Management of Atelectasis
Atelectasis should be managed with a combination of alveolar recruitment maneuvers, positive end-expiratory pressure (PEEP), airway clearance techniques, and treatment of underlying causes to improve mortality and morbidity outcomes. 1
Primary Management Strategies
Alveolar Recruitment Maneuvers (ARM)
- Recruitment maneuvers involving transient elevation of airway pressures (30-40 cm H2O for 25-30 seconds) effectively re-expand collapsed lung tissue 1
- ARMs are particularly beneficial in hypoxic patients following intubation 1
Positive End-Expiratory Pressure (PEEP)
- Higher PEEP strategies are recommended for patients with moderate or severe respiratory distress to reduce atelectasis 1
- PEEP helps maintain functional residual capacity (FRC) but does not restore it; therefore, ARM should be performed before increasing PEEP 1
- PEEP should be adjusted based on patient response to avoid alveolar overdistention or collapse 1
Airway Clearance Techniques
- Chest physiotherapy including postural drainage, percussion, and vibration techniques effectively mobilize secretions and promote airway clearance 2
- Forced expiration technique (huffing) increases airway clearance and can be taught to patients for self-management 2
- Respiratory muscle strength training improves ventilatory patterns, lung volumes, and respiratory muscle strength 2
Bronchoscopic Intervention
- Flexible bronchoscopy should be performed for direct visualization and removal of obstructing secretions in cases of persistent mucous plugs causing atelectasis 2
- Mucus plugs or blood clots in the airways causing atelectasis can be removed with the flexible bronchoscope 3
- Persistent mucous plugs that cannot be cleared by flexible bronchoscopy may occasionally require rigid bronchoscopy 3
Positioning and Mobilization
- Optimize patient positioning with head elevated at least 30 degrees to improve lung expansion 1, 2
- Early mobilization and physical activity should be encouraged as immobility contributes to deterioration in lung function 2
- For specific types of atelectasis, such as rounded atelectasis, careful positioning may help with re-expansion 3
Oxygen Therapy Considerations
- High FiO2 (>0.8) during emergence from anesthesia significantly increases atelectasis formation 1
- If clinically appropriate, use FiO2 <0.4 during emergence to reduce atelectasis 1
- Pre-oxygenation before extubation is vital, but should be balanced with the risk of promoting atelectasis 3
Special Considerations
Postoperative Management
- Consider CPAP immediately post-extubation, especially in obese patients 1
- Postoperative CPAP (7.5-10 cm H2O) may reduce atelectasis, pneumonia, and reintubation rates after major abdominal surgery 1
- Avoid routine suctioning of the tracheal tube just before extubation as it can reduce lung volume 1
Pediatric Considerations
- In children, the most common indications for bronchoscopy include persistent atelectasis (38%), unexplained episodes of cyanosis (11%), and unexplained respiratory distress (10%) 3
- Suctioning may be necessary when cough is inadequate to clear secretions, but routine deep suctioning should be avoided 2
Neonatal Management
- Newer flexible bronchoscopes with improved suction channels allow therapeutic maneuvers including aspiration of mucous plugs in neonates 3
- In neonates with persistent atelectasis, bronchoscopy can provide valuable diagnostic information and therapeutic intervention 3
Common Pitfalls to Avoid
- Applying PEEP without first performing recruitment maneuvers (PEEP maintains but does not restore FRC) 1
- Using high FiO2 during emergence from anesthesia (increases atelectasis formation) 1
- Turning off the ventilator to allow CO2 accumulation before extubation (causes alveolar collapse) 1
- Routine suctioning before extubation (reduces lung volume) 1
- Relying solely on supplemental oxygen without addressing the mechanical aspects of atelectasis 2