www.jcrpjournal.com Pulmonary Rehabilitation After Lung Transplantation E7 L ung transplantation (LTx) is a therapeutic, effective, and life-saving intervention for selected patients with end-stage pulmonary disease who are unresponsive to med- ical or surgical treatment. All chronic lung diseases com- monly occur in association with several comorbidities. One of the most common and important extrapulmonary manifestations is skeletal muscle dysfunction, 1,2 which re- sults in deteriorated physical activity, exercise capacity, and quality of life. 3 Although exercise capacity and quality of life have been found to be improve after LTx, especially after the first year, exercise capacity is lower than in healthy controls. 4,5 The most important reason for exercise intolerance is skel- etal muscle dysfunction. The main underlying mechanisms of skeletal muscle dysfunction are not fully understood, but there are several possible causes such as time spent in the intensive care unit, hospital stay duration, and sedentary lifestyle after discharge. Furthermore, muscle weakness may be influenced by infections, acute rejection, and the use of immunosuppressive medication in LTx recipients. 6 It has also been shown that changes in skeletal muscle are associated with decreased oxidative capacity, lactate threshold, and ratio of type I muscle fibers. 7 Therefore, pulmonary rehabilitation (PR), as a comprehensive, mul- tidisciplinary approach, is advocated pre-LTx and in the post-LTx period. The aim of this study was to investigate the effect of a multidisciplinary, comprehensive outpatient PR program on exercise capacity; hand, quadriceps, and respiratory muscle strength; dyspnea and quality of life; psychological status; pulmonary function; and body composition in LTx recipients in the early period after hospital discharge. METHODS SAMPLE CHARACTERISTICS Twenty-three bilateral LTx recipients were referred to the PR center between 2013 and 2017. This study was conduct- ed in accordance with the amended Declaration of Helsinki. The patients’ parameters were recorded after obtaining in- tuitional review board approval and receiving written in- formed consent. The diagnoses of the 23 patients were chronic obstruc- tive pulmonary disease (30%), idiopathic pulmonary fibro- sis (30%), histiocytosis-X (13%), silicosis (9%), bronchiec- tasis (9%), α-1 antitrypsin deficiency (4%), and pulmonary alveolar proteinosis (4%). Six patients did not complete the PR program. The reasons of dropout were 1 case each of bronchial stenosis, venous thrombosis, and pneumonia, and 3 with transportation problems. The initiation of the program was 75 ± 15 d after LTx. The demographic char- acteristics of patients are presented in Table 1. All patients were under immunosuppressive treatment including tacrolimus, mycophenolate mofetil, systemic ste- roids, and prophylactic antifungal, antibacterial, and anti- viral treatment as with the standard recommended medical treatment for LTx recipients. 8 None of the recipients had symptoms or diagnoses of infectious and noninfectious com- plications such as anastomotic problems, allograft rejection, The Efficacy of Outpatient Pulmonary Rehabilitation After Bilateral Lung Transplantation Ipek Candemir, MD; Pinar Ergun, MD; Dicle Kaymaz, MD; Nes ¸e Demir; Filiz Tas ¸demir; Fatma Sengul; Nurcan Egesel; Erdal Yekeler, MD Pulmonary Rehabilitation Author Affiliations: Ataturk Chest Diseases and Surgery Education and Research Hospital, Pulmonary Rehabilitation Center, Ankara, Turkey (Drs Candemir, Ergun, and Kaymaz and Mss Demir, Tas ¸demir, Sengul, and Egesel); and Division of Thoracic Surgery, Yüksek Ihtisas Education and Research Hospital, Ankara, Turkey (Dr Yekeler). The authors declare no conflicts of interest. Correspondence: Ipek Candemir, MD, Atatürk Gög ˘üs Hastalıkları ve Cerrahisi Eg ˘itim Aras ¸tırma Hastanesi, Sanatoryum caddesi Keciören, Ankara, Turkey 06280 (ipekcayli@yahoo.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/HCR.0000000000000391 Purpose: Pulmonary rehabilitation (PR) is advocated in the pre- and post–lung transplantation (LTx) periods. However, there is limited literature on the benefit of PR post-LTx. The aim of this study was to investigate the efficacy of an outpatient, multidisciplinary, comprehensive PR program in bilateral LTx recipients in the early period after LTx. Method: Twenty-three LTx recipients were referred to the PR center. Change in incremental and endurance shuttle walk tests, hand and quadriceps strength, respiratory muscle strength (maximum inspiratory/expiratory pressure), dyspnea (Medical Research Council score), quality of life (St George’s Respira- tory Questionnaire, Chronic Respiratory Questionnaire), and psychological status (Hospital Anxiety Depression Scale) were compared pre- and post-PR. Results: Seventeen of 23 (74%) recipients completed PR, comprising 15 male and 2 female patients whose median age was 51 yr. The initiation of the program was 75 ± 15 d after LTx. The incremental shuttle walk test distance was predicted as 23% before PR and it increased to 36% after PR ( P < .001); the endurance shuttle walk test distance also increased ( P < .01). Significant improvement was seen in upper and lower extrem- ity strength, and St George’s Respiratory Questionnaire and Chronic Respiratory Questionnaire scores and Hospital Anxi- ety Depression Scale scores reflected less anxiety and depressive symptoms. Furthermore, body mass and fat-free mass indices, maximum inspiratory pressure, and maximum expiratory pres- sure improved significantly. There was no significant change in forced expiratory volume in the first second of expiration, forced vital capacity, or Medical Research Council scores. Conclusion: This study demonstrated that patients who at- tended PR within 3 mo of bilateral LTx showed improvements in exercise capacity, respiratory muscle strength, quality of life, body composition, and psychological status. Key Words: exercise capacity • lung transplantation • pulmonary rehabilitation Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.