Early Mobility and Peds Conditions

Sequelae of Bed Rest

4-5% muscle strength loss each week

Tachycardia, decreased SV, CO, peak O2 uptake, orthostatic tolerance after 24 hours of bed rest

Shift towards fast twitch glycolytic

Insulin resistance, hypertriglyceremia, ectopic fat storage, decreased HDl cholesterol

Increased risk of delirium, CIPNM, and weakness

Benefits of early mobilization

earlier DC, improved respiratory function, reduced wasting/re-admission and mortality

CI for therapy for those with mechanical ventilation

MAP <65 or >120

Brady/tachycardia

RR <5 or >40

SpO2 <88%

ICP >20

Active GI blood loss, MI, procedure, insecure airway, agitation longer than 30m

Adaptations in fetal CVP

Placenta pools oxygenated blood and umbilical vein brings O2 towards but bypasses liver via the ductus venosus into the IVC

Alveoli are filled with fluid (low o2) which leads to hypoxic pulmonary vasoconstriction (increase resis in lungs, pulmonary arterial pressure, RV pressure, RA pressure)

Blood can enter LA from RA via foramen ovale

Ductus arteriosus blood from pulmonary artery → descending aorta →internal iliac arteries → umbilical arteries → placenta (low resistance pathway)

Surfactant

at 22wks, production occurs and is stored into lung cells

Endocrine adaptations

At birth, catecholamines (BP increase) increase and ventilation causes alveolar stretch

Cortical progressively increases from 30-36wks and rapid increase at birth to activate sodium pump to clear fetal lung fluid

What occurs during post-delviery

Placenta removed and lungs take in air

Umbilical cord is cut (increases resistance)

Lungs change from fluid to air (sodium pump allows for fluid to enter interstitial space; arterioles near alveoli dilate due to increased O2 → decreased RV/RA/pulmonary artery pressure and increased LA pressure, foramen ovale closes) (ductus arteriosus constricts due to lack of PGE from placenta; fully closed by 2-3wks)

What happens to adaptations post birth

Umbilical vein → ligamentum teres hepatis

Ductus venosus → ligamentum venosum

Foramen ovale → fossa ovalis
Umbilical Arteries → medial umbilical ligaments
Ductus arteriosus → ligamentum arteriosum

Patent Ductus Arteriosus

S/S: tachycardia, ejection systolic murmur, bounding pulse, increased respiratory distress, poor weight

Persistent opening of aorta

Patent Foramen Ovale

Venous thrombus may cross PFO into LA and enter systemic circulation (paradoxical embolism)

Present in 25% of adults; problem if clot forms

Endocardial Cushion Defect (ECD)

walls of chambers of heart are poorly formed/absent

Malformation of atrioventricular valves

Complete: involves atrial septal defect (ASD) and ventricular septal defect (VSD) - one large valve present

Partial: only an ASD or VSD - two valves but one is clefted

Surgery req <1y

Tetrology of Fallot

VSD, RV outflow obstruction, RV hypertrophy, aortic override → mixing of oxy and deoxy blood in LV via VSD and preferential flow of mixed blood through aorta because of obstruction to pulmonary valve

Cyanosis and crying/agitated

Pharm to maintain patency of ductus arteriosus to incre pulmonary BF

Respiratory Distress Syndrome

Due to lung immaturity, insufficient # of alveoli or surfactant (increased work of breathing and failure)

Most common in premie

Bronchopulmonary Dysplasia (BPD)

develops after chronic inury to lung with insufficiency healing (o2 toxicity and damage from mechanical ventilation) → inflammation, pulmonary edema, fibrosis

long term O2 therapy, decreased growth, increase neuro sequelae

Meconium aspiration syndrome

Respiratory distress in full term neonate born through meconium stained amniotic fluid (gasping prior to delviery or postnatal breaths)

→Peripheral airway blocked (atelectasis, pneumothorax, pulmonary HTN, BPD)

Cystic Fibrosis

Complex autosomal recessive disorder

S/S: chronic productive cough, abnormal x-ray, viscous mucus and impaired mucociliary transport, nasal polyps, digital clubbing, Na loss

→ chronic lung infections, fibrosis/bronchiectasis, nocturnal hypoxia

Cerebral Palsy

Altered respiratory mechanics, hypoventilation, clearing secretions, increased WOB, impaired phonation, aspiration, low physical activity

Down’s

1/3-1/2 have ECD, VSD, ASD, or tetralogy of fallot

Hypotonia (trunk tone reduced clearance; medullary compression from AA instability), delay in motor skills, hearing loss, cognition

Muscular Dystrophy

Duchenne’s: respiratory weakness and increased cardiac involvement with age (cardiomyopathy, arrhythmias, ECG, sudden death)

Becker’s: cardiac involvement earlier in life

Spinal Muscular Atrophy (SMA)

degeneration of anterior horn cells (LMN and progressive muscular atrophy)

ASD and VSD present

Weakness, contractures, fasciculations, scoliosis

Intervention Considerations

Elongation may not occur after physiological flexion and diaphragm may be impaired

Avoid Trendelenburg with reflux

Percussion with one hand for small children

With impaired ventilation (posterior pelvic tilt enhances diaphragm whereas prone improves ventilation to posterior lobe segments)