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ABSTRACT: BACKGROUND: Patients with end-stage lung disease often progress to critical illness, which dramatically reduces their chance of survival following lung transplantation. Pre-transplant deconditioning has a significant impact on outcomes for all lung transplant patients and is likely a major contributor to increased mortality in critically ill lung transplant recipients. The aim of this report is to describe a series of patients bridged to lung transplant with extracorporeal membrane oxygenation (ECMO) and examine the potential impact of active rehabilitation and ambulation during pre-transplant ECMO. METHODS: This retrospective case series reviews all patients bridged to lung transplantation with ECMO at a single tertiary care lung transplant center. Pre-transplant ECMO patients receiving active rehabilitation and ambulation were compared to those patients who were bridged with ECMO but did not receive pre-transplant rehabilitation. RESULTS: Nine consecutive patients between April 2007 and May 2012 were identified for inclusion. One year survival for all patients was 100%, with one patient alive at 4 months post-transplant. The five patients participating in pre-transplant rehabilitation had shorter mean post-transplant length of mechanical ventilation (4 days vs. 34 days, p = 0.01), ICU stay (11 days vs. 45 days, p = 0.01), and hospital stay (26 days vs. 80 days, p = 0.01). No patients who participated in active rehabilitation had post-transplant myopathy, compared to three of four patients who did not participate in pre-transplant rehabilitation on ECMO. CONCLUSIONS: Bridging selected critically ill patients to transplant with ECMO is a viable treatment option, and active participation in physical therapy, including ambulation, may provide a more rapid post-transplantation recovery. This innovative strategy requires further study to fully evaluate potential benefits and risks.
Respiratory care 12/2012; · 2.01 Impact Factor
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ABSTRACT: Extracorporeal membrane oxygenation as a bridge to lung transplantation has traditionally been associated with substantial morbidity and mortality. A major contributor to these complications may be weakness and overall deconditioning secondary to pretransplant critical illness and immobility. In an attempt to address this issue, we developed a collaborative program to allow for active rehabilitation and physical therapy for patients requiring life support with extracorporeal membrane oxygenation before lung transplantation.
An interdisciplinary team responded to an acute need to develop a mechanism for active rehabilitation and physical therapy for patients awaiting lung transplantation while being managed with extracorporeal membrane oxygenation. We describe a series of three patients who benefited from this new approach.
A quaternary care pediatric intensive care unit in a children's hospital set within an 800-bed university academic hospital with an active lung transplantation program for adolescent and adult patients. PATIENTS, INTERVENTIONS, AND MAIN RESULTS: Three patients (ages 16, 20, and 24 yrs) with end-stage respiratory failure were rehabilitated while on extracorporeal membrane oxygenation awaiting lung transplantation. These patients were involved in active rehabilitation and physical therapy and, ultimately, were ambulatory on extracorporeal membrane oxygenation before successful transplantation. Following lung transplantation, the patients were liberated from mechanical ventilation, weaned to room air, transitioned out of the intensive care unit, and ambulatory less than 1 wk posttransplant.
A comprehensive, multidisciplinary system can be developed to safely allow for active rehabilitation, physical therapy, and ambulation of patients being managed with extracorporeal membrane oxygenation. Such programs may lead to a decreased threshold for the utilization of extracorporeal membrane oxygenation before transplant and have the potential to improve conditioning, decrease resource utilization, and lead to better outcomes in patients who require extracorporeal membrane oxygenation before lung transplantation.
Critical care medicine 07/2011; 39(12):2593-8. · 6.37 Impact Factor
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David W Zaas
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ABSTRACT: Lung transplant is now an accepted treatment for end-stage lung disease with improving survival and an increasing number of transplants being performed every year. Recognition of the common medical complications after lung transplant is important for timely diagnosis and treatment. This review will highlight the clinical presentation, diagnosis, and treatment of several noninfectious pulmonary complications that are encountered in lung transplant recipients.
The review focuses on several broad areas of medical complications after lung transplant, including native lung complications, malignancies, venous thromboembolism, drug toxicity, and pleural disease. Each of these problems is a significant cause of morbidity and mortality after lung transplant. We review the recent publications in these areas that have identified improved ways to diagnose and treat these complications.
Despite its relatively short history, the field of lung transplantation has made significant progress over the past 25 years. The medical advances surrounding lung transplant are not only related to the surgical procedure and immunosuppression, but also to the ability of physicians to diagnose and treat the common complications after transplant. Improvements in the diagnosis and management of these posttransplant medical complications will hopefully lead to even greater survival after lung transplantation in the future.
Current opinion in organ transplantation 08/2009; 14(5):488-93. · 1.22 Impact Factor
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Journal of General Internal Medicine 10/2007; 22(9):1383. · 2.83 Impact Factor
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ABSTRACT: Cardiac amyloidosis can result from any of the systemic amyloidoses. The disease is often characterized by a restrictive cardiomyopathy although the particular signs and symptoms depend in part on the underlying cause. In addition to managing the symptoms of heart failure, treatment options vary depending on the etiology of amyloid deposition. It is therefore critical to identify the cause of cardiac amyloidosis before initiating definitive therapy. We present a patient with presumed immunoglobulin (AL) amyloidosis who had a circulating lambda monoclonal protein, but a bone marrow biopsy with kappa predominant plasma cells. This unusual finding called into question the diagnosis of AL amyloidosis and highlights the importance and difficulty of determining the cause of cardiac amyloid deposition before initiating treatment. We review the different forms of cardiac amyloidosis and propose a diagnostic algorithm to help identify the etiology of cardiac amyloid deposition before beginning therapy.
Journal of General Internal Medicine 08/2007; 22(7):1047-52. · 2.83 Impact Factor
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ABSTRACT: The superficial bladder epithelium is a powerful barrier to urine and also serves as a regulator of bladder volume, which is achieved by apical exocytosis of specialized fusiform vesicles during distension of the bladder. We report that type 1 fimbriated uropathogenic Escherichia coli (UPEC) circumvents the bladder barrier by harboring in these Rab27b/CD63-positive and cAMP-regulatable fusiform vesicles within bladder epithelial cells (BECs). Incorporation of UPEC into BEC fusiform compartments enabled bacteria to escape elimination during voiding and to re-emerge in the urine as the bladder distended. Notably, treatment of UPEC-infected mice with a drug that increases intracellular cAMP and induces exocytosis of fusiform vesicles reduced the number of intracellular E. coli.
Nature Medicine 06/2007; 13(5):625-30. · 22.46 Impact Factor
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ABSTRACT: Several traditionally extracellular pathogens not known to possess invasive capacity have been shown to invade various mucosal epithelial cells. The mucosal epithelium performs an important barrier function and is not typically amenable to bacterial invasion. Valuable clues to the underlying basis for bacterial invasion have emerged from recent studies examining the invasion of bladder epithelial cells by uropathogenic Escherichia coli and alveolar epithelial cells by Pseudomonas aeruginosa. In both cases, bacterial invasion is achieved through targeting of molecules specifically found within distinct glycosphingolipid- and cholesterol-enriched microdomains called lipid rafts. The importance of lipid rafts in promoting bacterial invasion was shown as disruptors of lipid rafts blocked cellular invasion by both E. coli and P. aeruginosa. In addition, molecular components of lipid rafts were found to be highly enriched in membranes encasing these intracellular bacteria. Furthermore, caveolin proteins, which serve to stabilize and organize lipid raft components, are necessary for bacterial entry. Taken together, targeting of lipid rafts appears to be an effective but poorly recognized mechanism used by pathogenic bacteria to circumvent the mucosal barriers of the host.
Journal of Investigative Medicine 10/2005; 53(6):318-21. · 1.96 Impact Factor
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ABSTRACT: Obstructive lung disease (OLD) is a worldwide health problem with major impact on health and economics, and can be easily diagnosed by spirometry. Recent expert panels have emphasized the underreporting and underrecognition of this condition. The goal of this study was to measure the prevalence of airway obstruction in patients admitted to an urban teaching hospital and to determine the frequency of a diagnosis of OLD at admission or discharge.
Prospective study of 153 patients admitted to a medicine service at the Johns Hopkins Hospital in Baltimore, MD. Patients completed bedside spirometry and a questionnaire.
Twenty-six percent of patients had airway obstruction (FEV(1)/FVC < 70%), including 6% with a very severe airway obstruction (FEV(1) < 30% predicted). At hospital discharge, a clinical diagnosis of OLD was present in only 33% of patients with mild airway obstruction (FEV(1) > 70% predicted), 30% of patients with moderate airway obstruction (FEV(1) 50 to 69% predicted), 33% of patients with severe airway obstruction (FEV(1) 30 to 49% predicted), and 89% of patients with very severe airway obstruction (FEV(1) < 30% predicted). Only 40% of patients with airway obstruction were receiving bronchodilator medication at hospital admission or discharge.
Airway obstruction is common in hospitalized patients and is usually undiagnosed and untreated. Spirometry may be a useful component of the examination of hospitalized medical patients to identify OLD.
Chest 02/2004; 125(1):106-11. · 5.25 Impact Factor
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ABSTRACT: The prevalence of asthma continues to increase throughout Western societies and now is estimated to affect nearly 10% of Americans. Asthma is a syndrome that results when a genetically susceptible individual is exposed to specific allergens, which triggers airway inflammation, bronchial hyperresponsiveness, and airway remodeling. Family and twin studies have shown that there is a major genetic component to the development of asthma and have attempted to determine the heritable risk. Linkage analysis has identified several areas of interest on multiple different chromosomes that have been associated with different asthma phenotypes. Candidate gene studies have looked at specific gene polymorphisms that are associated with the development of asthma. Finally, several genes are associated with the development of asthma in response to specific environmental allergen exposures. Asthma is a heterogeneous collection of diseases that can result from multiple different pathological processes. The inheritance of asthma is complex and not due to a single gene mutation. Rather, asthma appears to be the result of multiple genetic mutations that influence an individual's susceptibility to develop asthma in response to specific allergens.
Seminars in Respiratory and Critical Care Medicine 05/2003; 24(2):185-96. · 2.43 Impact Factor
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ABSTRACT: Foreign body aspiration in adults has a variety of clinical presentations and often goes unrecognized. We describe the case of a patient who experienced crack cocaine aspiration and presented with symptoms of an acute asthma exacerbation requiring mechanical ventilation until the eventual diagnosis and bronchoscopic removal of the foreign body.
Chest 06/2002; 121(5):1707-9. · 5.25 Impact Factor
