Before we begin:

Splinting your incision Before you begin your exercises it is important you know how to splint you incision site. With the coughing and huffing exercises, you will be using your abdominal and some accessory respiratory muscles, so it is important that if your incisions is around these muscle, that you correctly splint the site (Laws, 2010). This will not only help with keeping the incision intact, but will also help with some discomfort that may be incurred during the exercise (Laws, 2010) How do I splint my incision? 1. Place the palm of your hands on either side of your incision site, with them slightly over lapping.

2. Hold your elbows in tight on either side if your body. If your incision is larger than your hands, roll up a pillow and place that between your abdomen and hands, and place your hands in the position stated in steps one and two. Pain and discomfort: These exercises are important to getting you back to you normal daily living, and as stated previously can cause some discomfort and/ or pain, even with splinting. Therefore, taking pain medication before doing your exercises can reduce this discomfort. Talk to your doctor or nurse about when you should do this (usually about 35-40 minutes before doing the exercises), and what medication would be most suitable for you. (Acute pain service, QEII Halifax, 2009) Cold therapy can also be used to manage pain at your incision site, so ask your nurse for a cold pack or some ice. (Chailler, Ellis, Stolarik, & Woodend, 2010)

Pursed lip breathing:

What is it? Pursed lip breathing is breathing that is characterized by deep inspirations (breaths in) followed by prolonged expirations (breaths out) through pursed lips (such as when whistling). (Mosby, 2010)

It is a breathing technique that will help you to:

Gain control

over your breathing (Berman, 2010)

Improve ventilation

when suffering from dyspnea (difficulty breathing), despite feelings of relief from the dyspnea (Tiep, 2007)
Reduce

your respiration rate (Tiep, 2007)

Improve gas exchange

at the alveoli; the part of the lungs that enables blood to be oxygenated, and carbon dioxide to be removed before return of the blood to the heart and subsequent distribution to the body (Kaufman & Kent, 2010). and thereby improve oxygenation and the removal of Carbon dioxide from the blood (Tiep, 2007)
Prevent airway collapse Reduce

(Tiep, 2007)

postoperative complications such as airway collapse (Berman,

2010)

Diaphragmatic breathing
How Do I Do It? 1. Begin by lying on your back on a flat surface or in bed, with your knees bent and your head supported. You can use a pillow under your knees to support your legs. Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe (Clevelend Clinic, 2011). 2. Breathe in slowly through your nose for a 4 count so that your stomach moves out against your hand. The hand on your chest should remain as still as possible (Clevelend Clinic, 2011). 3. Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips for a 4 count. The hand on your upper chest must remain as still as possible (Clevelend Clinic, 2011). Now wait for a second or two until the body spontaneously begins the inhalation. This will occur naturally and of its own accord (Pegasus NLP, 2011). 4. Continue doing this for about 5-10 minutes. When you first learn the diaphragmatic breathing technique, it may be easier for you to follow the instructions lying down. As you gain more practice, you can try the diaphragmatic breathing technique while sitting in a chair with your knees bent and your shoulders, head and neck relaxed, as shown below (Clevelend Clinic, 2011). Practice the same as you do when you lie on your back. Tips and advice:

When do I do these exercises, and how often should I do them? Use this exercise whenever you feel short of breath or have difficulty breathing, and increase gradually to 5-10 minutes four times a day. Regular practice will help you to do this type of breathing without any conscious effort. The exercise, once learned, can be performed in any position (sitting upright, standing and walking). (Berman, 2010)

How do I do this exercises? 1. Assume a comfortable semi-sitting position in bed or a chair/a lying position in bed with one pillow 2. let your knees to relax the muscles of the abdomen 3. Place one or both hands on your abdomen, just below the ribs 4. Breathe in deeply through the nose for about 3 seconds, keeping the mouth closed 5. Concentrate on feeling your abdomen rise (expand) as far as possible; stay relaxed and avoid arching your back. If you have difficulty raising your abdomen, take a quick, forceful breath through the nose 6. Then purse your lips as if about to whistle and breathe out slowly and gently, making a slow whooshing sound without puffing out the cheeks. This pursed lip breathing creates a resistance to air flowing out of the lungs, increases pressure within the bronchi (main air passages) and minimizes collapse of smaller airways; a postoperative complication (commonly seen in those with COPD) 7. Concentrate on feeling the abdomen fall, and tighten the abdominal muscles while breathing out to enhance effective exhalation, count to 7 during exhalation. (Berman, 2010)

This exercise can also be performed when walking (Trudy Dwyer, 2010). At first, you will probably get tired while doing this exercise. But keep at it, because with continued practice, diaphragmatic breathing will become easy and automatic. (Clevelend Clinic, 2011). You may also experience sleepiness while doing this exercise. This sleepiness is just your body trying to catch up on the rest and relaxation. As you continue to practice this should recede (Pegasus NLP, 2011).

Huffing and coughing:

When and how often should I do this exercise? You should try to do three sets of coughing and huffing every hour while awake, in addition to your breathing exercises. (Hall, Tarala, Tapper, & Hall, 1996) Do not be afraid to cough. Your incision is firmly held together by stitches or staples. Huffing: Coughing is a natural way to force mucus out of your lungs. During huff coughing, you gently say the word "huff", which keeps your throat open. 1. To begin, inhale slowly and deeply, feeling your chest and back expand. 2. Hold your breath for three seconds. 3. Do a forced exhalation, whispering the word "huff" as you quickly let air out. (Department of Cardiothoracic surgery, University of Southern California, 2011)

Diaphragmatic breathing
What It Is? Diaphragmatic breathing, stomach breathing, abdominal breathing or coastal breathing is simply relaxed controlled deep breathing. It uses the diaphragm muscle, a strong dome shaped muscle located under our ribs and above our stomach. The diaphragm is obviously the most efficient muscle of breathing. Diaphragmatic breathing is also the way we automatically breathe when we are born. Observe how a very young baby breathes. You will see they use their diaphragm with each breath (Anxiety and Stress Management Service of Australia, 2008). How Does It Work?

Remember: The most comfortable position in which to cough is sitting upright. Hold a pillow or rolled-up blanket against your stitches or staples. Bending your knees may make coughing more comfortable. (The University of Chicago Medical Centre, 2011)

When we breathe in, we push the muscle down and our stomach moves forward. When we breathe out, the diaphragmatic muscle moves back to resting position and our tummy moves back in. There is little or no upper chest movement (Anxiety and Stress Management Service of Australia, 2008). This exercise facilitates a wide exchange of gases; helps to remove carbon dioxide from your blood while creating oxygen, an important source of energy (Seaward, B.L., 2005). It maximizes the amount of oxygen available to the cells (Seaward, B.L., 2005). Diaphragmatic breathing use less effort and energy to breathe, therefore help to relax muscles (Trudy Dwyer, 2010). It stimulates your internal organs for overall health (Pegasus NLP, 2010).

Coughing: When you cough, relax your neck and shoulders. Cough from your belly, not from your throat. 1. Breathe deeply into the lungs, and hold your breath for about three seconds. 2. After two deep inhalations, cough forcefully using the abdominal and other accessory respiratory muscles. 3. You can provide support for your incision by placing your palms on either side of the incision during coughing or by using a pillow. (The University of Chicago Medical Center, 2011)

Why Should I Do This Exercise? Diaphragmatic breathing exercise facilitates the respiratory function by helping in removing secretion from airway tract. Frequent deep breathing exercise automatically initiates the cough reflex, which enables you to remove mucous from the lung. This is important as if mucous stay trapped, you may be at risk of developing pneumonia (Lance Amstrong Foundation, 2011). By assisting in sputum clearance and lung expansion, diaphragmatic breathing reduces the chances of chest complications after surgery (atelectasis, infection, exacerbation of underlying chronic lung disease) (Lance Amstrong Foundation, 2011). It helps you cope with pain, manage anxiety and panic symptoms (Anxiety and Stress Management Service of Australia, 2008). It is the most accessible technique to facilitate the respiratory function as you do not need any devices (Seaward, B.L, 2005).