you have cared for these patients in your pulmonary rehabilitation programs, both before and after transplant. Thank you for that! I often receive emails with questions about the care of these patients, so would like to take this opportunity to review the care of these patients in pulmonary rehab.
Pre-Lung Transplant
Patients seeking lung transplant at the UIHC must participate in pulmonary rehab (PR) prior to being listed for transplant. This assists the patient in achieving a more optimal level of physical function, with improved surgical outcomes; and also shows motivation on the part of the patient. The UIHC Lung Transplant Medical Director requires that all patients seeking lung transplant be able to complete a minimum of 30 minutes of aerobic exercise, preferably on a treadmill. Ideally, this should be 30 minutes of continuous exercise at a minimum speed of 1.0 mph. Of course, not all patients can accomplish this initially, but with close supervision and support from the PR staff, most patients are able to achieve this goal. However, if it is not physically possible for the patient, then 30 minutes of continuous exercise on the NuStep may be acceptable. Keep in mind that some patients may require titration of supplemental oxygen to a level that maintains their SpO2 >88% while exercising. Please make sure your program’s policy allows you to titrate oxygen as needed.
Pre-lung transplant patients are billed for these services with the same codes as any other PR patient, based on diagnosis. Patients with a diagnosis of moderate to very severe COPD are billed with CPT code G0424. Patients with a diagnosis of chronic respiratory disease other than COPD are billed with Respiratory Therapeutic Services codes, G0237, G0238 and/or G0239. Pre-lung transplant patients should be discharged from the program within 36 sessions or less (for COPD patients), or in a similarly reasonable time period for patients with a diagnosis of chronic respiratory disease other than COPD. They must then transition into a maintenance exercise program, or be able to provide documentation of daily aerobic exercise to the UIHC Lung Transplant Team. It is important to keep in mind that patients with a diagnosis of COPD tend to remain on the lung transplant list longer than patients with some other chronic respiratory diagnosis. Therefore, use caution in the number of pulmonary rehab sessions provided these patients. Pre-lung transplant patients are end-stage and are at high risk for exacerbation and hospitalization. Each hospitalization may require a few sessions of PR to help the patient get back on track with exercise. That won’t be possible if they have used all of their “lifetime” sessions. Please find a way for these patients to participate in your maintenance programs, assisting them in any way possible if the patient has financial constraints or transportation issues.
Note: Patients who are noncompliant with attendance at PR will likely not be considered for lung transplantation, as this suggests a lack of interest in taking responsibility for their health.
Post-Lung Transplant
All post-lung transplant patients are required to participate in PR following discharge from the hospital. They spend the first 4 weeks post-transplant in the Iowa City area, staying in a hotel after discharge. They attend PR 5 days per week at the UIHC Pulmonary Rehab Program. When the Lung Transplant Team determines the patient is ready to be discharged to home, they will be referred to a pulmonary rehab program in their local community. The UIHC Pulmonary Rehab Team will provide a detailed treatment plan for that patient. Please follow it! The following is a list of the key points to remember when working with a post-lung transplant patient:
1. Protect the patient from potential infection: Do NOT mainstream these patients into your regular PR classes. These patients are very immunocompromised from their transplant medications. The patient is required to wear a mask at all times when in public places, but it is difficult to exercise wearing a mask. Ideally, attempt to schedule a time when the patient can exercise alone or far enough away from other patients that they can remove the mask. Do not allow a staff member to work with the patient if they are or have been ill recently. Make sure all exercise and monitoring equipment has been cleaned prior to use by the post-transplant patient. Remind the patient and all staff to use good hand hygiene.
2. Education: The patient and their support person(s) have received extensive education from the Lung Transplant Team. This can be reinforced by the PR staff if it is consistent with what has been taught. Each patient has a notebook containing the education material, as well as medication, vital sign, and exercise diaries. The UIHC PR Program staff has outlined the key education to reinforce in the individualized treatment plan for the patient. Post-lung transplant patients no longer have lung disease; therefore, teaching them about chronic lung disease is NOT appropriate. Even if the patient receives only a single lung transplant, the new lung typically takes over the majority of function, overshadowing the remaining diseased lung.
3. Exercise: Post-lung transplant patients must not have an interruption in their pulmonary rehab. They are often discharged from the UIHC PR Program on a Wednesday and should begin PR in your program by Friday, or Monday at the latest. The UIHC PR Program staff will fax the information you need to allow smooth transition into your program. This patient does not need a complete PR evaluation prior to beginning the program. If this must be done, please complete the evaluation when the patient attends exercise sessions, rather than delaying their start date until there is an opening in your new evaluation schedule. Post-lung transplant patients have 6-12 months to achieve maximal function from their new lungs. The best way to achieve maximal function is to challenge the new lungs with the deep breathing that occurs with exercise!
a. PR Frequency: Minimum of 3 times/week for 24-36 sessions. However, the patient will travel to Iowa City every Wednesday for first few months for an appointment in the Lung Transplant Clinic. Many of them choose to exercise in the UIHC PR Program that day. Therefore, they should participate in at least 2 sessions of PR/week in the local program. The patient should exercise independently the other days of the week.
b. Exercise Prescription: The UIHC PR Program will provide the local PR program with the most current exercise prescription for the patient. Please begin the patient’s exercise according to that prescription; however do progress the exercise program on a regular basis, using the guidelines provided in the Exercise section of the ITP provided you. There should be no reason to exercise the patient at a lower workload, unless the patient has had a change in physical health. In that situation, the UIHC Lung Transplant Team should be notified immediately.
c. A lifelong commitment to exercise should be encouraged in all transplant patients.
4. Billing: This patient no longer has lung disease; therefore their therapy should be billed with the Respiratory Therapeutic Services codes (G0237, G0238, or G0239) using the Lung Transplant ICD-9 code V42.6.