FINAL: Unit 4: Fetal Development+Congenital Heart Defects Flashcards
(113 cards)
1
Q
This system in terms of embryologic development
DEVELOPS EARLY
A
CARDIAC SYSTEM
2
Q
Cardiac System
Embryologic Development
DAY 22 to 23
A
Fusion of the endocardial heart tubes
*THE HEART BEATS*
3
Q
CARDIAC SYSTEM
Embryologic Dev
DAY 27
A
Heart starts circulating blood from the heart to the rest of the embryo
4
Q
CARDIAC SYSTEM
Embryologic Dev
WEEK 8
A
4 Chambers of heart FULLY DEVELOPED
==> NORM heart function
5
Q
CARDIAC SYSTEM
embryologic Dev.
WEEK 12***
A
Circulatory System is OPERATING
*NOTE: 12 weeks CARDIAC progress is 28-38wks progress for LUNGS
6
Q
CARDIAC SYSTEM
Embryological Dev.
1st-2nd Trimester
A
HEART CAN FUNCTION
7
Q
This system in terms of Embryologic Dev.
DEVELOPS LATE
A
PULMONARY SYSTEM
8
Q
PULMONARY SYSTEM
Embryologic Dev.
WEEK 24*
A
Mucosal glands functional
Surfactant begins production (so the lungs can work—INC surf area)
9
Q
PULMONARY SYSTEM
Embryologic Dev.
WEEK 28 TO TERM:
A
Surfactant production MATURES
10
Q
PULMONARY SYSTEM
Embryologic Dev.
WEEK 36-40***
A
Alveoli appear, and surfactant reaches FULL MATURITY and is FUNCTIONAL
**REMEMBER—heart is fully working WAY BEFORE THIS (week 8 and by week 12 circulatory system is FULLY WORKING)
11
Q
Fetal circulation is ________ from post-natal circulation
A
DIFFERENT
12
Q
Fetal Circulation
Placenta
*Umbilical cord connects the placenta TO IVC and contains___________
A
Contains umbilical artery and umbilical vein
- Umbilical artery brings De-O2’d blood OUT of body
13
Q
Fetal Circulation
Blood from the IVC goes where?
A
IVC—-> Rt. Atrium
*O2 comes from placenta
14
Q
Fetal Circulation
Foramen Ovale
A
- permits MOST OF (90%) oxygenated blood ENTERING R. ATRIUM to pass INTO L. Atrium
- **SKIPS R. VENTRICLE + LUNGS
15
Q
Fetal Circulation
Ductus Arteriosus
A
- Connects Aorta w/ the Pulm aa
-
SHUNTS most blood AWAY from lungs INTO aorta
- SKIPS LUNGS + L. SIDE OF HEART
- R. atrium–> R. vent–pulm aa–> aorta
16
Q
Fetal Circulation
10% of blood goes where
A
10% goes to LUNGS only to nourish the developing lung tissue
17
Q
BOTH Foramen Ovale and Ductus Arteriosus
Allow what?
A
- Allow blood to skip or shunt R. ventricle
OR
- Skip or shunt Lungs and L. side of heart
18
Q
Fetal Circulation
More on blood vessels of Pulmonary circulation
*remember LUNGS for most part (only 10%) are SKIPPED
A
- Vessels of pulm circulation are vasoconstricted in the fetus
- blood traveling to and thru lungs is primarily used to nourish and develop lung tissue
19
Q
Ductus Arteriosus
Blood b/w _______ and ________
A
Pulm aa & Aorta
20
Q
Foramen Ovale
Blood b/w _________ and ________
A
R. and L. Atria
21
Q
Umbilical Vein
O2’d blood into WHERE?
A
O2’d blood INTO IVC
**O2’d blood FROM PLACENTA
22
Q
MORE PICS ON
O2’d blood from Placenta
Foramen Ovale–blood from Rt. atrium to L. atrium
Ductus Ateriosus–shunts blood AWAY from lungs
A
see pics
23
Q
Fetal Circulation
Blood travels BACK TO PLACENTA via____________
A
Umbilical Arteries
*remember this is de-O2’d blood
24
Q
Pediatric Development
Neonatal
Fetal fluid in lungs is squeezed out while passing thru birth canal.
Remaining fluid is Absorbed by capillaries and lymph
So that WHAT HAPPENS???
A
So infants lungs can expand w/ air w/ their first breath
-
Surfactant is necessary to maintain patent alveoli
- PREVENTS COLLAPSE***
25
What closes the **foramen ovale after birth?**
Closes w/ **INCd Pressure in L. atrium**
26
**Ductus arteriosus begins to close when?**
* w/in 24hrs of birth **as lungs become filled w/ O2**
* **BABY NOW BREATHING**
* **causes PO2 lvls to rise**
27
Once baby PO2 lvls rise...
## Footnote
**what happens to ventricles?**
Shift from working in **parallel** to working in **series**
## Footnote
**\*R. vent slightly EARLIER vs. L. vent**
28
Alveoli grow until _________ yrs old
8 yrs old
\***NO smoking in the house\*\*\*\***
29
MSK Cardiopulm Development in Infants
**0-3 months**
**SHAPE OF THORAX:**
**DIRECTION OF RIBS:**
**PRIMARY MM'S USED FOR INSPIRATION:**
Triangular
Horizontal
Diaphragm
30
MSK Cardiopulm Development in Infants
## Footnote
**3 to 6 months**
**SHAPE OF THORAX:**
**DIRECTION OF RIBS:**
**PRIMARY MM'S USED FOR INSPIRATION:**
RECTANGULAR
HORIZONTAL
DIAPHRAGM + ACCESS. MM'S
\***Happens as infant _gains UE strength_**
31
MSK Cardiopulm Development in Infants
## Footnote
**6 to 12 months**
**SHAPE OF THORAX:**
**DIRECTION OF RIBS:**
**PRIMARY MM'S USED FOR INSPIRATION:**
Rectangular
Angled Downward
Diaphragm + Intercostals
\***NOTE:** @ around age 2, **should demo _little to NO activation of access mm's during quiet breathing_-----\> JUST DIAPHRAGM**
32
Shape of Ribs
## Footnote
**Infant---Triangle (0-3mos)**
**Adult or 12mo's--Angled Downward**
see pics
33
MOST COMMON BIRTH DEFECT
Congenital Heart Defects
## Footnote
**CHD**
34
Dx of cardiac dysf may be made when ?
Prenatally
@ Birth
T/O life
35
CHDs most often occurr when ?
8-10th wk of gestation
36
CHD
## Footnote
**Causes:**
* Genetics
* FAS, Fetal drugs
* Trisomy 21
* SMA
* Turners syndrome
* VATER assoc.
37
10% of children w/ **CHDs also have other phys malformations**
\*\*\*\*\*\*\*\*\*
38
CHD Categorization
2 Cats:
1. Acyanotic--\> **pts are PINK**
2. Cyanotic--\> **pts are BLUE**
39
Acyanotic vs. Cyanotic
see pics
40
CHD Categories
## Footnote
**Acyanotic**
**pts are PINK**
* **Blood Shunts:** L to R
* **Blood to body:** FULLY O2'D to **lungs and body**
* **SV:** LOW SV, heart works HARDER
* **SaO2:** NORM SaO2
* **Pulm blood flow:** INCd pulm blood flow
* **Color:** PINK
41
CHD Categories
**Cyanotic**
**pts are BLUE**
* **Blood Shunts:** R to L
* **Blood to Body:** UNoxygenated blood returned to body
* **SV:** GOOD quality SV
* **SaO2:** 15-30% BELOW NORM
* **\*RBCs:** INCd RBC formation
* **\*Viscosity:** INCd blood viscosity---\> risk of CVA
* **Color:** BLUE
42
Acyanotic vs. Cyanotic
## Footnote
**Common Lesions**
see pics
43
**Common Acyanotic Lesions :**
* Atrial **Septal Defects**- **ASDs**
* Ventricular **Septal Defects** -**VSDs**
* Atrioventricular **Septal Defects**-**AVSDs**
* Patent **Ductus Arteriosus**- **PDA**
* Coartication of the Aorta
* Pulmonary **Stenosis**
* Aortic **Stenosis**
## Footnote
**\*Alfred Ventured Ahead of Paula Cuz Paula Abdul**
44
Common **Cyanotic Lesions:**
* **Tetra**logy of Fallot
* **Trans**position of the **Great Arteries**
* **Tricuspid** Atresia
* **Pulmonary** Atresia
* **Truncus** Arteriosus
* Total Anomalous Pulmonary Venous Return
* Hypoplastic **Left-Sided** Heart Syndrome- **HLHS**
**\*Triple T, P, Double T, H**
45
Acyanotic
## Footnote
**Atrial Septal Defect**
**ASD**
**what is it**
* HOLE in septum b/w the **atria**
* ****persistent (long term) **foramen ovale**
46
**Acyanotic**
**Atrial Septal Defect**
**ASD**
**Allows _______ blood to flow from _______ to \_\_\_\_\_\_\_**
Allows oxygenated blood to flow from **L atria to R atria**
* **Mixerespirated blood**
* **Stresses heart===\> CHF**
* \>80% CLOSE in first yr w/out sx
47
**Acyanotic**
**Atrial Septal Defect**
**ASD**
**S/S**
* Murmur
* racing heart beat
* **Enlarged pulm aa**
48
**Acyanotic**
**Atrial Septal Defect**
**ASD**
**\>80% close w/out sx BUT**
**What is the Sx intervention?**
PATCH placed via open heart sx OR cath proc.
49
**Acyanotic Defects**
**Ventricular Septal Defect**
**VSDs**
**Explain generally**
* Opening in **Septum b/w L and R ventricle**
* **Blood flows b/w ventricles**
* HEART MUST WORK HARDER TO PUMP BLOOD TO BODY
50
**Acyanotic Defects**
**Ventricular Septal Defect**
**VSDs**
**LARGE DEFECTS...**
* LG. defects may lead to:
* **bacterial endocarditis**
* **pulm vascular obstructive dis.**
* **aortic regurgitation**
* **INCd incidence of lower resp tract infections**
* **CHF**
51
**Acyanotic Defects**
**Ventricular Septal Defect**
**VSDs**
**S/S**
* Murmur
* fatigue
* INCd HR
* poor growth/feeding
* irritability
* restlessness
* rapid breathing
52
**Acyanotic Defects**
**Ventricular Septal Defect**
**VSDs**
**Tx:**
* **Watch/Wait:** may spontaneously close
* **Sx:** close via patch w/ open heart sx
53
Acyanotic Defects
## Footnote
**Atrioventricular Septal Defect**
**AVSDs**
**\*BOTH PLACES**
**Explain generally...**
* Persistent (long term) **foramen ovale** AND **ventricle septal defect w/ _incomplete valve formation_**
* 15-40% children w/ **Downs/Trisomy 21**
54
**Acyanotic Defects**
**AtrioVentricular Septal Defect**
**AVSDs**
**S/S**
* Pulm HTN----usually assoc'd w/ R.side HF
* lung congestion
* HF
55
**Acyanotic Defects**
**AtrioVentricular Septal Defect**
**AVSDs**
**Tx:**
* **Sx usually required w/in first few months of life**
56
Acyanotic Defects
## Footnote
**Patent Ductus Arteriosus**
**PDA**
**"Open Passageway"**
**\*opening b/w Pulm aa & Aorta**
**Describe generally...**
* NORMALLY closes w/in 5-14 days after birth **bc changes in prostaglandin lvls w/ INC O2 lvls**
* **Often assoc'd w/:**
* ****prematurity/respiratory distress syndrome/hyaline membrane dis.
* ---\> **Hypoxia**: O2 lvls NEVER HIGH ENOUGH to signal closure
57
**Acyanotic Defects**
**Patent Ductus Arteriosus**
**PDA**
**"Open Passageway"**
**\*opening b/w Pulm aa & Aorta**
**S/S**
\*vary based on SIZE of opening
* **LARGE**:
* Compensatory tachycardia + INCd RR
* poor wt. gain
* **SMALL:**
* asymptomatic
58
**Acyanotic Defects**
**Patent Ductus Arteriosus**
**PDA**
**"Open Passageway"**
**\*opening b/w Pulm aa & Aorta**
**Tx:**
* Minimally invasive sx closure
* **Med mgmt w/ indomethacin**
59
Acyanotic Defects
**Coartication (narrowing) of the Aorta**
**Explain Generally....**
AKA **2\* HTN**
* **Narrowing** of the **Aorta** after it branches off to the UPPER BODY
* **Obstructed of blood flow to LOWER BODY**
* **INCd work on L. vent to pump**
* Can lead to **CHF**
60
Acyanotic Defects
## Footnote
**Coartication (narrowing) of the Aorta**
**S/S**
* INCd RR
* INCd sweating
* DECd growth
* DECd endurance
* murmur
61
Acyanotic Defects
## Footnote
**Coartication (narrowing) of the Aorta**
**Tx:**
* Cath to **dilate**
* **Stent to open**
* **Sx:**
* **REMOVE portion of aorta** and sew back together or enlarge w/ patch
* MAY RE-OCCUR
62
Acyanotic Defects
## Footnote
**PULMONARY STENOSIS**
**IN GENERAL....**
* **Fused, thickened or missing** leaflets of **pulm valve** causing OBSTRUCTION
* INCs work on **Rt. ventricle (bc this is where Pulm valve leaves)** to pump blood to lungs
63
Acyanotic Defects
## Footnote
**PULMONARY STENOSIS**
**S/S**
* Fatigue
* murmur
* **Rare cases have chest pain**
64
**Acyanotic Defects**
**PULMONARY STENOSIS**
**Dx:**
* ECG
* Chest X-ray
* SpO2
* Cath
* MRI
65
**Acyanotic Defects**
**PULMONARY STENOSIS**
**Tx:**
* DEPENDS on **anatomy and severity**
* **Cath**
* **Sx:**
* **Valvotomy**
* **homograft (self) valve**
* **New valve**
66
**Acyanotic Defects**
**AORTIC STENOSIS**
**In general...**
* **Fused, Thickened, missing** leaflets of **Aortic valve (its IN the name of the defect as what it IS\*)**
* Obstruction from LEFT vent to aorta (**bc this is where Aortic valve leads)**
* INCd work on LEFT ventricle to pump blood to body (**bc this is where Aortic valve is\*\*)**
67
**Acyanotic Defects**
**AORTIC STENOSIS**
**S/S**
**MOST ALL ACYANOTIC DEFECTS HAVE SAME S/S\*\*\***
* **Fatigue**
* **Murmur**
* **Rarely chest pain**
* **fainting**
* **arrhythmias**
68
Acyanotic Defects
AORTIC STENOSIS
**Dx:**
* Murmur
* ECG
* ECHO
* chest x-ray
* SpO2
* Cath
* MRI
69
**Acyanotic Defects**
**AORTIC STENOSIS**
**Tx:**
Depends on **severity**
* **Balloon Valvuloplasty via cath**
* **Sx:**
* ****artificial valve OR **Ross proc.**
70
CYANOTIC DEFECTS
these pts are\_\_\_\_\_\_
BLUE
"cyanotic"
71
Cyanotic Defects
**Tetrology or Fallot**
Tetra==4\*\*\*
**COMBINATION of defects:**
* VSDs
* Aortic Override
* Pulm Stenosis
* R. Ventricular Hypertrophy
72
**Cyanotic Defects**
**Tetrology or Fallot**
**Tetra==4\*\*\***
**What is it??**
* **50% of Cyanotic defects\*\*\***
* **DECd** blood flow to the **lungs**
* **POORLY oxygenated blood (bc SO much going on think about COMBO\*) pumps out _thru Aorta_**
* \*Degree of Cyanosis depends on **pulm stenosis**
73
**Cyanotic Defects**
**Tetrology or Fallot**
**Tetra==4\*\*\***
**S/S**
Cyanosis
murmur
\***clubbing**
**'Tet spell"**
74
Cyanotic Defects
Tetrology or Fallot
Tetra==4\*\*\*
**Tx:**
* Sx:
* **repair VSD**
* **dilate pulm valve (rt. vent--pulm aa)**
75
Cyanotic Defects
**Trans**position of the **Great Arteries**
**"Transposition" meaning everything is all OUT OF POSITION\*\*\***
**EXPLAIN**
* Aorta comes out of **R. Ventricle----NOT GOOD**
* Pulm artery comes out of **L. Ventricle----NOT GOOD**
* **NO COMMUNICATION B/W _SYSTEMIC_ AND** **_PULMONARY_** **CIRCULATIONS\*\*\***
76
Cyanotic Defects
**Trans**position **of the Great Arteries**
**S/S**
* Cyanosis
* INCd RR
* poor feeding/Wt. Gain/appetite
77
Cyanotic Defects
## Footnote
**Transposition of the Great Arteries**
**Dx:**
* Fetal ECHO
* ECG
* Cath
* MRI
* SpO2
* Chest x-ray
78
Cyanotic Defects
## Footnote
**Transposition of the Great Arteries**
**Tx:**
* ALL will need **open heart sx** for **arterial switch repair**
* **\*Arrhythmias or vent dysf's may develop later in life**
79
Cyanotic Defects
**Tricuspid Atresia**
**\*IN NAME-----**has to be something w/ **Tricuspid Valve\*\*\*\*\***
**General...**
* Tricuspid Valve (R. Atria--\>R. Vent) **fails to develop OR is patent**
* **SMALLER than normal R. Vent**
* **ALWAYS have** **_ASD_**
* **SOMETIMES VSD**
* **\*\*\*only 1 functioning ventricle**
80
Cyanotic Defects
## Footnote
**Pulmonary Atresia**
**\*\*IN NAME-----HAS to be something w/ Pulmonary valve (Rt. Vent---\> Pulm aa)**
**General....**
* Abnorm. formed **pulm valve**
* **Block of blood from R. SIDE of heart TO lungs**
* **\*\*often assoc'd w/ _VSD_**
81
Cyanotic Defects
## Footnote
**Pulmonary Atresia**
**S/S**
* cyanosis
* poor feeding/wt. gain
* SOB
82
Cyanotic Defects
**Pulmonary Atresia**
**Dx:**
* Fetal US
* ECG
* ECHO
* SpO2
* chest x-ray
* MRI
83
Cyanotic Defects
## Footnote
**Pulmonary Atresia**
**Tx:**
* Balloon valvuloplasty via Cath.
* Open heart sx
* **patch or Shunt**
84
Cyanotic Defects
**Truncus Arteriosus**
**General....**
* Missing **normal separation of the _Aorta_** **and** **_Main Pulm aa_ during fetal development**
* RESULTS IN **R. and L. vents empty into a _single Lg. vessel_**
* **Single GREAT ARTERY arises from the Vents**
* ****carries BOTH **_pulmonary_** and **_systemic_** blood flow
\***VSD ALWAYS present**
**\*Heart functions as a SINGLE VENTRICLE**
85
**Cyanotic Defects**
**Truncus Arteriosus**
**Tx**
Sx repair is **req'd** for correction
86
Cyanotic Defects
## Footnote
**Total Anomalous Pulmonary Venous Return**
**General....**
* **Pulm veins** attach to the **R. Atrium OR to other veins that drain into the R. Atrium**
87
Cyanotic Defects
## Footnote
**Total Anomalous Pulmonary Venous Return**
**S/S**
* Pulm congestion
* cyanosis
* HF
88
Cyanotic Defects
## Footnote
**Total Anomalous Pulmonary Venous Return**
**\*ASD may also be present.....what does this mean?**
\*ASD may also be present----\> **Aids R. Atrium _decompression_**
89
Cyanotic Defects
## Footnote
**Total Anomalous Pulmonary Venous Return**
**Sx:**
* Anastomosis (**surgical joining)** of the **pulm veins TO L. atrium**
* **PERFORMED EARLY AS POSS.**
90
CYANOTIC DEFECTS
**HYPOPLASTIC LEFT-SIDED HEART SYNDROME**
**HLSHS**
**Includes 3 things:**
1. Hypoplastic (**underdeveloped)** L. Vent
2. Aortic and Mitral Valve **stenosis** (narrowing) OR **atresia (complete closure)**
3. Coartication of the Aorta
91
Cyanotic Defects
## Footnote
**Hypoplastic (underdeveloped) L. Sided Heart Syndrome**
**HLHS**
**S/S**
* may be MINIMAL while PDA (**Patent Ductus Arteriosus) is open**
* **cyanosis**
* **poor feeding/wt. gain**
* **INCd work of breathing**
* **lethargy******
92
Cyanotic Defects
## Footnote
**Hypoplastic (underdeveloped) L. Sided Heart Syndrome**
**HLHS**
**Dx:**
* fetal echo
* ECG
* ECHO
* chest x-ray
* SaO2
* cath
* MRI
93
Cyanotic Defects
## Footnote
**Hypoplastic (underdeveloped) L. Sided Heart Syndrome**
**HLHS**
**Tx:**
* Prostaglandin E to maintain PDA (**Patent Ductus Arteriosus)**
* **Mech. Vent may be req'd until sx or heart transplant can occur**
* **3 staged sx procedure or transplant**
94
Pulmonary Patho of **infancy or childhood**
## Footnote
**Abnorm Development**
* \*\*Assess **chest wall\*\*\*\***
* Looking for **weakness and/or Tone imbalance:**
* ****Incomplete **elongation of ribcage**
* Rib cage **flaring-----ant or lat.**
* **LOWER resting pos. of diaphragm**
* Kyphotic posture
* Pectus excavatum
* **Abnorm dev of the chest can cause DEC in _pulm function_**
95
Soda Pop Model
**\*of Postural Support**
"If you can't breathe, you can't function."
Mary Massery
96
Soda Pop Model
## Footnote
**Ex. POOR POSTURE**
**EXTREME EXAMPLE**
SEE PICS
97
COMMON **Pediatric Pulmonary Dx's**
## Footnote
**3 NEW**
**Rest you already know!!!!!**
* **Meconium (baby's poop in womb) Aspiration Syndrome**
* **SIDS**
* **Tracheoesophageal Fistula**
* Asthma
* Resp. Distress Syndrome/Hyaline Memb Dis.
* Pectus deformities
* Bronchopulm Dysplasia (BPD)
* Broncholitis Obliterans (BO)
* Cystic Fibrosis (OLD)
* Lung Transplants
98
Meconium Aspiration Syndrome
## Footnote
**MAS**
**What is _Meconium?_**
contents of fetal/newborn bowel
99
**Meconium Aspiration Syndrome**
**MAS**
**WHEN occur?**
W/ FIRST **postnatal breaths**
100
Meconium Aspiration Syndrome
MAS
**Reversible when?**
Reversible IF airways are **suctioned immediately @ birth**
101
Meconium Aspiration Syndrome
MAS
**Can Cause:**
* Atelectasis
* Tension pneumothorax----WORSE KIND (one-way door)
* Persistent (long term) Pulm HTN
* Bronchiolitis
* Pneumonitis
102
Meconium Aspiration Syndrome
## Footnote
**MAS
Tx:**
* Pulm hygiene
* Supplemental Oxygen (PRN)
* Assisted ventilation (PRN)
103
**Sudden Infant Death Syndrome**
**SIDS**
**what is it?**
Sudden, **unexpected** death during **sleep** of an otherwise **healthy infant**
**\*MAY be linked be w/ _respiration infection_ and _brain stem dev._**
104
SIDS
## Footnote
**Risk Factors:**
* Male infant
* LOW birth wt
* active resp. infection
* sleeping on soft surfs
* sharing bed w/ adults/siblings/pets
* overheating
* age (**MOST RISK @ 2-3mos old**
* prematurity w/ immature **neural development**
* **2nd hand smoke**
* **maternal age \<20**
* **family hx**
* **inad. prenatal care**
105
SIDS and "**Back to Sleep"**
Sleep in SUPINE
\*incidence DECd by \>50% since "Back to Sleep"
106
SIDS
## Footnote
**PT Role**
**Back to Sleep/Tummy to Play**
107
SIDS
Back to Sleep/Tummy to Play
**Promoting compliance???**
**5 S's\*\*\*\***
**1. Shush**
**2. Sound**
**3. Swaddle**
**4. Swing**
**5. Suck**
108
**Tracheoesophageal Fistula**
* .02% of births
* **Abnorm connection b/w _esophagus_ and _trachea_**
* **__-----\> Causes fluids to pass thru esophagus INTO trachea and lungs**
* **\*\*Req's Sx**
109
Tracheoesophageal Fistula
## Footnote
**Commonly seen w/:**
Trisomy 13, 18 and 21
VATER syndrome
heart defects
defects of kidney + urinary tract
110
VATER syndrome
**V:** Vert abnormal
**A:** Anal Atresia
**T:** Trachea
**E:** Esophagus
**R:** Renal
111
NORM Vital Signs for Various Ages
Ranges + Avgs
RPE Also
see pics
112
Tx Ideas for CHDs and Pediatric Pulmonary Dx's
* Lateral costal breathing manual tech.
* put your hand where YOU want them to breathe INTO
* Diaphragmatic breathing QUICK STRETCH
* RIGHT AFTER LOOOONG EXHALE JUST BEFORE INHALE!!!
* Diaphragmatic breathing w/ visualization
* IMTs
* Flexibility
* Strength
* Posture
* Pulm toileting
* Functional Mobility
* Endurance training----**OBSTACLE COURSES!!!**
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