Initial Management of Right Lung Base Atelectasis
Begin with head elevation to 30 degrees, incentive spirometry, and early mobilization as first-line interventions for right lung base atelectasis. 1
Immediate Positioning and Mechanical Interventions
Position the patient with head of bed elevated at least 30 degrees to improve lung expansion and prevent further collapse. 1, 2 This positioning provides a mechanical advantage to respiration and is particularly important in obese patients or those with reduced mobility. 2
Initiate incentive spirometry immediately to encourage deep breathing and maximal inspiration, which helps prevent and treat atelectasis. 1 Teach the patient forced expiration technique (huffing) for self-management of secretion clearance. 1
Encourage early mobilization and physical activity as immobility directly contributes to deterioration in lung function. 1 Prolonged bed rest worsens atelectasis formation and should be avoided whenever clinically feasible. 3
Airway Clearance Strategies
Implement chest physiotherapy including postural drainage, percussion, and vibration techniques to mobilize secretions and promote airway clearance. 1, 3 These techniques are recommended by the American College of Chest Physicians as primary treatment approaches. 1
Consider positive expiratory pressure (PEP) therapy to open airways while promoting removal of secretions. 1 This can be particularly effective when combined with other airway clearance techniques.
Perform alveolar recruitment maneuvers involving transient elevation of airway pressures (30-40 cm H2O for 25-30 seconds) to effectively re-expand collapsed lung tissue. 1, 2 These maneuvers are more effective than PEEP alone at reopening atelectatic areas. 4
Oxygen Management
Avoid high FiO2 (>0.8) as it worsens atelectasis formation. 1, 2 High oxygen concentrations promote absorption atelectasis behind closed airways. 5, 4
Use FiO2 <0.4 if clinically appropriate to reduce atelectasis progression. 1, 2 Target oxygen saturation of 94% with the lowest possible FiO2. 2
Monitor oxygen saturation with pulse oximetry and supplement oxygen only when SpO2 falls below 94%. 2 The priority is preventing hypoxia while avoiding unnecessarily high oxygen concentrations that perpetuate collapse. 5
Secretion Management
Perform suctioning only when cough is inadequate to clear secretions—avoid routine deep suctioning. 1, 2 Suctioning should be done based on clinical assessment rather than on a fixed schedule. 2
For persistent mucous plugs causing atelectasis, perform flexible bronchoscopy for direct visualization and removal of obstructing secretions. 1, 3 This is indicated when conservative measures fail and secretions remain despite aggressive airway clearance. 3, 6
Respiratory Support Considerations
If mechanical ventilation is required, apply individualized PEEP to maintain functional residual capacity. 1, 2 PEEP maintains lung expansion but does not restore it—recruitment maneuvers must be performed first. 1, 2
PEEP should be set to avoid both alveolar overdistention and collapse, typically starting at 5 cm H2O and adjusting based on driving pressure (plateau pressure minus PEEP). 1, 2 The goal is the lowest driving pressure that achieves adequate tidal volume. 2
Consider CPAP immediately post-extubation in high-risk patients (obese, prolonged surgery, significant atelectasis intraoperatively) to reduce atelectasis and improve oxygenation. 1, 2 CPAP of 7.5-10 cm H2O has been shown to reduce reintubation rates and pulmonary complications. 2
Common Pitfalls to Avoid
Do not rely solely on supplemental oxygen without addressing the mechanical aspects of atelectasis. 1 Oxygen treats hypoxemia but does not resolve the underlying lung collapse. 6
Do not apply PEEP without first performing recruitment maneuvers—PEEP maintains functional residual capacity but does not restore it. 1, 2 This is a critical sequencing error that reduces effectiveness. 2
Do not perform airway clearance techniques without proper instruction, as improper technique significantly reduces effectiveness. 1 Patients and caregivers require demonstration and return demonstration. 2
Avoid routine tracheal suctioning before extubation as this reduces lung volume and promotes atelectasis formation. 2 Suctioning should be performed under direct vision only when secretions are present. 2
Special Populations
In obese patients, head-up positioning is especially critical as they have reduced functional residual capacity and increased risk of both developing and having more severe atelectasis. 2, 7 Higher BMI is associated with increased odds of moderate to severe atelectasis. 7
For patients with neuromuscular weakness, consider cough assist devices to improve forced vital capacity and peak cough flow when intrinsic cough is inadequate. 1
Evaluate for underlying causes in patients with recurrent respiratory infections, including gastroesophageal reflux disease or aspiration, which may contribute to persistent atelectasis. 1