Figure 49-4 A full, aggressive, preoperative respiratory preparation regimen consists of a five-pronged attack: (1) require the patient to stop smoking, (2) dilate the airways, (3) loosen secretions, (4) remove secretions, and (5) increase patient participation. Using these five maneuvers in the numbered sequence allows them to complement one another in improving removal of secretions. IS, incentive spirometer; PT, physical therapy. (From Benumof JL: Anesthesia for Thoracic Surgery. Philadelphia, WB Saunders, 1987.)