Gerene S. Bauldoff

Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals POSITION STATEMENT OF THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognizes that interdisciplinary health care professionals providing pulmonary rehabilitation services need to have certain core competencies. This statement updates the previous clinical competency guidelines for pulmonary rehabilitation professionals, and it complements the AACVPRs Guidelines for Pulmonary Rehabilitation Programs. These competencies provide a common core of 13 professional and clinical competencies inclusive of multiple academic and clinical disciplines. The core competencies include patient assessment and management; dyspnea assessment and management; oxygen assessment, management, and titration; collaborative self-management; adherence; medication and therapeutics; non-chronic obstructive pulmonary diseases; exercise testing; exercise training; psychosocial management; tobacco cessation; emergency responses for patient and program personnel; and universal standard precautions.

Cigarette smoking following lung transplantation: effects on allograft function and recipient functional performance.

PURPOSE: Despite mandatory tobacco abstinence following lung transplantation (LTX), some recipients resume smoking cigarettes. The effect of smoking on allograft function, exercise performance, and symptomatology is unknown. METHODS: A retrospective review was conducted of LTX recipients who received allografts over an 8-year interval and who were subjected to sequential posttransplant pulmonary function testing (PFT), 6-minute walk (6MW) testing, and assessments of exertional dyspnea (Borg score). Using post-LTX PFT results, recipients were determined to have either bronchiolitis obliterans syndrome (BOS), a manifestation of chronic allograft rejection, or normal pulmonary function (non-BOS). With respect to post-LTX pulmonary function, 6MW distances, and Borg scores, comparisons were made between these recipient groups and those who resumed smoking. RESULTS: Of 34 LTX recipients identified, 13 maintained normal lung function (non-BOS), while 16 demonstrated a decline in their PFT values consistent with BOS. Five recipients began smoking at median postoperative day 365 and smoked 1 pack per day for a mean of 485.6 days. Smokers developed a deterioration of their PFT values that was similar to those with BOS (P = .47) and tended to be worse than those in the non-BOS group (P = .09). All smokers experienced a decline in 6MW distances similar to those with BOS and non-BOS but reported less exertional dyspnea (lower Borg scores) than those with BOS. CONCLUSION: Recipients of LTX who resume cigarette smoking demonstrate a decline in pulmonary function similar to those afflicted with chronic allograft rejection but do not experience a decrement in their functional performance or increased dyspnea.

When to refer a patient for lung transplantation

Lung transplantation has become a therapeutic option for selected patients with end-stage pulmonary parenchymal or vascular disease. This is primarily because survival has increased to 60% locally (Figure 1) and internationally at 2 years after lung transplantation [1, 2]. When heart and lung transplantation was the only procedure to treat such patients and waiting times were <6 months, the principle criteria to determine transplant candidacy was the presence of right ventricular failure. Because isolated lung transplantation has replaced heart and lung transplantation and the average waiting time for a donor has increased to 18–24 months, criteria requiring right heart failure for transplant candidacy are no longer viable. Thus the appropriate time to refer, list and perform a lung transplant is unclear.

Cardiovascular Consequences of Pulmonary Hypertension

Pulmonary hypertension occurs when pulmonary vascular pressures are elevated. Pulmonary arterial hypertension is associated with occlusion of the pulmonary arterial tree, while pulmonary venous hypertension is seen when pulmonary vein outflow is impeded. Cardiovascular consequences are common with pulmonary hypertension, regardless of the underlying pathogenesis and whether management is complex. However, there are a number of interventions that may improve quality of life and survival of pulmonary hypertension. This article discusses current recommendations for diagnosis and management.