Question 1

Which of the following problems is associated with long-term heart transplant patients?

Accepted Answer

A troublesome and life-limiting problem in long-term heart transplant survivors,regardless of age,is the development of premature coronary artery disease or coronary vasculopathy,also known as graft atherosclerosis.

Question 2

What is the predominant problem leading to heart transplantation in children younger than 1 year of age?

Accepted Answer

Congenital cardiac lesions are the predominant problem leading to heart transplantation in children younger than 1 year of age,whereas cardiomyopathy predominates in older children.

Question 3

Which of the following cardiac problems is responsible for the vast majority of neonatal cardiac transplants?

Accepted Answer

Neonatal heart transplantation has been used almost exclusively for hypoplastic left-heart syndrome,which is uniformly fatal if surgical correction or transplantation is not offered.The current experience with either surgical correction or transplantation does not clearly indicate which is more appropriate to optimize survival.

Question 4

Which of the following medications is associated with a decreased white blood cell count caused by bone marrow suppression?

Accepted Answer

The major complication from both azathioprine and mycophenolate mofetil is a decreased white blood cell count caused by bone marrow suppression;this usually improves with temporary discontinuation of the medicine or a decrease in dose.

Question 5

Which of the following conditions are considered complications of thoracic organ transplantation?
I.Respiratory failure
II.Bronchiolitis obliterans
III.Lung allografts
IV.Infection

Accepted Answer

The complications of thoracic organ transplantation can be grouped into the following categories: (1)respiratory failure and related problems, (2)acute rejection, (3)infection, (4)chronic rejection or bronchiolitis obliterans, (5)drug toxicity,and (6)other complications.

Question 6

When could kidneys,liver,and lungs be procured for transplantation from a patient with anticipated cardiac arrest?

Accepted Answer

If circulatory arrest is anticipated within minutes of withdrawal of ventilatory support,organ donation may be possible.In that situation,the organ procurement center is contacted and recovery surgeons are notified and present in a nearby operating room at the time of extubation.If circulatory arrest occurs within 30 to 60 minutes,kidneys,livers,and lungs may be procured for transplantation.

Question 7

Months after receiving a lung transplant a patient with cystic fibrosis exhibits the following signs and symptoms:
Increasing dyspnea
Increased coughing with sputum production
Colonization with Pseudomonas species
The patient also appears to be in respiratory failure.Which of the following conditions is likely developing?

Accepted Answer

In the majority of patients,bronchiolitis obliterans is a progressive disease manifested by increasing dyspnea,increased coughing with sputum production,colonization or infection with Pseudomonas species,and eventual respiratory failure and death.

Question 8

Which of the following conditions is a frequent cause of graft failure occurring within the first 90 days after lung transplantation?

Accepted Answer

Deaths within the first 90 days after lung transplantation (early deaths)result most commonly from graft failure due to ischemia-reperfusion injury.Less common are surgical problems such as airway anastomotic dehiscence or massive hemorrhage.Even less common are overwhelming infection,either systemic or pulmonary;multiple organ failure;or acute graft rejection.Late deaths are generally related to infection or bronchiolitis obliterans,usually a manifestation of chronic rejection.

Question 9

Which of the following forms of interaction tend to occur between the respiratory therapist and a patient who receives a lung transplant?
I.Mechanical ventilation
II.Pulmonary rehabilitation
III.Bronchopulmonary hygiene
IV.Hyperbaric oxygenation

Accepted Answer

There are multiple areas of interaction between the respiratory therapist (RT)and the transplant patient.Care of the patient who undergoes thoracic transplantation always involves the teamwork of a variety of health care professionals.The child who receives a lung or heart-lung transplant is especially likely to require an RT on the team.Familiarity with the diseases leading to transplantation,as well as the transplantation process,will help the practitioner provide more comprehensive care to the patient as well as improve interaction with the health care team.The RT may already be familiar with the transplant candidate because of his/her role in providing routine care for the primary disease process,particularly for chronic pulmonary diseases such as cystic fibrosis.The RT may become a key contact with the transplant candidate in the initial evaluation process or during pulmonary function testing.After the patient has been accepted to the transplantation list,the RT may be involved in providing an exercise evaluation and rehabilitation program in an effort to optimize the patient's condition while he or she is awaiting transplantation.Immediately after the transplantation procedure,the RT will be involved with the patient in the intensive care unit,primarily providing mechanical ventilatory support and maintenance of the artificial airway.Because of the temporary interruption of ciliary function,the RT may be asked to provide aerosolized bronchodilators,mechanical aids to assist full inflation and cough,and bronchopulmonary hygiene.For most patients,this therapy is not required on a long-term basis.Shortly after the patient is taken off mechanical ventilation,the RT may be involved in additional mucus clearance measures.Exercise and rehabilitation should be resumed as soon as possible after extubation.

Question 10

What are some reasons for the decline in heart-lung transplants among infants?
I.Difficulty in obtaining a donor
II.Avoidance of cardiac rejection
III.Averting premature coronary artery disease
IV.Reducing the length of time on cardiopulmonary bypass

Accepted Answer

With the ability to successfully transplant a single lung or two lungs,the use of heart-lung transplantation for pulmonary disease has decreased.Multiple reasons exist for the decline in heart-lung transplants,including (1)the limited availability of satisfactory coupled heart-lung donations from a single donor (governed in part by the distribution algorithm unique to each country), (2)the practical advantage of using the heart-lung block for three separate donations (one heart and two single lungs), (3)the decreased risk of cardiac rejection if isolated lung transplantation is performed,and (4)the decreased risk of premature coronary artery disease.

Question 11

Which of the following chronic lung diseases is the most common indication for bilateral lung transplantation?

Accepted Answer

Cystic fibrosis is the most common indication for bilateral lung transplantation,almost exclusively above 6 years of age.

Question 12

Twenty-four hours after a pediatric patient has undergone lung transplantation,the therapist notices on the patient's chest X-ray features consistent with pulmonary edema.How should the therapist interpret this finding?

Accepted Answer

Reperfusion injury,which occurs in 10% to 20% of lung transplants,mimics the acute respiratory distress syndrome clinically and radiographically.On chest radiography,pulmonary edema,either immediately after transplantation or within the first 72 hours,is usually a sign of ischemic injury or reperfusion injury.Interruption of the pulmonary lymphatics,which are cut during the surgery,also contributes to pleural,alveolar,and interstitial fluid accumulation.

Question 13

Which of the following is the most common indication for heart transplantation?

Accepted Answer

In the 1980s the primary indication for heart transplantation was cardiomyopathy.However,in more recent years the proportion of transplantations for congenital heart defects has been increasing (see Table 21-2 in the textbook).Congenital lesions are the indication in 40% of patients,leading to heart transplantation in children younger than 1 year of age,especially in the United States,but only 25% in older children.

Question 14

Which of the following medications are used as antirejection agents?
I.Trimethoprim-sulfamethoxazole
II.Cyclosporine
III.Azathioprine
IV.Mycophenolate mofetil

Accepted Answer

Most immunosuppressive regimens for organ transplantations (thoracic and other solid organs)include the combined use of cyclosporine or tacrolimus,azathioprine or mycophenolate mofetil,and prednisone.Tacrolimus and mycophenolate mofetil are now the most commonly used immunosuppressants and are generally needed for the life of the transplant recipient.

Question 15

Why does the pulmonary infection rate for lung transplantation appear to be higher than with other solid organ transplants?

Accepted Answer

Although pulmonary infections are common because of the immunosuppression required with any solid organ transplant,the pulmonary infection rate for lung transplantation appears to be high.This may be partially explained by the fact that the lung is the only solid organ that,after transplantation,is regularly in direct contact with the external environment and multiple potential pathogens.Many pulmonary bacterial infections are readily identified but often require bronchoalveolar lavage (BAL)and culture for accurate diagnosis and treatment with antibiotics.

Question 16

What is the predominant cause of early postoperative mortality associated with heart transplantation?

Accepted Answer

Early postoperative mortality arises from graft failure and,less commonly,cardiac rhythm disorders.

Question 17

Which of the following microorganisms is associated with increased mortality among patients with cystic fibrosis?

Accepted Answer

The highly antibiotic-resistant Burkholderia cepacia complex organisms have been associated with significant morbidity and mortality in patients with cystic fibrosis.These resistant organisms are found most often in the older patient with advanced lung disease,and this is the patient with cystic fibrosis who most likely needs transplantation.Of concern is the report that Burkholderia species can be particularly lethal to transplant patients with cystic fibrosis who acquire it after transplantation.

Question 18

What typically makes lungs unsuitable for donation?

Accepted Answer

Lungs are frequently infected and/or atelectatic or injured during prolonged intubation and ventilation,or unsuitable because of pulmonary edema,trauma,or aspiration.

Question 19

The therapist notices the following signs in a pediatric patient who recently had a heart transplant:
Decreased cardiac contractility
Congestive heart failure
Tachycardia
Tachypnea
Malaise
How should the therapist interpret these signs?

Accepted Answer

In the lung transplant patient,tachypnea,bibasilar inspiratory crackles on auscultation,increased interstitial infiltrates on chest radiography,and hypoxemia by pulse oximetry are often associated with acute rejection (see Figure 21-6 in the textbook).For older patients who can perform spirometry,a drop in pulmonary function,either restrictive or obstructive,is often the most sensitive indicator of acute rejection.

Quiz 21: Thoracic Organ Transplantation