Pediatrics CVD

hypertension

the most common medical complication of pregnancy

blood pressure (rest, response to activity)

what should be regularly monitored in pregnant patients during PT sessions?

premenopausal

PRE-POST menopausal women appear protected against CVD compared with med and present with CVD 10 years later.

increased

menopause and oophorectomy result in DECREASED/INCREASED CVD incidence and severity, and prevalence of CAD.

estrogen

what female hormone is shown to be cardioprotective and decreases in postmenopausal women?

third

during what trimester of pregnancy is ventilation to dependent regions of the lungs impaired?

decreased

In the third trimester, a decrease in chest wall compliance is caused by INCREASED/DECREASED downward excursion of diaphragm.

8-40%

What is expiratory reserve volume (ERV) reduced to in third trimester?

increased

In the third trimester, the work of breathing is DECREAED/INCREASED

supine

specifically, what position may pregnant women have difficulty in taking a deep breath?

supine, standing

Exercises performed in ______ position are inadvisable after the first trimester as are prolonged periods of motionless _________.

cardiac output

Both supine and prolonged periods of motionless standing are associated with decreased ______ _____ in pregnant women?

4

development of respiratory system begins in what week of gestation?

a

Four periods of lung maturation: 6-16 weeks?

a. pseudoglandular

b. canalicular

c. terminal saccular

d. alveolar

b

Four periods of lung maturation: 16-26 weeks?

a. pseudoglandular

b. canalicular

c. terminal saccular

d. alveolar

c

Four periods of lung maturation: 26 weeks-birth?

a. pseudoglandular

b. canalicular

c. terminal saccular

d. alveolar

d

Four periods of lung maturation: 32 weeks-8 years?

a. pseudoglandular

b. canalicular

c. terminal saccular

d. alveolar

7

APGAR scores greater than ____ out of 10 is reassuring during hx-taking during eval

3

earliest development is a pair of endothelial strands (angioblastic cords) appearing in what week of gestation?

21

cords for heart tubes by what day of gestation?

22-23

heart beats by what days of gestation?

27

heart is circulating blood by what day of gestation?

4

the atrium begins to separate into R and L atria with sequential growth of two septa by the middle of what gestational week?

5

What gestational week?

dorsal part of the septum deteriorates, forming a new right-to-left shunt through the foramen secundum

7

What gestational week?

ventricles divide equally

8

What gestational week?

septum secundum grows from the ventrocranial wall of the atrium on the right side of the septum primum

10

What gestational week?

cardiac development is primarily complete

fetal

fetal/ post fetal - most of the blood bypasses the lungs and reaches the left ventricle via the foramen ovale or ductus arteriosus

placenta

fetus uses what to obtain O2 and get rid of CO2?

vasoconstricted

blood vessels of the pulmonary circulation are VASODILATED/VASOCONSTRICTED in the fetus

congenital heart disease (CHD)

Incidence: mod-sev forms, ~6/1000 live births, varies by state

Highest total costs for hospitalizations: hypoplastic L heart syndrome, coarctation of the aorta, tetralogy of Fallot

cyanotic

congenital heart defects - arterial O2 sat is decreased;

involve right-to-left shunting, where most of the blood bypasses the lungs

signals increased for RBC formation --> results in polycythemia

increased risk for CVA

cyanotic

ACYANOTIC/CYANOTIC:

tetralogy

transposition

truncus arteriosus

total anomalous pulmonary venous return

hypoplastic left heart syndrome

acyanotic

congenital heart defects - normal O2 saturation;

increase pulmonary BF --> fully oxygenated blood is shunted back into lungs and body (L and R shunting)

Symptoms: sweating, increased RR, heart failure

Problems: low PaO2 to periphery, low systemic SV, increased work on heart

acyanotic

ACYANOTIC/CYANOTIC:

ventricular septal defect (VSD)

atrial septal defect (ASD)

patent ductus arteriosus (PDA)

coarctation

atrial septal defects (ASD)

acyanotic lesions - caused by patent foramen ovale

a "hole" in the wall that separates top two chambers of heart

defect allows O2-rich blood to leak into the oxygen-poor blood chambers in the heart

defect in septum between the heart's atria

patent ductus arteriosus (PDA)

acyanotic lesions - occurs when normal circulatory pathway between descending aorta and pulmonary artery fails to close after birth

ventricular septal defect (VSD)

acyanotic lesions - characterized by one or more small openings in the wall separating the ventricles (ventricular septum)

hole in ventricular septum, causing higher pressure in heart or reduced O2 to body

atrioventricular septal defects

acyanotic lesions - atrioventricular canal defects or endocardial cushion defects

coarctation of aorta (COA)

acyanotic lesions - obstruction of left ventricular outflow because of narrowing of the aorta

narrowing affects blood flow where the arteries branch out to carry blood along separate vessels to upper and lower parts of body

can cause high BP or heart damage

complete atrioventricular canal defect (CAVC)

acyanotic lesions - a large hole in the center of the heart affecting all four chambers where they would normally be divided

allows O2-rich and O2-poor blood to mix and the chambers and valves do not properly route the blood to each station of circulation

tetralogy of Fallot

cyanotic lesions - (1) pulmonary stenosis, (2) VSD, (3) overriding aorta and (4) right ventricular hypertrophy

hypoplastic left-heart syndrome (HLHS)

cyanotic lesions - (1) hypoplastic (underdeveloped) left ventricle, (2) aortic and mitral valve stenosis (narrowing) or atresia (complete closure), and often (3) coarctation of aorta

transposition of great arteries

cyanotic lesions - positions of the aorta and pulmonary artery are reversed

tricuspid atresia

cyanotic lesions - tricuspid valve between right atrium and right ventricle is either not patent or absent

pulmonary atresia

cyanotic lesions - pulmonary valve fails to develop

truncus arteriosus

cyanotic lesions - a single great artery arises from ventricles, carrying both pulmonary and systemic blood flow

total anomalous pulmonary venous return

pulmonary veins attach to the right atrium or to other veins that drain into the right atrium

pediatric heart failure

cyanotic lesions - circulation does not meet the metabolic needs of the body because of decreased cardiac output (systolic HF) or decreased ventricular relaxation (diastolic HF)

tetralogy of Fallot

cyanotic lesions - heart defect features four problems:

hole between lower chambers of heart

obstruction from heart to lungs

aorta lies over the hole in the lower chambers

muscle surrounding lower right chamber becomes overly thickened

often seen in children with Down Syndrome

tricuspid atresia

cyanotic lesions - no tricuspid valve so blood cannot flow correctly from R atria to R ventricle

results in small, underdeveloped R ventricle

survival depends on there being an opening in the wall between the atria (atrial septal defect) and usually an opening in the wall between the two ventricles (ventricular septal defect)

hypoplastic left heart syndrome (HLHS)

cyanotic lesions - underdeveloped left side of the heart

aorta and left ventricles are too small and the holes in the artery and septum did not properly mature and close

poor prognosis

those who survive undergo multiple surgeries

pulmonary atresia

cyanotic lesions - no pulmonary valve exists

blood can't flow from right ventricle into the pulmonary artery and on to the lungs

right ventricle and tricuspid valve are often poorly developed

if PDA narrows or closes, lung blood flow is reduced to critically low levels which can cause serious cyanosis; symptoms develop soon after birth

Eisenmenger syndrome

cyanotic lesions - irregular blood flow in the heart and lungs

causes blood vessels in lungs to become stiff and narrow, resulting in increased BP in lung arteries (pulmonary arterial hypertension)

permanently damages blood vessels in lungs

truncus arteriosus

cyanotic lesions - rare, congenital, cyanotic heart defect characterized by a ventricular septal defect (VSD), a single truncal valve, and a common ventricular outflow tract (OT)

systemic venous blood and pulmonary venous blood mix at the VSD level, and the resulting desaturated blood is ejected

ventricular assist device (VAD)

mechanical pump to help blood flow through the body

placement in the pediatric population is used as a bridge to candidacy for transplant, recovery from illness, or destination therapy (last effort)

PT with this shows improvements in function, exercise capacity, and acceleration in recovery from transplant

non-critical

NON-CRITICAL/CRITICAL CHD:

~97% of babies born are expected to survive to one year of age.

non-critical

NON-CRITICAL/CRITICAL CHD:

~95% of babies born are expected to survive to 18 years of age.

critical

NON-CRITICAL/CRITICAL CHD:

~75% of babies born are expected to survive to one year of age.

critical

NON-CRITICAL/CRITICAL CHD:

~69% of babies born are expected to survive to 18 years of age.

37

premature babies are born before what week of gestation?

periodic

premature infants may demonstrate this breathing pattern, taking 5-10 second pauses in breathing

apnea of prematurity

pediatric respiratory conditions - cessation of breathing for 20 seconds or longer in an infant born at less than 37 weeks gestation, causing bradycardia, cyanosis or both

persistent pulmonary hypertension (PPHN)

pediatric respiratory conditions-

characterized by increased pulmonary vascular resistance

usually appears within the first 12 hours of life

associated with cyanosis, tachypnea, intercostal retractions, nasal flaring, or grunting

seen in Pts with RDS and meconium aspiration syndrome (MAS)

respiratory distress syndrome (RDS)

pediatric respiratory conditions - aka hyaline membrane disease

caused by deficient amount of pulmonary surfactant, causing the overall retractive forces of the lung to be greater than normal

decreases lung compliance

increases work of breathing

leads to progressive diffuse microatelectasis, alveolar collapse, increased ventilation-perfusion mismatching, and impaired gas exchange

respiratory distress syndrome (RDS)

pediatric respiratory conditions - characteristics include:

airless alveoli

inelastic lungs

respiration rate greater than 60 breaths per minute

nasal flaring

intercostal and subcostal retractions

grunting on expiration

peripheral edema

a

A therapist is planning to use percussion for assisting airway clearance with a patient with COPD admitted to the hospital. What major precaution might change the selection of intervention?

a. a platelet count of 20,000

b. dyspnea when in the Trendelenburg position

c. SaO2 ranging from 88-94% on RA

d. diagnosis of multilobe pneumonia

sudden infant death syndrome (SIDS)

pediatric respiratory conditions - sudden, unexpected death of an otherwise healthy infant during sleep

may be linked with respiration

"Back to Sleep" campaign encourages putting infants to sleep only in the supine position - significant increase in plagiocephaly

meconium aspiration syndrome

pediatric respiratory conditions - fetal stress may cause fetal rectal sphincter muscles to relax, resulting in meconium in the amniotic fluid

infant then ay aspirate amniotic fluid and meconium

branchopulmonary dysplasia (BPD)

pediatric respiratory conditions - chronic respiratory disorder characterized by scarring of lung tissue, thickened pulmonary arterial walls, and mismatch between lung ventilation and perfusion

persistence of respiratory symptoms after 1 month, abnormal radiographic findings, dependence on supplemental O2

ECMO (extracorporeal membranous oxygenation)

an external heart-lung bypass machine used as advanced life support

indicated when cardiac or respiratory failure is not responding to maximal medical intervention

removes blood, adds O2, and removed CO2 before moving blood back into child

venovenous (V-V)

type of ECMO - when lungs need assistance in functioning

venoarterial (V-A)

type of ECMO - when both the heart and lungs need assistance

cystic fibrosis

pediatric respiratory conditions - genetic, autosomal-recessive disease that affects exocrine gland function

all CF mutations affect the flow of water and chloride in and out of the cells lining various organs (including the lungs)

different classes of mutation cause different defects within the cells

cystic fibrosis

pediatric obstructive lung conditions - multisystem disorder in children and young adults that affects every organ system with epithelial surfaces

cystic fibrosis

pediatric obstructive lung conditions - mucus stasis occurs in the conducting airways of the lung, nasal sinuses, sweat glands, small intestine, pancreas and biliary system

cystic fibrosis

pediatric obstructive lung conditions - most prominent symptoms related to pulmonary, intestine and pancreatic involvement

cystic fibrosis

pediatric obstructive lung conditions - pulmonary system is affected by chronic airway obstruction and inflammation, thick tenacious mucus, and recurrent bacterial infections

cystic fibrosis

pediatric obstructive lung conditions - intestine develops thick mucous that interferes with nutrient absorption and results in malnourishment and low weight

pancreas develops pancreatic insufficiency

cystic fibrosis

pediatric obstructive lung conditions - other affected organs include upper airway (sinus infections), male reproductive tract (obstructive azoospermia), sweat glands (elevated sodium chloride levels in sweat)

cystic fibrosis

pediatric obstructive lung conditions - goals of medical management include

controlling lung infection

promoting mucus clearance

improving nutritional status

cystic fibrosis

pediatric obstructive lung conditions - implications for PT:

secretion clearance techniques

controlled breathing techniques

exercise (endurance and strength)

inspiratory muscle training

thoracic stretching exercises

postural re-education to avoid round-shouldered postures

CFTR (CF transmembrane regulator) modulators

target gene defect associated with CF; examples include ivacaftor, trikafta

Ivacaftor (Kalydeco)

CFTR modulator - first therapeutic agent to target the defective protein made by CFTR gene mutation

Trikafta (Elexacaftor/tezacaftor/ifacaftor)

CFTR modulator - combination of three drugs approved for Pts with CF at least 12 years old with at least one F508del mutation

asthma

pediatric obstructive lung conditions - chronic inflammatory disorder of the airways

involves abnormal accumulation of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells, and myofibroblasts

causes recurrent episodes of wheezing, dyspnea, chest tightness, and coughing

episodes often associated with widespread but variable airflow obstruction

asthma

pediatric obstructive lung conditions - key findings include:

reversibility of airway obstruction following the use of bronchodilator medications is hallmark

airway responsiveness occurs when the airways demonstrate excessive bronchoconstriction in response to inhalation of an irritating substance

results of pulmonary function tests help classify severity

asthma

pediatric obstructive lung conditions - four tx recommendations:

use objective measures of pulmonary function to assess severity and monitor therapy effectiveness

identify and eliminate factors that worsen symptoms, precipitate exacerbations, or promote ongoing airway inflammation

provide pharmacologic therapy to reverse bronchoconstriction and to reverse and prevent airway inflammation

create therapeutic partnership between Pt and care provider

asthma

pediatric obstructive lung conditions - PT implications:

PT should not begin unless appropriate medication therapy has been initiated and there is good symptom control

exercise-induced may require use of bronchodilator meds 30 minutes before exercise

asthma

pediatric obstructive lung conditions - key interventions:

secretion clearance techniques

controlled breathing techniques

exercise and strength training

thoracic stretching exercises

postural re-education to avoid round-shouldered postures

review of medications and timing

down syndrome

pediatric conditions with secondary cardiopulmonary issues - associated with endocardial cushion defect, VSD, ASD, tetralogy of Fallot

cardiac defects and sleep apnea more common

exercise throughout lifespan critical

DiGeorge syndrome

pediatric conditions with secondary cardiopulmonary issues - primary immunodeficiency caused by deletion of chromosome 22

cardiac anomalies can include TOF, truncus arteriosus, interrupted aortic arch, VSD, ad pulmonary atresia

VATER association

pediatric conditions with secondary cardiopulmonary issues - vertebral defects, imperforate anus, tracheoesophageal fistula, radial and renal dysplasia

VACTERL association

pediatric conditions with secondary cardiopulmonary issues - cardiac anomalies are added; renal and limb anomalies replace renal or radial anomalies

Marfan syndrome

pediatric conditions with secondary cardiopulmonary issues - autosomal-dominant connective tissue disease commonly associated with aortic aneurysm and aortic/mitral insufficiency; screens for as part of sports physicals

primary ciliary dyskinesia

pediatric conditions with secondary cardiopulmonary issues - rare disease in which mucociliary clearance is impaired because of defective motility of cilia

Williams syndrome

pediatric conditions with secondary cardiopulmonary issues - involves deletion of long arm of chromosome 7

associated with supravulvar aortic stenosis and supravulvar pulmonary stenosis

fetal alcohol syndrome

pediatric conditions with secondary cardiopulmonary issues - results from chronic alcohol exposure in utero

commonly associated with cardiac anomalies of VSD, TOF, pulmonary valve stenosis, and PDA

higher

Infants/young children have HIGHER/LOWER HR.

lower

Infants/young children have HIGHER/LOWER SV.