Surgical Outcomes Of Lung Transplant: Importance Of Quality Of Life

Importance of the study

Lung transplant is a surgery which is done to remove an ailing or diseased lung and replace it with a new lung which is received from another person. The transplant of lungs is done for both the lungs or on single lung. The lung transplant is performed on people of all ages ranging from a new born baby to an aged person of 65 years of age. The lung transplant procedures include single lung, double lung, heart-lung transplant and bilateral sequential. The lungs that are transplanted, are taken from deceased organ donators. This sort of lung transplant is called cadaveric transplant. Individuals who are non-smokers, healthy can donate one part of their lungs. This part of the lung is termed as lobe and the sort of transplant is called living transplant. People who donate a part of their lungs remain or stay healthy for the remaining part of their life. However, the people who undergoes lung transplant experience certain complication in the later part of their life (Gottlieb et al., 2012).

A detailed analysis of surgical outcomes of lung transplant is necessary because, the first year of lung transplant is the most vital because this is the time when major complications occur. Studies have shown that: only 78% of the patients survive the first year, 63% survive for 3 years and about 51% survive for 5 years. Although after a successful lung transplant, studies say that 80% of the people face no issues during their physical activity (Langer et al., 2012).  However, complications related to the lung transplant arise in the later part of their life. Immunosuppressant administered after the lung transplant though work to prevent body’s immunity to act against the transplanted lungs. The immune system although gets slowed but it does not stop either. However, what is not known is that, immunosuppressant drugs that are administered have side effects on the other organs of the body like the kidney, incidence of diabetes and body becomes vulnerable to several infections and diseases. Thus, the survival rate of the patients that undergo lung transplant is not as promising like the other organ transplant like the liver and the kidney. There are other complications and risks like the malignancies and cancer that arise due to constant administration of immunosuppressants, kidney damage, diabetes, stomach problems, blood clot and bleeding, thinning of bones (osteoporosis) (Singer et al., 2013).

The research question that will be addressed in this report is surgical outcomes of lung transplant. However, the study will also include a discussion on the quality of life after lung transplant. For the study on surgical outcomes of lung transplant, a study population of patients who had undergone lung transplant at the University of Vienna, Department of Cardiothoracic surgery. The patients who were above the age of 18 years, have the ability to read and understand German and have undergone lung transplant for more than 3 months are considered for the study. These patients were provided with a study kit when these patients visited the outpatient department of the institute. The study kit that are provided to the patients contained 4 sets of questionnaires and a self-addressed envelope so that they can send the completed questionnaire through mail (Smeritschnig et al., 2005).

The existing instrument which are used for this study purpose is a St. George’s respiratory questionnaire (SGRQ), Short Form -36 (SF-36), Hospital Anxiety and depression Scale (HADs), Self-reported questionnaire (SRQ).

The questionnaire is specially designed for the patients who are affected with COPD and asthma. SGRQ can be used in Bronchiectasis and it has been successful for other diseases like sarcoidosis and Kyphoscoliosis. Studies suggest that SGRQ is also applicable for its use in patients affected with cystic fibrosis. The questionnaire is divided into two parts; the first part is based on the symptoms scores, while the second part is based on the Activity-impact scores. A total score is also used for final analysis. The first part consists of 1-8 questions which addresses respiratory symptoms and its frequency. SGRQ is not designed to be epidemiologically precise, however, it addresses the patients that experiences respiratory problems. The second part consists of questions 9-16 and patient’s current state is addressed (Polatl? et al., 2013).

The SF-36 is a set of 36 item question questionnaire that measure Quality of Life (QoL) over the eight domains. The SF-36 is both emotionally and physically based. The SF-36 measures 8 domains which includes: physical health that causes role limitations, emotional problems that causes role limitations, physical functioning, fatigue/energy, social functioning, emotional wellbeing, general health and pain. The SF-36 is based on an individual perspective because it measures individual quality of life. The SF-36 can be used both for clinical measurements and service evaluation (Lam et al., 2013).

The HAD scale is a self-assessment scale which was developed to investigate the states of depression, emotional distress and anxiety among patients who are receiving treatment for various diseases or clinical complications. However, the scale is not meant to perform as a diagnostic tool. The scale consists of eight questions that is related to depression and anxiety, however the final scale is based on 14 questions. The scale is meant to assess the anxiety and depression after the occurrence of an injury. The scale was originally designed to be used among the hospital populations. However, it is also applicable non-hospital scenarios (Norton et al., 2013).

The SRQ consists of 25 questions among which 20 questions are based on neurotic symptoms, 4 based on psychotic symptoms, and one question based on convulsions or fits. The SRQ was developed by WHO for a collaborative study and to assess the mental health. SRQ was initially administered on a personal basis. However, it gained momentum and later it started to be used for interview purposes. The wider population may or may not be literate, thus the questionnaire is can be administered by the interviewers (Simonelli?Muñoz et al., 2012).

Review of existing instrument

St. George Respiratory Questionnaire (SGRQ) in an instrument which is designed to quantify and measure health related issues in patients that are experiencing the limitations in airflow. It has been found that, the questionnaire effectively measures the disease, disability, activity and symptom. The questionnaire is divided in to several parts among which, the first part deals with the symptoms that measures and quantifies symptomatology. The various symptoms which are quantified are cough frequency, production of sputum, breathlessness, wheeze. It also accounts the frequency and duration of attacks of wheeze and breathlessness. The second part consists of two components. The first is the Activity part and the second is Impact part. The Activity part addresses the activities that are responsible for breathlessness and the activities that get limited due to breathlessness. The Impact part include a wide range of factors that influence the employment, stigmatization, panic, health control, medication needs, side effects of the therapies prescribed, health expectations and disturbances in daily life. The total scores are based on a scale of 0 to 100. The higher the score the more the scale indicates poor health. The internal consistency is seen to be ranging from 0.87-0.91 (Ferrer & Jones, 2014).

Administering the SGRQ- The SGRQ is administered before all the other scheduled procedures. The test is an administered by self and in a quiet room through a clinical way away from the vicinity of family, friends and other patients. However, the test is not allowed to be taken at home. The test is handed over to the patient by a clinical nurse or a study coordinator for its completion. The patient is directed to perform the test as honestly as possible and should take care that there is nothing like wrong or right answer, but the answer must emphasize which best applies to the patient. Also, another information is necessary to be mentioned to the that every question needs to be answered and if any confusion arises, then the clinical nurse and the study coordinator is there to help them (Healthstatus.sgul.ac.uk, 2017).

Handling questions from the patients- how to frame the questions are provided in a guide to SGRQ section. The study coordinator that frames the question must review these guidelines before preparing the questions. It is mandatory that when a patient asks a question to the study coordinator, then he or she must not say the answer directly. The prime goal and motive of the questionnaire is to achieve an understanding of the patient’s own illness status. However, it is always advised that the study coordinator must redirect the question to the patient. There is a provision of reading out the questions to the patients that are unable to register their own response.

Description of the existing instrument

Completing the SGRQ- After the questionnaire is complete, the study coordinator must inspect all the answers to the questions. However, if any question is not responded by the patient then the study coordinator must refer to the patient without much issues. After checking the answers if the study coordinator finds that any answer is incorrect, then he must not refer it to the patient for further query. This provision of asking the correct answer from the patient is not present because this might create a confusion in the mind of the patient and might lead to alteration of the response (Healthstatus.sgul.ac.uk, 2017).

The data obtained from different instruments are fed into a statistical analysis software called SPSS 10.0. the clinical data, demographic data and the data received from the self-reported questionnaire (SRQ) represented as a percentage in the frequency distribution. The values of the variables are depicted as standard deviation, mean and range. The results obtained were considered p< 0.05 as statistically significant.

Results based on clinical and demographic data- 108 lung transplant patients are selected for the study among which 94 patients responded by sending the questionnaire.

Quality of life- Data collected from the SGRQ revealed that the patients who had lung transplant experience reduced rates of respiratory issues when compared with the data of the patients that had obstructive pulmonary diseases. Conversely, all the total scale groups and the sub scale group patients showed a relatively high standard of life. The data from the SF-36 were compared with healthy population. In the mental health, sub scale and the summary scale of mental health, the patients that had undergone lung transplant showed similar results in comparison to the healthy control population. the other scores were found to be lower as well (Smeritschnig et al., 2005).

Psychologic functioning- from the accumulated data it has been found that there is relatively no difference when compared with the health population with the depression and anxiety sub scales. Although, 12% of the patients showed clinical anxiety and the 10% of the patients depicted clinical depression.

Self-reported questionnaire- the first part of the assessment revealed 60% of the respondents were found to be sexually active. Fifty-six percent of the population reported that sex is a vital part of their quality of life. Although data showed that thirty-nine percent of the males were suffering from impotency. The second part of the assessment revealed that 11% of the patients that had undergone lung transplantation were suffering from the side effects of the immunosuppressant, while 29% and 24% suffered mildly and moderately. The third part of the assessment revealed that 76% of the respondents were extremely satisfied and twenty-two percent were fine with the results of the transplant, and ninety-two percent of the respondents expressed the eagerness of opting for the procedure again.

Quality of life and BOS-  the patients were segregated in to two different groups for the examination of quality of life due to the bronchiolitis obliterans syndrome. Patients who reported to have bronchiolitis obliterans syndrome had very poor score on the SGRQ.

Diagnosis and Quality of life-  the data accumulated from the different indication groups revealed that there are significant differences between them. The patients who had cystic fibrosis showed the fine quality of life scores on the SGRQ. Bronchiectasis, sarcoidosis and lymphangiomyomatosis are considered as the other indicators and they scored the highest on the summary scale component of SF-36. However, there were no differences on the component of physical summary scale (Smeritschnig et al., 2005).

Depending on the study of the lung transplant patients, 92% of the patients revealed their eagerness to again undergo lung transplantation. Seventy six percent were highly satisfied and twenty two percent were found to be satisfied with the transplantation outcome. Patients also mentioned that before the surgery they were on oxygen apparatus for as long as 24 hours, were unable move and were dependent on others. Thus, the results depict that the serious complications that arise after the lung transplantation seems to have no serious effect on the patients of Department of Cardiothoracic, University of Vienna (Medlineplus.gov, 2017). However, studies made on the surgical outcomes of lung transfer showed that patients experience different kinds of medical complications. Hence, the instrument for this study showed 10% depression and 12% anxiety among the patients, whereas the instrument was unable to highlight any major difference when compared with the healthy individuals.

Reference

Ferrer, M., & Jones, P. W. (2014). St. George's Respiratory Questionnaire. In Encyclopedia of Quality of Life and Well-Being Research (pp. 6314-6317). Springer Netherlands.

Gottlieb, J., Warnecke, G., Hadem, J., Dierich, M., Wiesner, O., Fühner, T., ... & Welte, T. (2012). Outcome of critically ill lung transplant candidates on invasive respiratory support. Intensive care medicine, 38(6), 968-975.

Healthstatus.sgul.ac.uk. (2017). SGRQ Downloads — Health Status Research Team. Healthstatus.sgul.ac.uk. Retrieved 20 December 2017, from

https://www.healthstatus.sgul.ac.uk/sgrq/sgrq-downloads

Lam, E. T., Lam, C. L., Fong, D. Y., & Huang, W. W. (2013). Is the SF?12 version 2 Health Survey a valid and equivalent substitute for the SF?36 version 2 Health Survey for the Chinese?. Journal of evaluation in clinical practice, 19(1), 200-208.

Langer, D., i Iranzo, M. C., Burtin, C., Verleden, S. E., Vanaudenaerde, B. M., Troosters, T., ... & Gosselink, R. (2012). Determinants of physical activity in daily life in candidates for lung transplantation. Respiratory medicine, 106(5), 747-754.

Medlineplus.gov. (2017). Retrieved 14 December 2017, from https://medlineplus.gov/ency/article/003010.html

Norton, S., Cosco, T., Doyle, F., Done, J., & Sacker, A. (2013). The Hospital Anxiety and Depression Scale: a meta confirmatory factor analysis. Journal of Psychosomatic Research, 74(1), 74-81.

Polatl?, M., Yorganc?o?lu, A., Aydemir, Ö., K?rk?l, G., Köktürk, N., Uysal, A., ... & Günakan, G. (2013). Validity and reliability of Turkish version of St. George's respiratory questionnaire. Tuberkuloz ve toraks, 61(2), 81-87.

Simonelli?Muñoz, A. J., Fortea, M. I., Salorio, P., Gallego?Gomez, J. I., Sánchez?Bautista, S., & Balanza, S. (2012). Dietary habits of patients with schizophrenia: A self?reported questionnaire survey. International journal of mental health nursing, 21(3), 220-228.

Singer, J. P., Chen, J., Blanc, P. D., Leard, L. E., Kukreja, J., & Chen, H. (2013). A thematic analysis of quality of life in lung transplant: the existing evidence and implications for future directions. American Journal of Transplantation, 13(4), 839-850.

Smeritschnig, B., Jaksch, P., Kocher, A., Seebacher, G., Aigner, C., Mazhar, S., & Klepetko, W. (2005). Quality of life after lung transplantation: a cross-sectional study. The Journal of heart and lung transplantation, 24(4), 474-480.