Exercise Testing and Prescription in Peds Flashcards
CV Responses for Children
CO increases 3-4 times above resting level (due to HR)
Low SV compared to adults; therefore, higher HR
Boys: HR is lower and SV slightly higher
Submax HR
Declines with age
Max HR
Ranges from 195-210
Declines in late teens or early 20s
Boys
Faster post-exercise decline in HR than girls
Obese Children
Higher submax HR than lean -> reduces HR reserve
Environment
High temp and humidity increase HR 10-20 bpm
Fear or Apprehension
HR may increase due to being scared
See if they can relax more after test, than take a resting HR
Mode of Testing
Affect HR
Pharmacologic agents
May increase or decrease HR
Rely on 1-20 scale instead
BP
Rhythmic exercise will cause rise in systolic proportion to exercise intensity
African americans have higher BP due to stiffer arterial surfaces
Normal Responses to Exercise
SBP increases
>220 = concern
DBP varies +/- 6-10
Unique Responses to Exercise
VO2 - higher at submax, higher/equal at max
HR - higer at both max/submax
All other variables are lower
Voluntary Hypohydration
Even forced to drink, most children are underhydrated
Perpetual Response Difference to Exercise
Children tend to be slower/weaker BUT perceive intensities to be lower, recover faster
Considering Exercise Testing a Child
Begin around 6-8 yo
Testing Protocols
Bruce/Modified Bruce
Balke
CMH Max
Manual
Bruce/Modified Bruce
Most traditional
3 min stages at 10% grade and increase grade 2% each stage
Steep grades/large MET increases/long stages difficult for young pts
Balke
3.0-3.5 mph with 2% increase every min or 2.5% increase every 2 min
CMH Max
Used with athletes
No longer than 12 minutes
Tilt Table Indications
Presyncope
Dizziness
Tachycardia
Extreme fatigue
Tilt Table Monitoring
HR
BP
O2 Sat
Passive Tilt
20 min supine
20 min with HOB @ 80 deg
Assess patients whose symptoms occur with change of position/non-exercise related
Most common in slender, rapidly growing adolescents w/limited fluid intake
Active Tilt
Exercise test followed by 20 min with HOB @ 80 deg
Assess patients whose symptoms are related to exercise
Most common in competitive athletes
Tilt Table Positive Findings
LOC
Symptomatic hypotension/bradycardia/asystole
Persistent tachycardia w/o dec BP (POTS)
Inappropriate hypotension (HR gives out before BP)
Ped Chest Pain and SOB
More likely in chronic/recurring issues
Ped Chest Pain and SOB Acute Causes
Pericarditis
Trauma
Arrhythmias
Ped Chest Pain and SOB Non-cardiac Causes
Pneumothorax
Pleurodynia
Acute esophagitis
Foreign body
Ped Chest Pain and SOB Chronic Causes
MI Coronary artery anomalies Pericarditis Esophagitis Costochondritis Asthma Sickle cell Vocal cord dysfunction
Asthma
Spirometry changes on expiration
Most common serious chronic childhood disease
Don’t have to have a wheeze
Exercise Induced Asthma Symptoms
Coughing
Wheezing
Tightness
Typically begin 5-20 min after exercise on dry/cold days
EIA Management
Use Rx 10-20 min prior to exercise
Quick acting: beta agonists, albuterol, anticholinergics, atrovent
Long acting: anti-inflammatories, leukotriene modifiers corticosteroids
Treatment with Short Acting Beta Agonist
2/3 must be positive to ddx reversible airway obstruction:
- FEV1 - 200 mL or 12% increase after abutter dose
- FVC - 10+% increase
- FEF 25-75% - 20% increase
Vocal Cord Dysfunction
Spirometry changes on inspiration, normal expiration
Paradoxical closure or adduction of vocal cords during inspiration
Mimics EIA but symptoms don’t respond to asthma meds
Occur with high intensities, but not sport specific
VCD Triggers
Bronchitis/pneumonia Fumes/odors Smoke Post nasal drip Emotions Singing
VCD Symptoms
Stridor (noise on inhale)
Tightness
Abrupt onset/resolution
Feeling faint
VCD Treatment
Education
Belly breathing
Throat relaxation
Swallow-breath technique
GERD
Treating can improve both EIA and VCD
Dehydration believe to increase incidence
Can lead to tracheal malacia
Spirometry Purpose
Classify lung function
Spirometry Contraindications
Pneumothorax
Thoracic aneurysms
Eye/ab/thoracic symptoms
MI/unstable angina
FVC
Max volume of air forcefully exhaled after deepest inhale
Decreased with restrictive
Decrease or normal with obstructive
FEV1
Forced expiratory volume in 1 sec
Indicator of large airway obstruction
>80% predicted
FEV1/FVC
Ratio to classify lung function
Obstructive =
FEF 25-75%
Mean forced expiratory flow during middle half of FVC
Indicator of SMALL airway function
Norm = >60-70%
Obstructive = decreased
EISOB Evaluation Protocol
Get HR to 160-180 bpm for 6-8 min
Perform flow-volume loops pre-exercise and 5/10/15 min post-exercise
Airway Obstruction
Any disease affecting diameter of airways
Low flow rate relative to lung volume
Obstruction Classification
Mild - 65-80%
Moderate - 50-60%
Severe -
Restricted Lung Disease
Restriction of lung tissue or capacity of lungs to expand and hold predicted volumes of air
Low volumes with normal flow rates
RLD Causes
Fibrosis
Scarring
Physical deformity
Combined Lung Disease
CF
Excessive mucous production and damage to lung tissue
Bethesda Guidelines
For which activities/sports can be participated in
Conservative, probably lower PA level than needed
Aortic Stenosis
Valves don’t open/close properly allowing back flow into ventricles
Aortic Coarctation
“Kink in hose”
Elevated S/DPB
Better assessed with right arm BP
Typically treated with stent
Hypertrophic Cardiomyopathy
Strong, thick muscle that doesn’t pump effectively, smaller ventricles, altered conduction
HTCM Evaluation
For ischemic changes, ventricular ectopy and abnormal BP response
ST depression
Decrease in SPB
Coronary Conditions
Kawasaki’s
Anomalous origin/course of coronary artery
Transposition of great vessels
Single Ventricle
Blunted HR response
EKG abnormalities
Decrease O2
Dysrhythmia
Lack of sleep
Stress
Caffeine
Dysrhythmia Types
Ectopic: PVC, PAC
Sick Sinus Syndrome
Long QT Syndrome
Tachyarrhythmias
