Breathing and Coughing Exercises for Hospitalised Patients

Hospitalised patients with respiratory conditions, particularly those who have undergone chest or abdominal surgery, should perform breathing and coughing exercises in order to prevent further issues and complications (Allina Health 2015).

Breathing and coughing exercises are crucial for assisting breathing and clearing excess secretion in the recovery stage. If sputum builds up in the lungs, it may become infected and increase the risk of pneumonia (My Health Alberta 2019; Penn Medicine 2016).

Furthermore, excess sputum impedes the ability of the lungs to oxygenate effectively (Stewart 2019).

A study by the University of Melbourne found that preoperative education and teaching of respiratory exercises halves the rate of post-surgery complications for major abdominal surgery patients (Boden & Denehy 2018)

Which Patients Should Perform Respiratory Exercises?

Patients with chronic obstructive pulmonary disease (COPD);
Patients with an interstitial lung disease;
Patients with cystic fibrosis;
Patients undergoing lung, chest or abdominal surgery;
Patients with a muscle-wasting disorder that affects breathing muscles;
Patients with asthma;
Patients undergoing surgery for a lung transplant or lung cancer; and
Any patient who may be immobile for whatever reason.

(MedlinePlus 2018; NIH 2019)

What are the Benefits of Respiratory Exercises?

Performing respiratory exercises can help to:

Strengthen accessory muscles around the lung, as they become weak when a patient is not able to mobilise;
Strengthen the diaphragm, allowing it to assist with lung expansion and improve air reaching the base of the lung;
Take the burden off other muscles in the neck, back and chest that are used when the diaphragm is not working to full capacity;
Clear the airway of excess sputum;
Improve lung function; and
Reduce the risk of developing respiratory infections or atelectasis (alveoli collapse).

(American Lung Association 2020; Tokarczyk, Greenberg & Vender 2013 pp. 301-323)

Preparing Patients for Breathing Exercises

Consider administering analgesia prior to starting. If the patient has pain they will not be able to perform the exercises.

Mobilise the patient to ensure they do not acquire a lung infection or atelectasis.

Sit the patient out of bed or up in bed (the aim is to optimise lung expansion).

Critical care patients can sit out of bed if they are haemodynamically stable (this allows for better lung expansion). Ensure you have two to three clinicians assisting with any intravenous lines, cardiac monitoring, drain tubes etc.

Ensure the patient is comfortable.

Place a folded towel up against the patient’s chest or abdomen to provide comfort and security around any wounds they may have

The Active Cycle of Breathing Techniques (ACBT)

The Active Cycle of Breathing Techniques (ACBT) is an exercise comprising three sections:

Breathing control;

Chest expansion exercises; and

Huffing (forced expiration technique).

(Bronchiectasis Toolbox 2018)

This technique is used to clear excess sputum and improve ventilation of the lungs, and can be performed in any breath enhancing position (Bronchiectasis Toolbox 2018).

1. Breathing Control

This is a period of relaxed breathing at a rate comfortable for the patient. The patient should breathe in through their nose and out through their nose or mouth until they are ready to progress to the next stage.

(Bronchiectasis Toolbox 2018; Troughton 2015)

2. Chest Expansion Exercises

This exercise aims to mobilise sputum in the lungs.

The patient should breathe in deeply and slowly, through the nose if possible, while trying not to rely on accessory muscles. After holding the breath for two to three seconds, they should breathe out gently while keeping their shoulders and chest relaxed. This should be repeated up to five times.

(Bronchiectasis Toolbox 2018; Troughton 2015)

3. Huffing

A huff is forceful exhalation of breath with an open throat.

This technique (also known as forced expiration technique) is used to shift sputum from the lower airways to the upper airways so that it can be expelled through the mouth.

The patient should use different lengths of inhalation in order to move the sputum upwards:

A low-medium volume huff involves taking a small breath in and then huffing. It is used to shift the sputum upwards from the lower airways.

Once the sputum has moved higher up into the chest, a high-volume huff is then used to move it to the mouth. This involves taking a deep breath in and then huffing.

A rumbling or rattling noise in the chest indicates that the huffing is moving the sputum successfully.

Only one to two huffs should be performed consecutively before another period of breathing control, as they can cause chest tightness or wheezing.

(Bronchiectasis Toolbox 2018; Troughton 2015; ACPRC 2011)

A typical cycle of ACBT comprises:

Breathing control (until the patient is settled and ready to proceed).

Chest expansion exercises (three to five).

Breathing control (until the patient returns to their normal resting breathing rate).

Chest expansion exercises (three to five).

Breathing control.

Huffs.

Breathing control.

(Bronchiectasis Toolbox 2018)

This cycle is generally repeated until huffing is no longer producing sputum, or the patient needs to rest (Bronchiectasis Toolbox 2018).

Other Breathing Exercises Coughing Exercise

If the patient is lying on their back, they should bend their knees (with permission from their surgeon) and rest their feet on the bed.

If the patient has had surgery, the incision should be supported with their hands or a small pillow.

The patient should breathe in deeply and cough firmly.

Clear any sputum into a tissue.

This should be repeated until the cough is unproductive, however, if the patient has a large amount of sputum they may need to take a break.

(My Health Alberta 2019

Pursed Lip Breathing

The patient should relax their neck and shoulder muscles.

Breathe in through the nose for two seconds.

Exhale gently through pursed lips for four seconds.

Repeat as necessary.

(American Lung Association 2015)

Diaphragm Breathing

The patient should sit up straight and place their hands on their abdomen.

Alternatively, the patient can lie down if it is more comfortable for them.

Take a slow, deep breath in through the nose, ensuring the abdomen expands with the breath.

Exhale slowly and gently through pursed lips.

Repeat for 5 to 10 minutes.

(American Lung Association 2015)

Considerations

The patient may begin to feel dizzy. If this occurs, stop the exercise and observe their vital signs.
If sputum obstructs the airway, perform basic life support and call for help.
The patient may experience pain during exercises from surgery or their condition.
Critical care patients may deteriorate while sitting out of bed due to the sensitive nature of their condition, or other complications.

Conclusion

In order to improve lung function and recovery, it is important for the patient to perform breathing and coughing exercises frequently. Patient education is imperative to ensure the exercises are done accurately.

Additional Resources

American Lung Association, Breathing Exercises, https://www.lung.org/lung-health-diseases/wellness/breathing-exercises
Bronchiectasis Toolbox, The Active Cycle of Breathing Technique (ACBT) video, https://bronchiectasis.com.au/resources/videos/the-active-cycle-of-breathing-technique

Multiple Choice Questions Q1. By how much was preoperative education and teaching of respiratory exercises found to reduce the rate of post-surgery complications for major abdominal surgery patients?

10%

20%

50%

60%

Q2. Which type of huff is used to move sputum from the upper airways into the mouth?

Low-medium volume huff.

High-volume huff.

Q3. Which stage typically comes first in an ACBT cycle?

Breathing control.

Chest expansion exercises.

Huffing.

References

Allina Health 2015, Respiratory Exercises, Allina Health, viewed 27 April 2020, https://www.allinahealth.org/health-conditions-and-treatments/health-library/patient-education/preparing-for-your-hysterectomy/preparations/respir atory-exercises-breathing-exercises
American Lung Association 2015, Belly Breathing, online video, 18 September, viewed 27 April 2020, https://www.youtube.com/watch?time_continue=87&v=wai-GIYGMeo&feature=emb_title
American Lung Association 2020, Breathing Exercises, American Lung Association, viewed 27 April 2020, https://www.lung.org/lung-health-diseases/wellness/breathing-exercises
American Lung Association 2015, Pursed Lip Breathing, online video, 9 September, viewed 27 April 2020, https://www.youtube.com/watch?time_continue=136&v=7kpJ0QlRss4&feature=emb_title
A ssociation of Chartered Physiotherapists in Respiratory Care 2011, The Active Cycle of Breathing Techniques, Association of Chartered Physiotherapists in Respiratory Care, viewed 27 April 2020, https://www.acprc.org.uk/Data/Publication_Downloads/GL-05ACBT.pdf
Boden, I & Denehy, L 2018, Training for Recovery Before Major Surgery, Pursuit, 12 March, viewed 27 April 2020, https://pursuit.unimelb.edu.au/articles/training-for-recovery-before-major-surgery
Bronchiectasis Toolbox 2018, The Active Cycle of Breathing Technique (ACBT), Bronchiectasis Toolbox, viewed 27 April 2020, https://bronchiectasis.com.au/physiotherapy/techniques/the-active-cycle-of-bre athing-technique
Bronchiectasis Toolbox 2018, Forced Expiration Technique (FET), Bronchiectasis Toolbox, viewed 27 April 2020, https://bronchiectasis.com.au/paediatrics/airway-clearance/forced-expiration-technique
MedlinePlus 2018, Pulmonary Rehabilitation, MedlinePlus, viewed 27 April 2020, https://medlineplus.gov/pulmonaryrehabilitation.html
My Health Alberta 2019, Deep Breathing, Coughing, and Moving After Surgery, My Health Alberta, viewed 27 April 2020, https://myhealth.alberta.ca/Alberta/Pages/deep-breathing-coughing-after-surgery.aspx
National Heart, Lung, and Blood Institute 2019, Pulmonary Rehabilitation, National Heart, Lung, and Blood Institute, viewed 27 April 2020, https://www.nhlbi.nih.gov/health-topics/pulmonary-rehabilitation
Troughton, J 2015, The Active Cycle of Breathing Techniques, Oxford University Hospitals NHS Trust, viewed 27 April 2020, https://www.ouh.nhs.uk/patient-guide/leaflets/files/11659Pbreathing.pdf
Penn Medicine 2016, Breathing After Surgery, Penn Medicine, viewed 27 April 2020, https://www.pennmedicine.org/updates/blogs/heart-and-vascular-blog/2016/october/breathing-after-surgery
Stewart, N 2019, Chest Physiotherapy, Physio Works, viewed 27 April 2020, https://physioworks.com.au/treatments-1/chest-physiotherapy
Tokarczyk, A J, Greenberg, S B & Vender, J S 2013, ‘Chapter 14 - Oxygen Delivery Systems, Inhalation Therapy, and Respiratory Therapy’, Benumof and Hagberg's Airway Management (Third Edition), viewed 27 April 2020, https://www.sciencedirect.com/topics/nursing-and-health-professions/breathing-exercise

( Answers: c, b, a)

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