How is postoperative atelectasis managed?

From the Guidelines

Atelectasis is considered a postoperative pulmonary complication and should be managed accordingly to reduce morbidity, mortality, and improve quality of life. The management of postoperative atelectasis involves a combination of preventive measures and active interventions.

Preventive Measures

• Early mobilization, encouraging patients to get out of bed and move as soon as safely possible after surgery 1
• Deep breathing exercises and incentive spirometry should be performed regularly, typically 10 breaths every hour while awake, to expand collapsed lung tissue 1
• Adequate pain control using appropriate analgesics is essential, as pain can limit deep breathing and coughing efforts 1

Active Interventions

• Positioning therapy, particularly upright or semi-Fowler's position, helps maximize lung expansion 1
• For more severe cases, chest physiotherapy including percussion and postural drainage may be necessary 1
• Supplemental oxygen should be provided to maintain adequate saturation levels, typically aiming for SpO2 >92%
• In cases that don't respond to conservative measures, continuous positive airway pressure (CPAP) at 5-10 cmH2O or bilevel positive airway pressure (BiPAP) may be required
• Bronchoscopy might be performed for mucus plugging causing significant atelectasis
• Nebulized bronchodilators such as albuterol (2.5-5 mg every 4-6 hours) can help if bronchospasm is present These interventions are effective because they address the underlying mechanisms of atelectasis: they improve ventilation, clear secretions, reduce airway closure, and promote re-expansion of collapsed alveoli, thereby restoring normal lung function and preventing complications like hypoxemia and pneumonia. Key points to consider in the management of postoperative atelectasis include:
• Patient-related risk factors, such as chronic obstructive pulmonary disease, age older than 60 years, ASA class of II or higher, functional dependence, and congestive heart failure, increase the risk for postoperative pulmonary complications 1
• Procedures such as prolonged surgery, abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, and emergency surgery are at higher risk for postoperative pulmonary complications 1
• General anesthesia and serum albumin levels below 35 g/L are also strong markers of increased risk 1

From the Research

Postoperative Atelectasis Management

• Postoperative atelectasis is a common problem following any surgery, and its management is crucial to prevent complications 2.
• Limited atelectasis is usually well-tolerated and easily reversible, but complete atelectasis of the remaining lung following partial lung resection may be poorly tolerated 2.
• Prophylaxis includes preoperative and postoperative physiotherapy and medications, which should be graded in accordance to the individual patient's risk factors 2.
• Large atelectasis requires bronchoscopy to remove mucous plugs, and tracheostomy should be considered in patients with relapsing atelectasis or swallow disorders 2.

Role of Ventilatory Strategies

• Ventilator settings during anesthesia, especially with higher tidal volumes and without positive end expiratory pressure (PEEP), are associated with lung injury even in healthy, but partially collapsed, lungs 3.
• The use of continuous positive airway pressure and 'lower' FiO(2) during anesthetic induction, intraoperative use of lower FiO(2), low tidal volumes, lung recruitment, and PEEP ('protective ventilatory strategy') may help in maintaining lung aeration, thereby decreasing hypoxemia and risk of postoperative pneumonia 3.
• A goal-directed ventilatory approach keeping an 'open lung' condition during the perioperative period may reduce the incidence of postoperative pulmonary complications 3.

Effectiveness of Interventions

• The use of PEEP during mechanical ventilation can significantly reduce the incidence of atelectasis 4.
• Perioperative intervention, including physical therapy and non-invasive pressure support ventilation, can be effective in preventing postoperative atelectasis and other complications 4.
• A systematic review and meta-analysis found that perioperative interventions can affect the probability of patients with atelectasis after surgery, and that the incidence of atelectasis can be reduced with the use of PEEP and other interventions 4.

Atelectasis and Infiltrate

• Atelectasis describes the state of absent air in alveoli attributable to collapse, but recent findings suggest that alveoli are filled with foam and fluid 5.
• Atelectasis may contribute to serious postoperative pulmonary complications, including respiratory failure and pneumonia, but it is not explicitly stated whether atelectasis counts towards postoperative pulmonary dysfunction (PGD) as infiltrate 5, 3.