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CHARALAMPOS KOTSONIS PEDIATRICIAN-INTENSIVIST PICU, UNIVERSITY HOSPITAL RIO.

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Presentation on theme: "CHARALAMPOS KOTSONIS PEDIATRICIAN-INTENSIVIST PICU, UNIVERSITY HOSPITAL RIO."— Presentation transcript:

1 CHARALAMPOS KOTSONIS PEDIATRICIAN-INTENSIVIST PICU, UNIVERSITY HOSPITAL RIO

2 Cardio-Circulatory Conditions Coronary Heart Disease (CHD) Heart Failure Arrhythmias Congenital Heart Disease Pacemaker Function

3 Cardio-Circulatory Conditions Introduction Analysis of information provided by tourists seeking visas in Nepal: 20% were 50 years or older Austria 1985 – 1991: 416 deaths were sudden (30% of mountain sport related deaths) Hikers were more than two times as likely as skiers to die Risks of death: age and lack of prior physical activity JAMA. 1989;261(7):1017 N Engl J Med. 1993;329(23):1738

4 Cardio-Circulatory Conditions Introduction Prior myocardial infarction (MI) appears to be the greatest predictor of risk regarding sudden cardiac death (SCD) among those who downhill ski Previous MI had a 93 times higher adjusted SCD risk, (41% vs. 1.5%; p<0.001) when compared to controls Int J Sports Med. 2000;21(8):613

5 Cardio-Circulatory Conditions Coronary Heart Disease (CHD) Exercise at altitude in patients with stable coronary heart disease (CHD) appears to be relatively safe However, the acute hemodynamic changes associated with altitude/hypoxemia result in earlier onset of angina symptoms or ischemic ECG changes (shorter time to symptoms) Heart. 2006;92(7):921 Am Heart J2010 Jan;159(1):25-32

6 Cardio-Circulatory Conditions Coronary Heart Disease: Undiagnosed CHD Coronary Occlusion Holter monitor evaluation was performed in 149 selected skiers beginning at an altitude of 3430 meters Only 5.6% of the skiers >40 yrs showed ECG evidence of ischemia (5% incidence of ischemia noted in screening stress tests in asymptomatic individuals at sea level) Arch Intern Med 1990 Jun;150(6):1205-8

7 Cardio-Circulatory Conditions Coronary Heart Disease: Undiagnosed CHD Plaque Rupture ‘We do not expect that high altitude would have a major influence’ Regular physical activity has been shown to protect against plaque rupture Heart. 2006;92(7):921

8 Cardio-Circulatory Conditions Coronary Heart Disease: Recommendations Rapid ascent and submaximal exercise can be considered safe at an altitude of 3454 m for: Low risk patients Six months after revascularization for an acute coronary event and a normal exercise stress test at low altitude Heart. 2006;92(7):921

9 Cardio-Circulatory Conditions Coronary Heart Disease: Recommendations Patients at a higher risk may be in danger when exposed to such an altitude Evaluate the patient’s functional level, clinical status and anticipated stress Heart. 2006;92(7):921

10 Cardio-Circulatory Conditions Coronary Heart Disease: Recommendations Patients should be warned that anginal symptoms will probably occur more easily at lower workloads SOS Strenuous activities should be approached with more caution, particularly during the first 3 or 4 days at altitude Heart. 2006;92(7):921 Am Heart J2010 Jan;159(1):25-32

11 Cardio-Circulatory Conditions Heart Failure Patients with heart failure are especially susceptible to the physiological changes from high altitude exposure The pulmonary vasoconstriction and hypertension impairs right ventricular performance UpToDate Am Heart J2010 Jan;159(1):25-32

12 Cardio-Circulatory Conditions Heart Failure: Recommendations Patient who exhibits symptoms at rest or during minimal activity, or requires oxygen therapy at rest (NYHA class IV) Even the stress of air flight may be significant and should be approached with caution UpToDate

13 Cardio-Circulatory Conditions Heart Failure: Recommendations No flying or exposure to altitude for six weeks after an acute left ventricular failure episode Patients with only mild functional compromise at sea level will probably tolerate moderate altitudes Heart. 2010;96 Suppl 2:ii1

14 Cardio-Circulatory Conditions Heart Failure: Recommendations Advise patients that they may become symptomatic at lower exercise workloads at high altitudes (>2500 meters) Limit activity at moderate or high altitudes to a lower maximal level than typically performed at sea level (80-90%), especially true during the first few days at altitude UpToDate

15 Cardio-Circulatory Conditions Arrhythmias Patients with Underlying Heart Disease Heightened sympathetic activity associated with high altitude may increase the frequency and duration of supraventricular and ventricular arrhythmias UpToDate

16 Cardio-Circulatory Conditions Arrhythmias Healthy Elderly Men (Age years) The incidence of both supraventricular and ventricular premature beats (VPBs) was nearly doubled at an altitude of 1350 m (4428 feet) as compared to 200 m (656 feet) At higher altitude (2632 m), the frequency of ectopy was increased six- to sevenfold Physiol Res. 2000;49(2):285

17 Cardio-Circulatory Conditions Arrhythmias Patients with Stable CHD VPBs were significantly increased with acute exposure, but returned to sea level values after acclimatization Circulation. 1997;96(4):1224

18 Cardio-Circulatory Conditions Arrhythmias: Recommendations It appears that altitude can aggravate arrhythmias The patient should be warned to keep activities less than their sea level baseline (80-90%), particularly during the first five days at altitude Deaths at high altitude are often sudden and the contribution of arrhythmias is unknown UpToDate

19 Cardio-Circulatory Conditions Congenital Heart Disease: Non Cyanotic Intracardiac or extracardiac shunts with a net shunting of blood from the left to the right However, with exposure to high altitude/hypobaric hypoxia, pulmonary vascular resistance and right-sided pressures are increased resulting in a reverse of the shunt, leading to arterial oxygen desaturation UpToDate

20 Cardio-Circulatory Conditions Congenital Heart Disease: Non Cyanotic Patent Foramen Ovale (PFO) Was roughly 4 times more frequent in HAPE-susceptible mountaineers than in participants resistant to this condition HAPE-susceptible participants with a large PFO had more severe hypoxemia JAMA. 2006;296(24):2954

21 Cardio-Circulatory Conditions Congenital Heart Disease: Cyanotic Exposure to moderate altitude (1,500 to 2,500m) has been reported to be safe Commercial air travel do not appear to be detrimental Circulation. 1996;93(2):272

22 Cardio-Circulatory Conditions Congenital Heart Disease: Recommendations Advice must be individualized and based upon the nature of the congenital defect and expected stresses Consultation with a pediatric or adult cardiologist specializing in congenital defects should precede altitude exposure Circulation. 1996;93(2):272 Am Heart J2010 Jan;159(1):25-32

23 Cardio-Circulatory Conditions Pacemaker Function Inhalation of 10% O2, produced a significant but reversible increase in stimulation thresholds Hypocapnia, induced by mechanic hyperventilation, led to a reduction in pacing stimulation thresholds Scand J Thorac Cardiovasc Surg Suppl. 1971;8:1

24 Cardio-Circulatory Conditions Pacemaker Function Stepwise simulated hypobaric chamber ascent from 450 meters to 4000 meters ( feet) produced NO change in stimulation threshold Pacing Clin Electrophysiol. 2000;23(4 Pt 1):512

25 Cardio-Circulatory Conditions Pacemaker Function: Recommendations Pacing thresholds can be expected to remain unchanged at the moderate altitudes seen with air travel and recreational skiing The safety of pacemakers at the extreme altitudes, as with trekking and mountaineering, is not known UpToDate

26 Cardio-Circulatory Conditions Implantable Cardioverter-Defibrillators (ICD) Effects of altitude on implantable cardioverter-defibrillators are unknown at this time Am Heart J2010 Jan;159(1):25-32

27 Cardio-Circulatory Conditions Heart Transplant Patients Patients living >2000 ft have improved survival after heart transplantation This advantage is even more pronounced in patients living above 4000 ft Analysis still seems to lack a unifying explanation J Thorac Cardiovasc Surg 2012;143:735-41

28 Cardio-Circulatory Conditions General Recommendations If unsure of a patient's cardiac status, in any male or female >40 years, consider performing an exercise treadmill stress test before planned activity at high altitude Am Heart J2010 Jan;159(1):25-32

29 Cardio-Circulatory Conditions General Recommendations Patients with recent unstable cardiovascular conditions should be directed to refrain from altitude exposure Stable patients who exercise at sea level without symptoms can generally exercise at altitude Am Heart J2010 Jan;159(1):25-32

30 Respiratory Conditions Asthma COPD Pulmonary Hypertensive Disorders

31 Respiratory Conditions Asthma And High Altitude Positive Aspects House-dust mites decrease with increasing altitude Less dense gases have better flow through narrow airways Higher levels of cortisol and catecholamines at altitude may play a protective role Eur Respir J 2007; 29: 770–792

32 Respiratory Conditions Asthma And High Altitude Negative Aspects Hypoxia increases bronchial responsiveness Hypocapnia adversely affect airway resistance Inhalation of cold air may also worsen asthma symptoms Eur Respir J 2007; 29: 770–792

33 Respiratory Conditions Asthma And High Altitude: Recommendations Patients with mild-intermittent or mild-persistent asthma can ascend to altitudes as high as 5,000 m Continue baseline medications and carry an ample supply of rescue inhalers and prednisone for potential exacerbations Consider using balaclava or bandana over mouth to warm and humidify air in cold environments Eur Respir J 2007; 29: 770–792

34 Respiratory Conditions Asthma And High Altitude: Recommendations Patients with more severe disease at baseline should be cautioned against travelling to remote high-altitude regions In general, asthmatics appear to have NO higher risk of high altitude illness than non-asthmatics Eur Respir J 2007; 29: 770–792

35 Respiratory Conditions Chronic Obstructive Pulmonary Disease Physiological Problems of COPD Gas-exchange inefficiency Increased ventilatory requirements Reduced muscle strength Mild–moderate pulmonary hypertension Eur Respir J 2007; 29: 770–792

36 Respiratory Conditions Chronic Obstructive Pulmonary Disease: Recommendations Counsel patients with pre-existing pulmonary hypertension against high-altitude travel Continue baseline medications and carry supply of rescue inhalers and prednisone for potential exacerbations Eur Respir J 2007; 29: 770–792

37 Respiratory Conditions Pulmonary Hypertensive Disorders: Recommendations Counsel patients against high-altitude travel If high-altitude travel cannot be avoided, counsel patients about the risks, symptoms and signs of HAPE Eur Respir J 2007; 29: 770–792

38 Respiratory Conditions Pulmonary Hypertensive Disorders: Recommendations Administer supplemental oxygen for trips above 2000 m even in patients not on supplemental oxygen at baseline For patients not on pre-existing medical therapy, prophylaxis with Nifedipine SR 20 mg b.i.d is recommended Eur Respir J 2007; 29: 770–792

39 Metabolic Conditions Diabetes Mellitus (DM) And High Altitude Glucose monitors may under or over read at altitude Insulin must not be allowed to freeze or go too hot Insulin and some test devices are also sensitive to UV UIAA GUIDELINES

40 Metabolic Conditions Diabetes Mellitus (DM) And High Altitude Type II DM: Should have no problems with altitude, once their disease is well controlled and no severe complications have occurred Type I DM: can tolerate even vigorous exercise, including participation in competitive triathlons UpToDate

41 Hematologic Conditions Sickle Cell Disease Sickle cell crisis can occur at altitudes as low as 1500m (4900 ft) Symptoms are common at 2300 m (7500 ft) Patients with sickle cell trait may become symptomatic from splenic sequestration or infarct at altitudes >2500 m (8000 ft) UpToDate

42 Pediatric Mountaineering Physiology Certain anatomic and physiologic factors make infants and young children more susceptible to hypoxia than adults This susceptibility may be translated into a greater frequency of HAI at very high altitudes (>3500 m [11,375 ft]) However, most healthy children can travel safely to altitudes lower than 3500 m and are not at greater risk than adults UpToDate

43 Pediatric Mountaineering Diagnosis of AMS in Preverbal Children Children's Lake Louise Acute Mountain Sickness Scoring System: Pediatric Symptom Score Eating0 – Normal 1 – Slightly less than normal 2 – Much less than normal 3 – Vomiting or No eating Playfulness0- Normal 1 – Playing slightly less 2 – Playing much less than normal 3 – No playing Sleeping0 – Normal 1 – Sleeps slightly less or more than normal 2 – Sleeps much less or more than normal 3 – not able to sleep Arch Pediatr Adolesc Med 1998; 152:683

44 Pediatric Mountaineering Diagnosis of AMS in Preverbal Children Arch Pediatr Adolesc Med 1998; 152:683

45 Pediatric Mountaineering Diagnosis of AMS in Preverbal Children Children were scored by combining the mean fussiness score (0-6) with the pediatric symptom score (0-9) Total score 7 (including a fussiness score 4 and pediatric symptom score 3) is considered to be diagnostic of acute mountain sickness Arch Pediatr Adolesc Med 1998; 152:683

46 Pediatric Mountaineering Special Considerations The use of Nifedipine for prevention of HAPE in children has not been studied Acetazolamide prophylaxis is indicated in situations where gradual ascent is not possible and in children who have had AMS when previously exposed to a similar altitude and rate of ascent UpToDate

47 Conclusions Individualize Medical Advise Upon: Specific medical condition and demographic features Baseline functional capacity Expected altitude that will be encountered Anticipated activity level while at altitude UpToDate

48 Conclusions General Recommendations SOS Keep a lower threshold for evacuation to a lower altitude as regards patients with pre-existing medical conditions and children UpToDate

49 Safety First ΛΕΜΕ Κοτρωνάρος Παναγιώτης

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