ROLE OF PHYSIOTHERAPY IN POST-ROLE OF PHYSIOTHERAPY IN POST-OPERATIVE OPERATIVE

CONGENITAL HEART DISEASECONGENITAL HEART DISEASE

INTRODUCTIONINTRODUCTION

• PREVALANCE:IN INDIA -0.8 – 5.2/1000 LIVE PREVALANCE:IN INDIA -0.8 – 5.2/1000 LIVE BIRTHS(ACCORDING TO A STUDY DONE BY BIRTHS(ACCORDING TO A STUDY DONE BY REGENCY HOSPITAL,KANPUR,U.P)REGENCY HOSPITAL,KANPUR,U.P)

• IN WESTERN COUNTRIES-6-8/1000 LIVE IN WESTERN COUNTRIES-6-8/1000 LIVE BIRTHSBIRTHS

• MORE RECENT STUDIES-1/1000 LIVE BIRTHSMORE RECENT STUDIES-1/1000 LIVE BIRTHS

• BENEFITS OF CHEST PHYSICAL THERAPY BENEFITS OF CHEST PHYSICAL THERAPY FOR THE SUGICAL PATIENT HAVE BEEN FOR THE SUGICAL PATIENT HAVE BEEN WELL DOCUMENTEDWELL DOCUMENTED

• SURGICAL INTERVENTION IN PEDIATRIC SURGICAL INTERVENTION IN PEDIATRIC POPULATION MAY RESULT IN POST POPULATION MAY RESULT IN POST OPERATIVE PULMONARY COMPLICATIONSOPERATIVE PULMONARY COMPLICATIONS

• POST OPERATIVE CHEST PHYSICAL THERAPY POST OPERATIVE CHEST PHYSICAL THERAPY FOR PEDIATRIC CARDIAC PATIENT SHOULD FOR PEDIATRIC CARDIAC PATIENT SHOULD INCLUDE FREQUENT POSITION INCLUDE FREQUENT POSITION CHANGE,BREATHING EXERCISES AND CHANGE,BREATHING EXERCISES AND INSTRUCTION IN EFFECTIVE COUGHING INSTRUCTION IN EFFECTIVE COUGHING WITH INCISIONAL SPLINTING OR AIRWAY WITH INCISIONAL SPLINTING OR AIRWAY ASPIRATION AS NECESSARYASPIRATION AS NECESSARY

• MODIFIED BRONCHIAL DRAINAGE MODIFIED BRONCHIAL DRAINAGE TECHNIQUES WITH CONSIDERATION OF THE TECHNIQUES WITH CONSIDERATION OF THE NECESSARY POST-OPERATIVE PRECAUTIONS NECESSARY POST-OPERATIVE PRECAUTIONS ARE PERFORMED ONLY IF THERE IS ARE PERFORMED ONLY IF THERE IS SECRETION RETENTIONSECRETION RETENTION

• MOBILITY EXERCISES INCLUDING RANGE MOBILITY EXERCISES INCLUDING RANGE OF MOTION,BED MOBILITY AND OF MOTION,BED MOBILITY AND PROGRESSIVEAMBULATION SHOULD ALSO PROGRESSIVEAMBULATION SHOULD ALSO BE PART OF THE POST OPERATIVE PROGRAM BE PART OF THE POST OPERATIVE PROGRAM

ETIOLOGYETIOLOGY

• IN CHILDREN OF MOTHERS WHO ARE IN CHILDREN OF MOTHERS WHO ARE DIABETIC OR WHO ARE ALCHOHOLICDIABETIC OR WHO ARE ALCHOHOLIC

• VIRAL INFECTIONSIN THE FIRST TRIMESTER VIRAL INFECTIONSIN THE FIRST TRIMESTER OF PREGNANCYOF PREGNANCY

• DRUGS LIKE THALIDOMIDE AND METABOLIC DRUGS LIKE THALIDOMIDE AND METABOLIC FACTORS LIKE IDIOPATHIC FACTORS LIKE IDIOPATHIC HYPERCALCEMIA RESULTS IN SPECIFIC HYPERCALCEMIA RESULTS IN SPECIFIC TYPES OF CHDTYPES OF CHD

• GENETIC AND CHROMOSOMAL GENETIC AND CHROMOSOMAL ABERRATIONS CAN ALSO PRDISPOSE ABERRATIONS CAN ALSO PRDISPOSE TO CHDTO CHD

MAIN DIFFERENCES BETWEEN FOETAL MAIN DIFFERENCES BETWEEN FOETAL CIRCULATION AND POST NATAL CIRCULATIONCIRCULATION AND POST NATAL CIRCULATION

• Presence of placental circulation which provides the gas exchange for the foetus

• Absence of gas exchange in the collapsed lungs , little blood flow to the lungs,very little pulmonaryvenous return to the left atrium

• Presence of ductus venosus joining the portal vein with IVC

• Widely open foramen ovale.

•Widely open ductus arteriosus.

CLASSIFICATION OF CONGENITAL CLASSIFICATION OF CONGENITAL HEART DISEASESHEART DISEASES

• GROUP I LEFT TO RIGHT SHUNTSGROUP I LEFT TO RIGHT SHUNTS

• GROUP II RIGHT TO LEFT SHUNTSGROUP II RIGHT TO LEFT SHUNTS

• GROUP III OBSTRUCTIVE LESIONSGROUP III OBSTRUCTIVE LESIONS

• THREE MAIN LEFT TO RIGHT SHUNTS:THREE MAIN LEFT TO RIGHT SHUNTS:

1) ATRIAL SEPTAL DEFECT1) ATRIAL SEPTAL DEFECT

2) VENTRICULAR SEPTAL DEFECT2) VENTRICULAR SEPTAL DEFECT

3) PATENT DUCTUS ARTERIOUSUS3) PATENT DUCTUS ARTERIOUSUS

• GROUP II RIGHT TO LEFT SHUNTS:GROUP II RIGHT TO LEFT SHUNTS:

1) TETROLOGY OF FALLOT 1) TETROLOGY OF FALLOT

2) TRICUSPID ATRESIA2) TRICUSPID ATRESIA

3) TRANSPOSITION OF GREAT 3) TRANSPOSITION OF GREAT VESSELSVESSELS

• OBSTRUCTIVE LESIONS:OBSTRUCTIVE LESIONS:

1) AORTOIC STENOSIS1) AORTOIC STENOSIS a) SUPRA VALVULARa) SUPRA VALVULAR b) SUBVALVULARb) SUBVALVULAR

2) COARCTATION OF THE AORTA2) COARCTATION OF THE AORTA

3) PULMONIC STENOSIS3) PULMONIC STENOSIS

TREATMENTTREATMENT

• ASD ASD - TREATING CHEST INFECTIONS - TREATING CHEST INFECTIONS

- SURGERY(ASD CLOSURE)- SURGERY(ASD CLOSURE)

• VSD VSD - CONTROL OF CONGESTIVE CARDIAC - CONTROL OF CONGESTIVE CARDIAC

FAILURE FAILURE

- TREATMENT OF REPEATED CHEST INFECTIONS

- TREATING ANEMIA AND INFECTIVE ENDO - TREATING ANEMIA AND INFECTIVE ENDO CARDITISCARDITIS

- SURGERY(CLOSURE OF VSD WITH DACRON PATCH)SURGERY(CLOSURE OF VSD WITH DACRON PATCH)

- COMPLICATIONS OF SURGERYCOMPLICATIONS OF SURGERY - COMPLETE HEART BLOCK - COMPLETE HEART BLOCK - BIFASCICULAR BLOCK- BIFASCICULAR BLOCK - RESIDUAL VSD- RESIDUAL VSD

PDA PDA

- LIGATION OF THE PERSISTENT DUCTUS ARTERIOSUSLIGATION OF THE PERSISTENT DUCTUS ARTERIOSUS

TOF TOF 1) BLALOCK – TAUSSIG SHUNT1) BLALOCK – TAUSSIG SHUNT 2) POTT’S SHUNT 2) POTT’S SHUNT 3) WATERSON’S SHUNT3) WATERSON’S SHUNT

- TRICUSPID ATRESIATRICUSPID ATRESIA

- MANAGEMENT SAME AS FOR TOFMANAGEMENT SAME AS FOR TOF

- ANASTOMOSING SVC TO RIGHT PULMONARY ANASTOMOSING SVC TO RIGHT PULMONARY ARTERY CALLED GLENN SHUNTARTERY CALLED GLENN SHUNT

• TRANSPOSITION OF GREAT VESSELSTRANSPOSITION OF GREAT VESSELS - CONTROL OF CONGESTIVE FAAILURE- CONTROL OF CONGESTIVE FAAILURE - PULMONARY ARTERY AND AORTA ARE TRANSECTED- PULMONARY ARTERY AND AORTA ARE TRANSECTED

• DISTAL AORTA IS ANASTAMOSED TO THE PROXIMAL DISTAL AORTA IS ANASTAMOSED TO THE PROXIMAL PULMONARY STUMP AND THE PULMONARY ARTERY TO PULMONARY STUMP AND THE PULMONARY ARTERY TO THE PROXIMAL AORTIC STUMPTHE PROXIMAL AORTIC STUMP

- THE CORONARIES ARE SHIFTED TO THE AORTA- THE CORONARIES ARE SHIFTED TO THE AORTA

• AORTIC STENOSISAORTIC STENOSIS - BALLON AORTIC VALVULO PLASTIC- BALLON AORTIC VALVULO PLASTIC - AORTIC VALVOTOMY- AORTIC VALVOTOMY - AORTIC VALVE REPLACEMENT- AORTIC VALVE REPLACEMENT

• COARCTATION OF AORTACOARCTATION OF AORTA

- BALLON ANGIOPLASTY- BALLON ANGIOPLASTY

- RECOARCTATION OF AORTA- RECOARCTATION OF AORTA

• PULMONIC STENOSISPULMONIC STENOSIS

- RIGHT VENTRICULOTOMY - RIGHT VENTRICULOTOMY

PHYSICAL THERAPY ASSESSMENTPHYSICAL THERAPY ASSESSMENT

• REVIEWING THE MEDICAL RECORDREVIEWING THE MEDICAL RECORD

• COMPLETE HISTORY OF LABOR AND DELIVERYCOMPLETE HISTORY OF LABOR AND DELIVERY

• APGAR SCORESAPGAR SCORES

• CLINICAL COURSE OF THE BABY FROM BIRTH TO PRESENTCLINICAL COURSE OF THE BABY FROM BIRTH TO PRESENT

• HISTORY OF RESPIRATORY DISTRESS AND OXYGEN AND HISTORY OF RESPIRATORY DISTRESS AND OXYGEN AND VENTILATION ASSISTANCE SINCE BIRTHVENTILATION ASSISTANCE SINCE BIRTH

• ABG HISTORYABG HISTORY

• PREVIOUS CHEST X-RAYSPREVIOUS CHEST X-RAYS

• MODE AND FREQUENCY OF NUTRITION AND FEEDINGMODE AND FREQUENCY OF NUTRITION AND FEEDING

• CHEST EVALUATIONCHEST EVALUATION

• OBSERVATION OF THE BABY:OBSERVATION OF THE BABY: - SIGNS OF RESPIRATORY DISTRESS- SIGNS OF RESPIRATORY DISTRESS - CHEST CONFIGURATION- CHEST CONFIGURATION

• SKIN COLORSKIN COLOR - CYANOSIS- CYANOSIS - PLETHORA OR REDNESS- PLETHORA OR REDNESS - PALLOR, MOTTLING- PALLOR, MOTTLING

• BREATHING PATTERNBREATHING PATTERN - TACHY PNEA- TACHY PNEA - IRREGULARITY OF RESPIRATION- IRREGULARITY OF RESPIRATION - APNEA- APNEA

• COUGHING AND SNEEZINGCOUGHING AND SNEEZING

• AUSCULTATIONAUSCULTATION - BREATH SOUNDS- BREATH SOUNDS - ABNORMAL BREATH SOUNDS- ABNORMAL BREATH SOUNDS - AIR ENTRY- AIR ENTRY

• PALPATIONPALPATION - POSITION OF TRACHEA- POSITION OF TRACHEA - SYMMETRY OF CHEST WALL MOTION- SYMMETRY OF CHEST WALL MOTION

• PERCUSSIONPERCUSSION

PHYSICAL THERAPY TREATMENTPHYSICAL THERAPY TREATMENT

• BRONCHIAL DRIANAGE TECHNIQUESBRONCHIAL DRIANAGE TECHNIQUES

• CHEST PERCUSSIONCHEST PERCUSSION

• VIBRATION VIBRATION

• AIRWAY SUCTIONINGAIRWAY SUCTIONING

• THERE ARE MANY PRECAUTIONS AND THERE ARE MANY PRECAUTIONS AND CONTRA INDICATIONS FOR VARIOUS CONTRA INDICATIONS FOR VARIOUS POSITIONS, CHEST PERCUSSIONS, VIBRATION POSITIONS, CHEST PERCUSSIONS, VIBRATION AND SUCTIONING.THE MOST APPROPRIATE AND SUCTIONING.THE MOST APPROPRIATE AND SAFEST TREATMENT PROGRAM MUST AND SAFEST TREATMENT PROGRAM MUST BE INDIVIDUALLY DESIGNED FOR EACH BE INDIVIDUALLY DESIGNED FOR EACH BABYBABY

POSITIONINGPOSITIONING

• 12 CLASSIC POSITION12 CLASSIC POSITION

• MANUAL PERCUSSION AND VIBRATIONMANUAL PERCUSSION AND VIBRATION

• 3-5 MINUTES PER POSITION IS EFFECTIVE3-5 MINUTES PER POSITION IS EFFECTIVE

• TOTAL TIME OF 20-30 MINUTES IS ADEQUATETOTAL TIME OF 20-30 MINUTES IS ADEQUATE

• AIRWAY SUCTIONING WILL HELP BABY AIRWAY SUCTIONING WILL HELP BABY CLEAR THE SECRETIONS LOOSENED BY CLEAR THE SECRETIONS LOOSENED BY BRONCHIAL DRIANAGE TREATMENTBRONCHIAL DRIANAGE TREATMENT

POST OPERATIVE PEDIATRIC CARDIAC POST OPERATIVE PEDIATRIC CARDIAC REHABILITATIONREHABILITATION

• TECHNIQUES TO INCREASE RESPIRATION,MOBILIZE TECHNIQUES TO INCREASE RESPIRATION,MOBILIZE SECRETIONS,PROGRESS PHYSICAL MOBILITYSECRETIONS,PROGRESS PHYSICAL MOBILITY

• BREATHING EXCERCISES AND COUGHING NEED TO BE BREATHING EXCERCISES AND COUGHING NEED TO BE MODIFIED BASED ON CHILD’S AGE AND COGNITIVE LEVELMODIFIED BASED ON CHILD’S AGE AND COGNITIVE LEVEL

• IMMOBILISATION AFTER CARDIAC SURGERY IS AVOIDED IMMOBILISATION AFTER CARDIAC SURGERY IS AVOIDED AS MUCH AS MEDICALLY POSSIBLEAS MUCH AS MEDICALLY POSSIBLE

• PROM INITIATED IMMEDIATELYPROM INITIATED IMMEDIATELY

• AMBULATION INITIATED ONCE THE CHILD IS EXTUBATEDAMBULATION INITIATED ONCE THE CHILD IS EXTUBATED

• CHILD AND FAMILY EDUCATION IS IMPORTANT PART OF CHILD AND FAMILY EDUCATION IS IMPORTANT PART OF PCRPCR

HOME PROGRAMHOME PROGRAM

• TEACHING PARENTS BRONCHIAL DRIANAGE TEACHING PARENTS BRONCHIAL DRIANAGE POSITIONSPOSITIONS

• MANUAL TECHNIQUES IS USUALLY TAUGHT MANUAL TECHNIQUES IS USUALLY TAUGHT TO THE PARENTS SO THAT BABY WILL TO THE PARENTS SO THAT BABY WILL BENEFITBENEFIT

• PARENTS NEED TO BE TAUGHT HOW TO PARENTS NEED TO BE TAUGHT HOW TO STIMULATE A COUGHSTIMULATE A COUGH

CASE STUDIESCASE STUDIESNAME: ZainabiNAME: ZainabiAGE: 5 yearsAGE: 5 yearsSEX: FemaleSEX: FemaleDIAGNOSIS: Ventral Septal DefectDIAGNOSIS: Ventral Septal DefectNAME OF SURGERY: Intra Cardiac Repair + Trans Annular PatchNAME OF SURGERY: Intra Cardiac Repair + Trans Annular PatchDATE OF SURGERY: 25/11/2010DATE OF SURGERY: 25/11/2010NUMBER OF POST-OPERATIVE DAY: 8th dayNUMBER OF POST-OPERATIVE DAY: 8th dayVITALS-VITALS-BLOOD PRESSURE: 78/46BLOOD PRESSURE: 78/46 HEART RATE: 128HEART RATE: 128 RESPIRATORY RATE: 42RESPIRATORY RATE: 42TEMPERATURE: 98.2TEMPERATURE: 98.2 F FARTERIAL BLOOD GAS ANALYSIS-ARTERIAL BLOOD GAS ANALYSIS- SPo2- 100SPo2- 100 PH- 7.41PH- 7.41 Pco2- 53.2Pco2- 53.2 Po2- 39Po2- 39 HCO3- 33.4HCO3- 33.4 Hemoglobin- 10.8Hemoglobin- 10.8 Electrolytes- Na-135Electrolytes- Na-135 K- 2.9 Ca-1.0K- 2.9 Ca-1.0HISTORY-HISTORY-Personal History: Not a consanguineous marriagePersonal History: Not a consanguineous marriageDrug History: T. InderalDrug History: T. InderalIntra Venous Infusions: Adrenaline infusion Intra Venous Infusions: Adrenaline infusion Surgical History: Undergone Intra cardiac repair + Trans annular patchSurgical History: Undergone Intra cardiac repair + Trans annular patchOBSERVATIONOBSERVATIONModerately built and nourishedModerately built and nourishedOn Oxygen mask- flow of oxygen through face maskOn Oxygen mask- flow of oxygen through face mask2 Mediastinal drains present- 1 on right side and other on left side2 Mediastinal drains present- 1 on right side and other on left sideVitals monitor attachedVitals monitor attached

Pulse oximeter presentPulse oximeter presentUrinary catheter presentUrinary catheter presentVentilatory pattern- Breathing spontaneouslyVentilatory pattern- Breathing spontaneouslySURGICAL HISTORYSURGICAL HISTORYName of surgery- Intra cardiac repairName of surgery- Intra cardiac repairType of incision- MidsternotomyType of incision- Midsternotomy Mediastinal drainsMediastinal drainsPeripheries- Grade II clubbing + central cyanosis presentPeripheries- Grade II clubbing + central cyanosis presentPalpation- Not using accessory muscles of breathingPalpation- Not using accessory muscles of breathing Hyperkinetic chest movementsHyperkinetic chest movements Chest wall movements equal on both sidesChest wall movements equal on both sidesAuscultation-bilateral air entry equal on both sidesAuscultation-bilateral air entry equal on both sides Tachypnea 30 breaths per minTachypnea 30 breaths per minPhysiotherapy treatmentPhysiotherapy treatment -positioning on bed-positioning on bed -training in ADLS-training in ADLS -chest percussion-chest percussion -breathing exercises-breathing exercises

NAME: Sai RavalikaNAME: Sai RavalikaAGE: 13yearsAGE: 13yearsSEX: FemaleSEX: FemaleDIAGNOSIS: Atrial Septal DefectDIAGNOSIS: Atrial Septal DefectNAME OF SURGERY: Sinus venosus type ASD closure with rerouting of NAME OF SURGERY: Sinus venosus type ASD closure with rerouting of Pulmonary Veins Pulmonary Veins DATE OF SURGERY: 3/12/2010DATE OF SURGERY: 3/12/2010NUMBER OF POST-OPERATIVE DAY: 5thNUMBER OF POST-OPERATIVE DAY: 5thVITALS:VITALS:BLOOD PRESSURE: 110/70BLOOD PRESSURE: 110/70HEART RATE: 109HEART RATE: 109RESPIRATORY RATE: 21/minRESPIRATORY RATE: 21/minARTERIAL BLOOD GAS:ARTERIAL BLOOD GAS: SPo2: 100%SPo2: 100% PH: 7.42PH: 7.42 Pco2: 37Pco2: 37 Po2: Po2: HISTORYHISTORYPersonal History: Not consanguineousPersonal History: Not consanguineousDrug History: Regular medications (Anticoagulant)Drug History: Regular medications (Anticoagulant)Intravenous Infusions: Nil; shifted to wardIntravenous Infusions: Nil; shifted to wardOBSERVATIONOBSERVATIONModerately built and moderately nourished.Moderately built and moderately nourished.Not on oxygen maskNot on oxygen maskNo Mediastinal drainsNo Mediastinal drainsCentral Venous Pressure line presentCentral Venous Pressure line presentVitals monitor not attachedVitals monitor not attachedNo pulse oximeterNo pulse oximeterNo urinary catheterNo urinary catheterVentilatory pattern: Breathing spontaneouslyVentilatory pattern: Breathing spontaneously

SURGICAL HISTORY: SURGICAL HISTORY: Name of surgery: Sinus venosus type of ASD closure with rerouting of Pulmonary Name of surgery: Sinus venosus type of ASD closure with rerouting of Pulmonary VeinsVeinsType of incisionType of incision: Median sternotomy: Median sternotomyPeripheriesPeripheries: No clubbing: No clubbing No cyanosisNo cyanosisPalpation:Palpation: Chest wall expansion decrease (due to repair) Chest wall expansion decrease (due to repair) Symmetrically expanding on both sidesSymmetrically expanding on both sidesRatio of chest expansion:Ratio of chest expansion: A: N: X = 1:1:1A: N: X = 1:1:1AuscultationAuscultation: Bilateral equal on both sides: Bilateral equal on both sides No added breath soundsNo added breath soundsPHYSIOTHERAPYPHYSIOTHERAPY TREATMENTTREATMENT PositioningPositioningMobilizationMobilizationBreathing exercises – diaphragmatic breathingBreathing exercises – diaphragmatic breathingWalking – 100m corridorWalking – 100m corridor

NAME: AnithaNAME: AnithaAGE: 10 yearsAGE: 10 yearsSEX: FemaleSEX: FemaleDIAGNOSIS: Ostium Secundum Atrial Septal DefectDIAGNOSIS: Ostium Secundum Atrial Septal DefectNAMENAME OFOF SURGERY: ASD ClosureSURGERY: ASD ClosureDATEDATE OFOF SURGERY: 21/12/2010SURGERY: 21/12/20101st POST OPERATIVE DAY1st POST OPERATIVE DAYHISTORY:HISTORY:PRE SURGICAL HISTORY``PRE SURGICAL HISTORY``GENERALGENERAL COMPLAINTSCOMPLAINTS:: Cough (dry) since 3 monthsCough (dry) since 3 months Shortness of breath since 3 monthsShortness of breath since 3 monthsNo history of cyanosisNo history of cyanosisNot a consanguineous marriageNot a consanguineous marriageSURGICAL HISTORYSURGICAL HISTORYOstium secundum type ASD Closure doneOstium secundum type ASD Closure done1st post operative day:1st post operative day:Medial sternotomy incisionMedial sternotomy incisionMediastinal drain presentMediastinal drain presentVitals monitor and pulse oximeter attachedVitals monitor and pulse oximeter attachedVITALS: VITALS: SPO2 :100%SPO2 :100%Respiratory rate: 25/minRespiratory rate: 25/minHeart rate: 96/minHeart rate: 96/minBlood pressure: 98/56 mm of HgBlood pressure: 98/56 mm of Hg

OBSERVATION:OBSERVATION:GENERALGENERAL CONDITIONCONDITION OFOF THETHE BABY: UnconsciousBABY: UnconsciousModerately built and moderately nourishedModerately built and moderately nourishedOn ventilator: CPAP modeOn ventilator: CPAP modeMediastinal drains and CVP lines are presentMediastinal drains and CVP lines are presentPeripheriesPeripheries: : Clubbing and cyanosis presentClubbing and cyanosis presentPalpationPalpation: : Chest wall expansion: symmetrical and reduced on both sidesChest wall expansion: symmetrical and reduced on both sidesPhysiotherapy treatmentPhysiotherapy treatment -positioning on bed-positioning on bed -training in ADLS-training in ADLS -chest percussion-chest percussion -breathing exercises-breathing exercises

BIBLIOGRAPHYBIBLIOGRAPHY

• O.P.GHAIO.P.GHAI

• LASTS ANATOMYLASTS ANATOMY

• SCOTT IRWINSCOTT IRWIN

• DONNA FROWNFELTERDONNA FROWNFELTER

• MOYNA PARKERMOYNA PARKER

WEBLIOGRAPHYWEBLIOGRAPHY

• WWW.PUBMED.COMWWW.PUBMED.COM

• WWW.CHESTJOURNAL.ORGWWW.CHESTJOURNAL.ORG

• WWW.MEDSCAPE.COMWWW.MEDSCAPE.COM