pediatric cardiopulmonary challenges of altitude · copacabana –titicaca, 3812m. ... born full...
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Pediatric cardiopulmonarychallenges of altitude
Damian Hutter, MD
Center of congenital heart disease
University Children’s Hospital Bern
Switzerland
Isabelle Rochat, MD
Pediatric pulmonology Unit
DMCP CHUV-HEL, Lausanne
Switzerland
SSC, SSP, SSPP meeting, Lausanne, June 2016
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No conflict of interest.
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Introduction
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High Altitude
H. Duplain et al., Rev Med Suisse 2014 ; 10 : 1024-7
1500
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Introduction
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Introduction
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Introduction
100.00 mm Hg → 133.32 hPa
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Introduction
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Introduction
Copacabana – Titicaca, 3812m
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Introduction
Copacabana – Titicaca, 3812m
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Introduction
Little Matterhorn – Wallis, 3883m
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Introduction
Little Matterhorn – Wallis, 3883m
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Introduction
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Introduction
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High altitude (>2500m)
Oxygen saturation of hemoglobin is < 90%
Tissues are hypo-oxygenated
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Hypoxia/Hypoxemia stimulate the cardiovascular system to adapt in order to maintain a sufficient oxygenation of
the tissues
Adaptation
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• Erythrocytosis
Adaptation to altitude
• Increased affinit
oxygen-hemoglobin
• Pulmonary
vasoconstriction, cerebral
vasodilation
• Increased ventilation
and cardiac output
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Adaptation and acclimatization
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Interindividual variability
Rimoldi, Sartori et al Prog Cardiovasc Dis 2010;52:512-24
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visual sensitivity
personnality trait
manual ability
balance
reaction time
decision making
judgment
behavior
character
affect
orientation
memory
concentration
Alterations observed at 2500 m
sense of reality
mood, impulse control
hearing sensitivity
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What may happen?
1.AMS – acute mountain sickness
2.HACE – high altitude cerebral edema
3.HAPE – high altitude pulmonary edema
4.Re-Entry HAPE – high altitude residents HAPE
5.CMS – Chronic Mountain sickness (Monge)
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What may happen?
1.AMS – acute mountain sickness
2.HACE – high altitude cerebral edema
3.HAPE – high altitude pulmonary edema
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AMS HACE HAPE
Irritability
Headache
Anorexia
Dizziness
Nausea, vomiting
Sleep disturbances
Asthenia
Severe Headache
Ataxia
Coordinationdisturbances
Consciousness
Loss of focal neurologicfunctions
Dyspnea
Tachypnea
Tachycardia
Dry or productivecough
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AMS Incidence
Children and Adolescents 22% to 27%
Adults 48% to 62%
Bloch J, Duplain H, Rimoldi SF, et al. Prevalence and time course of acute mountain sickness in older children and adolescents after rapid ascent to 3450meters. Pediatrics 2009;123:1-5.
Rexhaj E, Garcin S, Rimoldi SF, et al. Reproducibility of acute mountain sickness in children and adults : A prospective study. Pediatrics2011;127:e1445-8.
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AMS Treatment
- Recovery- Symptomatic treatment- Acetazolamide 2.5mg/kg/dose 2-3x/d- Descent when symptoms persist
H. Duplain et al., Rev Med Suisse 2014 ; 10 : 1024-7
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AMS HACE HAPE
Irritability
Headache
No appetit
Dizziness
Nausea
Sleep disturbances
Asthenia
Severe Headache
Ataxia
Coordinationdisturbances
Consciousness
Loss of focal neurologicfunctions
Dyspnea
Tachypnea
Tachycardia
Dry or productivecough
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HACE
AMS HACE
Never been reportedin children
Low incidence (0.3%) – high mortality
The cerebral effects of ascent to high altitudes Mark H Wilson, MRCS, Stanton Newman, DPhil, Chris H Imray, FRCS The Lancet
Neurology Volume 8, Issue 2, Pages 175-191 (February 2009)
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HACE Treatment
- Urgent evacuation
- Oxygen
- Decompressionchamber
- Dexamethasone0.15mg/kg 4x/d
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AMS HACE HAPE
Irritability
Headache
No appetit
Dizziness
Nausea
Sleep disturbances
Asthenia
Severe Headache
Ataxia
Coordinationdisturbances
Consciousness
Loss of focal neurologicfunctions
Dyspnea
Tachypnea
Tachycardia
Dry or productivecough
Hemoptysis
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HAPE Incidence
Adults 1%Children 0%
Adolescents 17%(re-entry HAPE)
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HAPE Clinic
Tachypnea, Cough, Tachycardia
36 to 72 hours after arrival at high altitude
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HAPE
1. Exagerated pulmonary arterial hypertension2. Decreased alveolar fluid clearance
Duplain H, Sartori C, Scherrer U. Maladies de haute altitude. Rev Med Suisse 2007;3:1766-9.
Das BB, Wolfe RR, Chan KC, et al. High-altitudepulmonary edema in children with underlying cardiopulmonary disorders and pulmonary hypertension living at altitude. Arch Pediatr Adolesc Med 2004;158:1170-6.
Pathophysiology
Patient at risk
1. Congenital heart disease2. Pulmonary disease3. Trisomy 214. Epigenetics (perinatal Hypoxia, Preeclampsia, IVF)
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But…
Sartori C, Allemann Y, Trueb L, et al. Exaggeratedpulmonary hypertension is not sufficient to trigger high altitudepulmonary oedema in humans. Schweiz MedWochenschr 2000;130:385-9.
Exagerated pulmonary arterial hypertension is not sufficient totrigger pulmonary oedema in humans
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Trisomy 21
0
5
10
15
20
25
30
35
40
1
P < 0.05
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Environmental insults occurring during the fetal / perinatal period
Low birth weight
Augmented risk of cardiovascular diseases in adulthood
Coronary heart disease, Hypertension, Diabetes
The Barker hypothesis Developmental origin of adult diseases
Systemic vascular dysfunction
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Low altitude High altitude (4559 m)
Pulmonary artery pressure(mm Hg)
Transient perinatal hypoxia predisposes to exaggerated hypoxic pulmonary hypertension later in life
76
48
20
Sartori et al, Lancet 1999;353:2205-07
Transient perinatal hypoxia
Controls
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0
25
50
75
100
Offspring of preeclampsia, a novel risk factor for hypoxic pulmonary hypertension?
Preeclampsia (n=4)
Incidence of HAPE (%)
No preeclampsia (n=4)
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Long-term vascular dysfunction in the offspring ?
Preeclampsia
Maternal circulation
Vasoactive substances
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Offspring of mother with preeclampsia display pulmonary hypertension at high altitude
Jayet et al., Circulation 2010;122;488-94
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Vascular dysfunction later in life
FETAL INSULT PERINATAL INSULT
???
EMBRYONAL INSULT
PREECLAMPSIA HYPOXIA
Premature cardiovascular diseases
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Assisted Reproductive Technologies
Have been done for almost 3 decades
Account for a steadily increasing number of births
Make up for 1-4% of the population in developed
countries
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Assisted reproductive technology (ART)
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Long-term vascular dysfunction ?
Hypothesis
ART
Early embryonnal
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65 healthy children (11±2 y) born by ART
57 age-, sex-, birth weight- and gestational age-matched controls
Pulmonary and systemic vascular function
3450 m for 72 hours
Methods
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Pulmonary-artery pressureFlow-mediated vasodilationPulse wave velocity
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Exaggerated hypoxic pulmonary hypertension in children born from ART
Scherrer et al., Circulation 2012; 125:1890-1896
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Vascular dysfunction in ART children is induced by ART per se and not to parent related factors
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Vascular dysfunction later in life
FETAL INSULT PERINATAL INSULT
ART
EMBRYONAL INSULT
PREECLAMPSIA HYPOXIA
Premature cardiovascular diseases
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AMS HACE HAPE
Irritability
Headache
Anorexia
Dizziness
Nausea, vomiting
Sleep disturbances
Asthenia
Severe Headache
Ataxia
Coordinationdisturbances
Consciousness
Loss of focal neurologicfunctions
Dyspnea
Tachypnea
Tachycardia
Dry or productiveCough
Hemoptysis
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Risk factors for AMS
Pollard A. and al., High Altitude Med Biol 2001;2:389
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Prevention of high altitude sickness
1.Planning and education
1.Steady ascent above 3000m (300-400m/day)
3. First day – keep it quiet!
4. Hydration and nutrition
5. Sun protection APF 30-50
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Prevention of high altitude sickness
http://www.kardiologie.insel.ch/de/spezial-sprechstunden/hoehenmedizinsprechstunde/
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Ignacio, 5 months old
Born full term, no complications
Breast feeding, gaining weight
The family wants to go to Bogota, altitude 2640 m, to meet the grand parents. Should they:
Cancel the trip because the baby is too young?
Take an oxymeter with them?
Advise and go
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AMS is not specific in children!
- Increased fuzziness- Decreased play- Decreased appetite- Poor sleep
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Modified Lake Louise Score
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Ignacio, 5 months old
Born full term, no complications
Breast feeding, gaining weight
The family wants to go to Bogota, altitude 2640 m, to meet the grand parents. Should they:
Cancel the trip because the baby is too young?
Take an oxymeter with them?
Advise and go
Barben J, Paediatrica 2010;21:1
Hutter D, Paediatrica 2006:17:1
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Clara, 12 years old
Cystic fibrosis DF 508 homozygote diagnosed at 13 months of age
Chronic colonisation with S. aureus
Infection with M. abcessus, under treatment
FEV1 29%, SpO2 on room air 94%
A trip to Brazil is scheduled; what should we do?Nothing, let her go as she is
Do a hypoxic challenge test
Do a 6 minute walk test
Give her oxygen for the flight anyways
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What happens in flight?
Cabin pressure ≈ altitude 1’400-2’500 m ↘ FiO2 and ↗ gas volume↘ PaO2 and SpO2, even in healthy subjects
Who needs O2 during a flight?
NOSpO2 > 95%
SpO2 92-95% no risk factors
YESSpO2 < 92%
Already on O2
MAYBEDo a hypoxic challenge test
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Hypoxic challenge test
How?Measure SpO2 while breathing a gas mixture with 15.1% O2
No routine blood gas or ECG in children
Normal hypoxic challenge if SpO2 > 85% during the test
Who?Ex premature baby < 1 y old at the time of travel, BPDSevere CF (FEV1 < 50%)Severe restrictive lung diseaseCardiac disease
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What happens in flight?
Cabin pressure ≈ altitude 2’500 m ↘ FiO2 and increased gas volume↘ PaO2 and SpO2 even in healthy subjects
Who needs O2 during a flight?
Anyone with a SpO2 < 85% or SpO2 < 75% during > 1 minute
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Oxygen on board
Prepare well ahead of departure date!
Medical certificate
Enough medication supply
Compressed and liquid oxygen are prohibited on board aircraft (FAA, may 2016)
→ Portable oxygen concentrator (POC)
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Medical certificate template
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Kiara, 2 years old
Ex 28 WGA premie, twin, severe BPD
Severe RSV bronchiolitis (ICU) just before her 2nd
birthday
1 month later, the mother wants to go to Portugal by plane
Resting SpO2 97%, hypoxic challenge test SpO2 75%
Repeated HCT 5 months later, SpO2 87%
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Ben, 17y
Wants to go ski with his dad
Previous episode of malaise while skiing in Saas Fee
AMS prevention with acetazolamide 2.5mg/kg/d 2-3x/d
Severe cyanosis with tachypnea dyspnea, malaiseDid we miss something?
Cardiac work up and hypoxic test
ASD! Failed hypoxic test!
So double the acetazolamide dose?
Close the ASD?
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Children at altitude
• Be sure this is a sensible holiday for
children
• Young children can’t tell you how they feel
• Treatment for children with altitude illness
is the same as for adults (but, smaller
doses, prefer syrups!)
• Remember descent is the best treatment!
• When in doubt, refer to a specialised
consult
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Thanks
Research Group of Urs Scherrer
Yves, Stefano, Emrush, Rodrigo
Claudio Sartori
Audience
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