What are the guidelines to treat atelectasis?

Management of Atelectasis

Primary Treatment Strategy

Atelectasis should be managed with alveolar recruitment maneuvers (ARM) followed by individualized PEEP, combined with airway clearance techniques and treatment of the underlying cause. 1, 2

Immediate Interventions

Alveolar Recruitment Maneuvers

• Perform ARM by transiently elevating airway pressures to 30-40 cm H₂O for 25-30 seconds to re-expand collapsed lung tissue. 1, 2
• ARMs are particularly beneficial in hypoxic patients following intubation. 1
• Always perform ARM before increasing PEEP, as PEEP maintains functional residual capacity but does not restore it. 1

Positive End-Expiratory Pressure (PEEP)

• After ARM, apply PEEP of 5-10 cm H₂O to prevent re-collapse of recruited alveoli. 3, 1
• Zero end-expiratory pressure (ZEEP) is not recommended. 3
• Higher PEEP strategies are particularly important for patients with moderate or severe ARDS to reduce atelectasis. 1, 2
• Individualize PEEP settings after ARM to avoid alveolar overdistention or collapse. 1, 2

Patient Positioning

• Position patients with head of bed elevated at least 30 degrees (beach chair position) to improve lung expansion and reduce diaphragmatic compression. 3, 1, 2
• Avoid flat supine positioning. 3
• Consider lateral decubitus positioning with the unaffected lung dependent to improve ventilation-perfusion matching. 1

Airway Clearance Techniques

Bronchoscopic Intervention

• For persistent mucous plugs causing atelectasis, perform flexible bronchoscopy for direct visualization and removal of obstructing secretions. 1, 2
• In children with persistent atelectasis, flexible bronchoscopy can clear most mucus plugging; occasionally rigid bronchoscopy is needed for large resistant plugs. 1

Physiotherapy and Secretion Management

• Patients with chronic productive cough or difficulty expectorating should be taught airway clearance techniques by a trained respiratory physiotherapist, performed once or twice daily. 3
• Nebulized hypertonic saline or inhaled mannitol may be useful adjuncts to airway clearance in patients with persistent atelectasis. 1
• Avoid routine suctioning of the tracheal tube just before extubation as it reduces lung volume. 1

Pharmacological Adjuncts

• Acetylcysteine (mucolytic) is FDA-approved for atelectasis due to mucous obstruction. 4
• Dosing: 3-5 mL of 20% solution or 6-10 mL of 10% solution nebulized 3-4 times daily. 4
• For direct instillation: 1-2 mL of 10-20% solution every 1-4 hours into the tracheostomy or via catheter. 4

Ventilation Strategies During Anesthesia

Tidal Volume and FiO₂ Management

• Set ventilator to deliver tidal volume of 6-8 mL/kg predicted body weight (PBW), not actual body weight. 3, 5
• This is particularly critical in obese patients, as lung volume does not increase proportionally with body weight. 3, 5
• If clinically appropriate, use FiO₂ <0.4 during emergence from anesthesia to reduce atelectasis formation. 1, 2
• High FiO₂ (>0.8) during emergence significantly increases atelectasis formation. 1, 2

Monitoring Parameters

• Monitor dynamic compliance, driving pressure (plateau pressure minus PEEP), and plateau pressure on all mechanically ventilated patients. 3
• Patients with obesity may require higher cut-off values of protective driving pressure than non-obese patients. 3, 5

Postoperative Management

Non-Invasive Ventilation

• Consider CPAP (7.5-10 cm H₂O) immediately post-extubation, especially in obese patients, to reduce atelectasis, pneumonia, and reintubation rates. 1, 2
• Before loss of spontaneous ventilation during induction, use non-invasive positive pressure ventilation (NIPPV) or CPAP to attenuate anesthesia-induced respiratory changes. 3
• Continuous positive airway pressure should be continued until respiratory rate and effort return to normal with no episodes of hypopnea or apnea for at least one hour. 3

Pulmonary Rehabilitation

• Adult patients with bronchiectasis and impaired exercise capacity should participate in a pulmonary rehabilitation program and take regular exercise. 3
• Pulmonary rehabilitation (6-8 weeks) improves exercise capacity, reduces cough symptoms, improves quality of life, and may reduce exacerbations. 3

Special Populations

Obese Patients

• Obese patients develop larger atelectatic areas and may benefit more from CPAP immediately post-extubation. 1
• Use predicted body weight for tidal volume calculations, not actual body weight. 3, 5
• Consider recruitment maneuvers and individualized PEEP to reduce postoperative atelectasis. 3

Pediatric and Neonatal Patients

• In children, perform flexible bronchoscopy for persistent atelectasis, unexplained cyanosis, and unexplained respiratory distress. 2
• Suctioning may be necessary when cough is inadequate, but avoid routine deep suctioning. 2
• In neonates with persistent atelectasis, bronchoscopy provides valuable diagnostic information and therapeutic intervention. 2

Critical Pitfalls to Avoid

• Do not apply PEEP without first performing recruitment maneuvers—PEEP maintains but does not restore functional residual capacity. 1
• Do not use high FiO₂ (>0.8) during emergence from anesthesia, as this increases atelectasis formation. 1, 2
• Do not turn off the ventilator to allow CO₂ accumulation before extubation, as this causes alveolar collapse. 1
• Do not routinely suction before extubation, as this reduces lung volume. 1
• Do not use actual body weight for tidal volume calculations in obese patients—always use predicted body weight. 3, 5

Treatment of Compressive Atelectasis

• For pleural effusion causing atelectasis, consider drainage procedures such as thoracentesis or placement of indwelling pleural catheters for recurrent effusions. 1
• Non-invasive ventilation has been shown to decrease the need for re-intubation and reduce hospital mortality in patients who developed respiratory failure after lung cancer resection. 1