Pre-operative Inspiratory Muscle Strength Training in Total Joint Surgery

Inclusion Criteria:

* 18 or older
* History of current or previous tobacco use (including vaping containing nicotine products)
* One or more risk factors for post operative pulmonary complications including history of current or previous tobacco use, a clinically diagnosed lung disease, shortness of breath with minimal exertion, FEV1 or FVC less than 80% than predicted or respiratory muscles strength below lower limit of normal for age and sex.
* History of smoking related lung disease
* Projected surgical time \> 30 minutes
* Ability to follow instructions to complete IMT exercises
* Ability to communicate adverse effects such as pain or fatigue or the need for assistance

Exclusion Criteria:

* American Society of Anesthesiologists physical status classification of 4 or greater .
* Recent history of acute pneumonia or lower respiratory infection in the previous two weeks requiring acute corticosteroid or antibiotic medication,
* Preoperative dependence on continuous supplemental oxygen dependence.
* Preoperative dependence on positive pressure breathing support while awake and upright (night time CPAP permitted),
* Diagnosis of a neurologic condition (i.e. MS, ALS, Parkinson's, stroke),
* Participating in a pulmonary rehabilitation program
* Severe obstructive pulmonary disease (Classification of Global Initiative for Chronic Obstructive Lung Disease (GOLD) 3 or higher, indicating FEV1\<50% predicted.
* Patients with an infectious disease requiring isolation (i.e. COVID-19).