The Clamshell Protocol: Rewriting the Rules After Lung Transplantation

Movement precautions after lung transplantation (LTx) through a clamshell approach often mirror sternal precautions, but anatomical differences between incisions and emerging evidence supporting less restrictive sternal precautions raise questions about their necessity for LTx. This article describes the development of a novel protocol at a single LTx center introducing reduced clamshell precautions alongside a supervised early progressive functional rehabilitation protocol. These reduced precautions permit immediate upper extremity use for functional tasks, with movement and weight restrictions gradually lifted by week 8. A 12-week rehab protocol, starting upon transfer from the intensive care unit, incorporates structured aerobic, strength, and flexibility training while adhering to these precautions. A comprehensive approach is proposed to monitor the impact of the revised clamshell precautions and rehab protocol, including tracking adverse events related to healing of the surgical site and assessing key patient outcomes including health-related quality of life, aerobic capacity, dyspnea, and pain.