LIPPSMAck POP trial - Lung Infection Prevention Post Surgery (Major Abdominal) with Pre-Operative Physiotherapy education.

One (1) 20-30 minute pre-operative education session delivered by a Physiotherapist at the standard outpatient Pre-Admission Clinic appointment. The education is to be provided within 6 weeks of the schedued operation date and will be performed in person, however, if this is not possible, the patient will be contacted by phone and provided with the education and training via telephone and the booklet sent via mail. The pre-operative physiotherapy session will consist of education on the prevention of post-operative pulmonary complications stressing the importance of early post-operative ambulation and the performance of self-directed deep breathing and coughing (DB&C) exercises immediately from waking from the operation. Patients will be informed that the further they walk and the more often they walk away from the bedside each day following their operation the better their chance of avoiding serious post-operative complications (chest infection or deep vein thrombosis). They will be informed that a Physiotherapist will see them on the first post-operative day and assist them out of bed to walk as far as possible. They will be told that they will be walking at a pace that gets them a bit breathless and will be familiarised with the 0-10 Borg scale Rating of Perceived Exertion (RPE). They will be told that each time they walk it should feel like a 3-4/10 in exertion. After the first post-operative day session with the Physiotherapist they will be encouraged strongly to walk or exercise by their bedside as often as they can by themselves or with the assistance of a nurse or carer. As it is frequently not possible to ambulate as early and as often as recommended, participants will be encouraged (during the pre-operative intervention) to perform self-directed breathing exercises to protect their lungs during this time in bed. They will be instructed to perform the DB&C exercises immediately from waking from the anaesthetic and then every hour during daytime waking hours until their first ambulation session, and then at any time when they are not ambulant. The physiotherapist will then coach each participant in at least three repetitions, and as many as required to master technique, of two sets of 10 slow-flow breaths to maximum inspiratory capacity with two to three inspiratory sniff breath stacking manoeuvres. Each breath is held for three to five seconds. Each set of 10 breaths are followed by three coughs, or a forced expiratory technique with an open glottis called a “huff”, with a small firm pillow pressed over on the abdominal incision to support the wound and to encourage greater expiratory force. Participants will be encouraged to practice these exercises prior to their operation to develop familiarity. Each patient in the intervention group will be given an estimate of their likelihood of getting a PPC based on available pre-operative information (type of procedure proposed, booked post-operative admission to ICU, usual length of procedure, respiratory co-morbidity, self rated fitness levels, current smoker). Patients will be informed that aggressive early self directed DB & C exercises and ambulation is effective in reducing this known risk of a PPC. Participants will be provided with an accompanying education booklet outlining what was presented on prevention of PPC, post-operative physiotherapy, early ambulation, self directed DB&C (2 sets of 10 DB followed by 3 coughs every hour during daytime) and the expected recovery process. Post-operatively participants will be provided with a standardised physiotherapy assisted early mobilisation program and reminded to do the DB&C exercises as per the booklet provided. No further coached respiratory physiotherapy is provided.