As physical therapists, we may encounter infants and children with heart defects in every setting in which we practice. A physical therapist may see a child with a congenital heart defect (CHD) in acute care before and/or after surgery, in rehabilitation settings, in school and home care, and as an outpatient. Physical therapists should also be aware of what a congenital heart defect is, how it affects a child’s cardiovascular system during exercise, and the complications that are common in this population. It is also important to note that CHDs often accompany other genetic disorders that cause developmental delays, so they may also see a physical therapist.
Patient History
The examination begins with the patient's age, date of birth, primary language, and race. The child's medical and surgical history is also very important and may be very complex. Note the medications the child is taking, including blood thinners (warfarin, Coumadin) and immunosuppressants. These medications have side effects such as rapid bleeding time, which must be considered in physical therapy treatment.
Arterial Blood Gas Value
Arterial blood is the most reliable way to assess oxygen (O2) transport. Hypoventilation causes a shift of the normal curve to the right with increased CO2 and decreased pH, resulting in respiratory acidosis. Hyperventilation causes a shift to the left with decreased CO2 and increased pH, resulting in respiratory alkalosis.
General Appearance of the Patient
It is important to note the general body color. Anemia causes pallor, polycythemia causes plethora, a condition of excess blood volume causing swelling and redness of the skin and oxygen desaturation causes a blue or cyanotic color. Document the individual's body type as to whether it is cachectic, obese or age appropriate. Digital clubbing should be documented and is a sign of hypoxia, where the tips of the distal phalanges become bulbous and the fingernails protrude outward with an increased nail angle.
It is important to note whether the child is using a support device. Support devices can be extracorporeal membrane oxygenation (ECMO), mechanical ventilation, or ventricular assistive devices (left ventricular, right ventricular, or biventricular assists)
Integument
Examine the condition of the integumentary system, starting with the general appearance of the skin. Does the skin appear shiny, swollen, loose, bruised, or damaged? Anticoagulation can cause bruising and skin damage, and fluid retention can cause the skin to appear shiny or puffy.
Check capillary refill in the extremities. The test is performed by pressing down on the nail bed, which should blanch and return to normal within 1 to 2 seconds after pressure is removed. Capillary refill is ideally assessed by compression of the big toe.
Edema should also be assessed, as peripheral and central edema may be evident in children with CHD. Peripheral edema is caused by the inability of the heart to maintain adequate cardiac output. Central edema or jugular venous distention is due to fluid overload as fluid is retained centrally because the heart's pumping ability is impaired and fluid backs up into the lungs and venous system.
Thorax
Thoracic deformities should be assessed, including pectus excavatum, pectus carinatum, barrel chest, rib flaring, and midtrunks folds. Pectus excavatum may be caused by surgical procedures, which result in tightening of the upper chest muscles. Pectus carinatum may be caused by surgical procedures, which result in deformity of the sternum. Barrel chest deformity may be caused by overinflation of lung tissue, rib flaring is caused by an imbalance of the abdominal muscles with the diaphragm, and midtrunks folds are caused by an imbalance of the chest wall muscles to oppose the diaphragm.
Chest wall movement can be checked by palpation and measurement. Place your hands over the upper lobes of the lungs with the base of the hand on the fourth rib, fingertips on the upper trapezius, and thumbs on the sternal angles, you can check the symmetry, range of motion, and general movement of the chest during breathing. Measure the chest circumference with a measuring tape at the axillary level wrapped around the chest. Measure the change in circumference during normal inhalation and exhalation.
Respiratory Examination
Children with CHD often present with respiratory problems as their chief complaint. Sixty percent of people who undergo cardiac or thoracic surgery experience pulmonary complications; therefore, a respiratory examination and chest wall examination will provide valuable information for the physical therapist's treatment plan.
Musculoskeletal Examination
Examination of joint range of motion, postural alignment, and sensation is also necessary. Scoliosis, kyphosis, or syndromic abnormalities of the musculoskeletal system may be present in the patient and may impact the child's pulmonary system before, during, or after CHD surgery.
Muscle Strength
Strength measurements should take into account children at risk for steroid-induced myopathy, osteopenia, and osteoporosis before surgery or after transplantation.
Vital Sign
Monitoring vital signs at rest, during treatment, and during and after physiotherapy interventions can provide invaluable information about a child's cardiovascular response to activity.
Functional Mobility
Functional mobility screening includes testing of bed mobility, transfers, balance, gait, and stair climbing, as well as developmentally appropriate activities.
Aerobic Capacity and Ability
Aerobic testing in clinical care typically includes a 6-, 9-, or 12-minute walk test. The 6-minute walk test is usually the most common test performed.
Also read: Acute Bronchitis: What is it?
Reference :
- Tecklin, Jan S. 2008. Pediatric Physical Therapy fourth edition. Philadelphia : Lippincott Williams & Wilkins
