How is atelectasis managed?

From the Guidelines

Atelectasis management should prioritize treating the underlying cause and re-expanding collapsed lung tissue, with treatment typically beginning with addressing any airway obstruction through suctioning, bronchoscopy, or removal of foreign bodies, as supported by the most recent evidence from 2022 1.

Key Components of Treatment

• Positioning therapy is essential, with patients encouraged to change positions frequently and lie on their unaffected side to promote drainage and expansion of the collapsed area.
• Deep breathing exercises, incentive spirometry, and chest physiotherapy are crucial components of treatment, helping to increase lung volume and clear secretions.
• In more severe cases, supplemental oxygen may be provided to improve oxygenation.
• For patients with significant mucus plugging, mucolytic medications like N-acetylcysteine may be prescribed to thin secretions.
• Bronchodilators such as albuterol (2-4 puffs every 4-6 hours) can help open airways, particularly in patients with underlying respiratory conditions.
• If infection is present, appropriate antibiotics are administered.

Ventilation Strategies

• Low tidal volumes (6-8 mg/kg of predicted body weight) and low positive end-expiratory pressure (PEEP) level without recruitment manoeuvres may be used to protect lungs from ventilated-induced lung injury 1.
• Individualized PEEP settings can reduce postoperative atelectasis while improving intraoperative gas exchange and driving pressures.
• Pressure-controlled ventilation (PCV) or volume-controlled ventilation (VCV) can be used with inversed respiratory ratio, ideally avoiding increases in driving pressure from adjustments in PEEP.

Prevention Strategies

• Early mobilization after surgery, adequate pain control to allow for deep breathing, and smoking cessation are important prevention strategies.
• Atelectasis requires prompt treatment because prolonged collapse can lead to hypoxemia, infection, and respiratory failure, as highlighted in the 2019 guidelines for lung-protective ventilation for the surgical patient 1.

From the Research

Management of Atelectasis

Atelectasis can be managed through various techniques, including:

• Incentive spirometry, which has been shown to be effective in reducing the incidence of atelectasis in children undergoing cardiac surgery 2
• Airway clearance techniques, such as postural drainage and coughing, and bronchial suctioning using bronchoscopy or tracheal catheter 3
• Chest physiotherapy, postural drainage, bronchodilator and anti-inflammatory therapy 4
• Removal of persistent mucous plugs by bronchoscopy 4
• Application of positive end-expiratory pressure (PEEP) to prevent atelectasis or to reopen collapsed lung tissue 5
• Inflation of the lungs to an airway pressure of 40 cm H2O, maintained for 7-8 seconds (recruitment or "vital capacity" manoeuvre) to re-expand collapsed lung tissue 5
• Ventilation with a moderate fraction of inspired oxygen (FIO2, e.g. 0.3-0.4) to prevent formation of atelectasis 5

Prevention of Atelectasis

Prevention of atelectasis can be achieved through:

• Smoking cessation 3
• Optimization of underlying chronic obstructive pulmonary disease (COPD) 3
• Adequate pain control 3
• Intensive oral care 3
• Preoperative treatments for patients with COPD, such as long-acting bronchodilators and pulmonary rehabilitation 3
• Avoiding high fractions of oxygen in inspired gas during induction and maintenance of anaesthesia 5
• Use of a gas mixture that includes a poorly absorbed gas, such as nitrogen, during induction of anaesthesia 5

Treatment of Postoperative Pneumonia

Treatment of postoperative pneumonia involves:

• Microbiologic studies on respiratory samples 3
• Assessment of existence or non-existence of sepsis, severity of the disease using I-ROAD (immunodeficiency, respiration, orientation, age, dehydration) prognostic guidelines, and risk factors for multidrug-resistance pathogens 3
• Adequate selection of antibiotics and escalation or de-escalation principle according to the new guidelines recently published by the Japanese Respiratory Society 3