Coughing and Deep Breathing: Nursing Techniques and Patient Education

Coughing and deep breathing exercises are essential nursing interventions to prevent post-operative pulmonary complications such as atelectasis and pneumonia. They are especially critical for surgical, immobile, and opioid-treated patients whose shallow breathing puts them at high risk for alveolar collapse and retained secretions.

Definitions

• Deep breathing: slow, sustained inhalation of air to fully expand the lungs.
• Coughing: a forced expiratory maneuver that clears secretions from the airways.
• Together, these techniques prevent atelectasis (alveolar collapse) and pneumonia in post-operative and immobile patients.

Indications

• Post-operative patients (abdominal, thoracic, cardiac surgery) — prevents atelectasis from shallow breathing.
• Immobility or prolonged bed rest — shallow breathing leads to collapsed alveoli.
• Patients on opioids — opioids cause respiratory depression.

Upper abdominal and thoracic surgeries carry the highest risk for post-operative pulmonary complications.

Deep Breathing Technique

Patient Instructions

• Sit upright or elevate the head of the bed to at least 45–60 degrees. Place hands on the lower rib cage.
• Exhale normally, then inhale slowly and deeply through the nose. The abdomen should rise, not the chest (diaphragmatic breathing).
• Hold the breath for 3 to 5 seconds.
• Exhale slowly through pursed lips.
• Repeat 3 to 5 deep breaths per session, every 1 to 2 hours while awake.

Nurse Responsibilities

• Instruct the patient to use diaphragmatic breathing (abdomen rises).
• Splint the incision with a pillow for post-operative patients.

Coughing Technique

Patient Instructions

• Sit upright and splint the incision by holding a pillow firmly against the surgical site.
• Take 3 to 5 deep breaths, then inhale deeply and cough forcefully from the diaphragm.
• Keep the mouth open and cough in short, sharp bursts (huff cough).
• Repeat 2 to 3 times per session. Rest after each session.

Nurse Responsibilities

• Instruct the patient to cough AFTER deep breathing, not before — deep breathing loosens secretions first.
• Teach the huff cough (open mouth, short bursts) for patients with pain or weak respiratory muscles.

Splinting the Incision

• Splinting supports the incision and reduces pain during deep breathing and coughing.
• Pain is the main barrier to effective coughing.
• Instruct the patient to hold a pillow firmly against the surgical site before coughing. For abdominal incisions, splint across the incision.

The Huff Cough

• The huff cough (cascade cough) is a less forceful technique for patients with incisional pain or respiratory muscle weakness.
• The patient inhales deeply, opens the mouth, and says "huff, huff, huff" while expelling air in short bursts.

Complications of Improper Technique

• Atelectasis — caused by shallow breathing; prevented by deep breathing every 1–2 hours. Most common complication of shallow breathing.
• Pneumonia — caused by retained secretions; prevented by effective coughing.
• Wound dehiscence — caused by forceful coughing without splinting; prevented by splinting the incision.

Patient Education

• Explain that these exercises prevent pneumonia and lung collapse.
• Teach the patient to splint the incision before coughing.
• Perform exercises every 1 to 2 hours while awake, in an upright position.
• Encourage fluids (unless contraindicated) to thin secretions.
• Wait at least 30 minutes after eating to avoid aspiration.

Monitoring and Evaluation

• Assess lung sounds and SpO₂ before and after exercises.
• Assess pain level before exercises.
• Administer pain medication 30 to 60 minutes before exercises if pain limits deep breathing.
• Document patient tolerance, number of breaths, and secretions expectorated.

Common Exam Traps

• Do not instruct the patient to cough before deep breathing — deep breathing loosens secretions first.
• Do not allow shallow chest breathing — instruct diaphragmatic breathing (abdomen rises).
• Do not skip splinting for post-operative patients — pain prevents effective coughing.
• Do not suppress a productive cough — the patient needs to expectorate secretions.
• Do not perform exercises while lying flat — upright positioning is essential.
• Do not perform exercises immediately after eating — wait 30 minutes.

Key takeaways

• Deep breathing first, then cough — deep breathing loosens secretions so coughing can clear them.
• Position the patient upright (≥45 degrees) and use diaphragmatic breathing with a 3–5 second hold and pursed-lip exhalation.
• Perform exercises every 1–2 hours while awake; wait 30 minutes after meals.
• Splint the incision with a pillow to reduce pain and prevent wound dehiscence.
• Use the huff cough for patients with incisional pain or weak respiratory muscles.
• Premedicate for pain 30–60 minutes before exercises and monitor lung sounds and SpO₂.