Introduction
Health care abnormalities represent one of the important concerns in the society. Addressing the complications of health ailments is always a challenging task to the health care system and to the family members as well. Certain cases appear in need of much clinical attention such as those encountered during early stages of life or late adult stages. Management of such cases necessitates both skill and professional expertise. In such context, the present description is concerned with highlighting about a condition, ‘Patent Ductus Arteriosus’.
The thesis statement is that ‘It is not known whether PDA management is feasible with evidence based approaches.
Briefly, patent ductus arteriosus (PDA) is an abnormality where the blood vessel ductus arteriosus fails to close. Here, the name patent indicates open. Ductus arteriosus facilitates blood to circulate the lungs of baby prior to birth (Schneider & Moore, 2006).
Following the birth, the lungs become inflated with air, and that is why involvement of ductus arteriosus is not necessary now. It normally undergoes closure in a very soon following birth. PDA contributes to impaired flow of blood between the artery and aorta of pulmonary system which move blood from the cardiac region.
The main complaints could include shortness of breath, sweating while feeding, fatigue very easily, rapid pulse, fast breathing and poor growth (Schumacher & Arbor, 2014).
At the time of admission, physical examination appears vital for the early detection of the condition. Say, patients could display a persistent murmur situated at the boundary of sternum. It frequently radiates towards the left down area of sternum and then backwards (Schneider & Moore, 2006).
Very often, the patient could produce a rumbling diastolic sound at the cardiac apical. This could occur in moderate or complicated ductal shunts. An increased pulse pressure could also possible if the shunt is moderate or complicated.
The past history of patients with PDA shows much variation. Many patients usually proceed for the examination of murmur sounds of heart that occur asyptomaticaly (Schnieder & Moore, 2006). Others go for echocardiogram checkups even though they do not show overt clinical manifestations. Some patents possess reactive airways disease.
Social history
PDA if accompanied to adult stages could lead to a problematic quality of life. They could encounter issues like a history of muscle aches, chills, and intermittent fevers. If undiagnosed they could also encounter atrial arrhythmia, heart failure, or differential cyanosis confined to the lower extremities. Such condition could reflect unoxygenated blood shunting from the pulmonary to systemic circulation (Lankipalli et al., 2005). As a result, their routine interaction with the society members could be disturbed.
Pulmonary diagnosis
Very often, patients with less confined or much non confined patent ductus are vulnerable to the development of pulmonary vascular disorder that is irreversible (Schnieder & Moore, 2006).
Majority of cases reflect continuous primary pulmonary vascular disease instead of that occurred due to ductus. But, in few patient profiles, pulmonary circulation could have overload issues related to volume (Schnieder & Moore, 2006).
The presence of a much sized patent ductus among certain proportion of pediatric patients does not make them feel the regular fall in postnatal period. In addition, pulmonary vascular disorder could progress further and lead to fatal cases even when the ductus gets closed (Schnieder & Moore, 2006).
Hospital course
The hospital course could involve a variety of features such as audible heart murmur at birth, failure to thrive in the first year, recurrent infection of the respitratory tract, bronchitis, pneumonia, electrocardiography signs of right and left ventricular hypertrophy to closure of ductus at the time of discharge who undergo surgical intervention (Khositseth & Wanitkun, 2012).
Medications
Drugs like IV ibuprofen or Intravenous (IV) indomethacin are recommended for traeating neonates and premature infants with PDA. For ibuprofen, the dose is 10 mg/kg bolus and then 5 mg/kg/d for another two days (Kim, 2012). Earlier, researchers believed that Ibuprofen had low side effects, like low incidence of cerebral hypoperfusion, gastrointestinal (GI) toxicity and oliguria. Its use could lead to chronic lung disease and of pulmonary hypertension.
Similarly, and indomethacin is another drug of choice. Depending on the presentation and comorbidities, the selection of any one drug could take place in health centers. Indomethacin could be associated with Renal toxicity. But a careful dose regulated b-type natriuretic peptide (BNP) administration could lessen such risks (Kim, 2012).
Some of the well known branded and marketed names of generic product ibuprofen are: A-G Profen ,Actiprofen, Addaprin, Genprin,Haltran, IBU,IBU-200,IBU-4,IBU-6, and IBU-8.Similarly, for those of indomethacin are: Indocin, Indocin-IV,Indocin –SR. All these drugs belong to the category of non-steroidal anti-inflammatory drugs (Patent Ductus Arteriosus Medications, 2014).
Indications for diagnosis
In majority of full-term infants, medical professionals primarily suspect PDA if a audible heart murmur is present during a regular checkup. A large PDA could lead to enhanced blood flow to lungs and volume overload where as a small PDA remains undiagnosed until the later stages.
So, a doctor may advise that child to visit a pediatric cardiologist. On the other hand, premature babies with PDA could not represent symptoms that resemble heart murmurs as seen in full-term babies. Immediately following birth, doctors might suspect PDA in premature babies and recommend diagnostic tests such as Echocardiography and Electrocardiogram for further confirmation.
Echocardiography (echo) constitutes a painless lab examiantion that utilizes ultrasound waves to develop a heart’s moving picture (How Is Patent Ductus Arteriosus Diagnosed?,2011). It is assisted with a computer device. Doctors can diagnose when the echo shows the PDA’s dimensions and the magnitude of heart’s reaction towards the condition (How Is Patent Ductus Arteriosus Diagnosed?, 2011). Further, doctors can also diagnose a treated condition. Say, echoes could demonstrate if the therapies applied for closing a PDA are efficient or not. Effect on other organs: It is clear that PDA affects the cardiovascular and pulmonary systems. However, a heightened blood flow via the lungs might also lessen the flow of blood to the other body regions (Patent Ductus Arteriosus, 2014). As a result, there could be malformations in gastrointestinal and renal systems are more likely (Patent Ductus Arteriosus, 2014).
Catheter based procedures: These are one of the recommended approaches applied to close the PDA in infants or children who could sustain them. It is very often performed on small PDAs to avoid infections to endocardium (Patent Ductus Arteriosus, 2014). Here, the child receives a sedative drug, and then the doctor inserts the catheter into a large blood vessel in the region of upper groin and directs it the heart. Later, a device is allowed to pass via the catheter and inserted on the PDA to prevent the blood circulation (Patent Ductus Arteriosus, 2014).
Catheter-based interventions enable the child recover soon and do not involve the surgical opening of chest. It is advised for outpatient cases mostly. It has an occasional and short term side effects such as infection, bleeding and blocking device dislocation.
However, in clinical setting, the strategies generally employed to close the DA to prevent PDA-led consequences are:
- prophylactic approach and
- Therapeutic approach.
- Prophylactic approach is followed within 24 hours regardless of the presence or absence of DA.
For instance, prophylactic indomethacin contributes to significant outcomes such as decrease of PDA, requirement for surgical site closure, severe hemorrhage in the intra ventricular and pulmonary regions (Thébaud & Lacaze, 2010).
Therapeutic approach is followed within seven days to close PDA among subjects whose echocardiography results show PDA signs.
It is important to note that regular surgical ligation of a PDA is the mostly preferred method in practice. There are reports that PDA fails to close properly with indomethacin if the PDA is linked with left aorta/atrium ration on EKG and that hence surgical ligation could become the better choice (Thébaud & Lacaze, 2010)
Lab findings
Therefore, with the advent of medical technology, various lab investigations have reported diagnostic data. Some labs report that echocardiographer and neonatal clinicians must be aware of occult congenital heart disease, especially prior to closing the ductus. They mention that large shunts possess an increased left atrial:aortic root ratio (>1.3:1 or >1.5:1),and a ductal diameter >1.4 mm (Skinner, 2001).
Like wise, there is association between prolonged persistent PDA (PP-PDA) and other severe abnormalities in infants who weigh about 1250 g. These morbidities appear highly prevalent with long lasting consequences (Saldeño, Favareto & Mirpuri, 2012).
Further, patients with a consistent PDA are less mature and have reduced birth weight compared to those with closed ductus (Noori et al., 2009). When adjusted for perinatal factors, there is an eight fold higher occurrence of patients morbid pathologies, death hazards and disease severity compared to closed ductus cases (Noori et al., 2009).
Recommendations
In view of the accumulated data, the recommendations for an efficient management of PDA is to close the PDA. This is for patients who have a left atrial enlargement or reversible pulmonary arterial hypertension (PAH). The reason is that closure contributes to a reduction in the occurrence or PAH severity and Eisenmenger syndrome. PDA closure is not for patients with severe and irreversible PAH. The reason is risk associated with the procedure, very low improved survival, need of right-to-left ductal shunting to enable cardiac output during high pulmonary vascular resistance (Doyle, Kavanaugh-McHugh, Soslow, & Hill, 2014).
Additionally, maintaining the good lung health is also of paramount importance.Tests like infant pulmonary function testing (IPFT), whole-body plethysmography, pressure transducers, jackets, and tidal breathing parameters could help in assessing the respiratory functions in infants An adherence to the European Respiratory Society/American ThoracicSociety Task Force on Standards for Infant Respiratory Function Testing could also assist in addressing any malformations and ensuring the respiratory welbeingness (Sly, Tepper, Henschen, Gappa, & Stocks, 2000).
Conclusion
DA constitutes a vital structural component in fetal life. Many studies appear to focus on the issues that surround PDA closure at the earliest without any further consequences. Complaints like cardiac murmur sounds, low birth weight and failure to thrive are one of the important clinical signs that draw the attention of clinicians. Drugs like ibubrofen and indomethacin are among the first-line treatment options.
Further, in preterm infants prophylactic PDA closure remained a controversy due to certain neonatal complications and potential impact of treatment strategies followed for closing the DA. Diagnostic tests like, Echocardiogram and EKG have come up with promising benefits. At the same moment, there is also a growing attention on the assessment of respiratory functions due to the risk of PDA related complications. There is a need of recognizing biological, genetic, echocardiographic and clinical markers that are of great utility in predicting PDA.
References
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