What is the treatment for atelectasis?

Treatment for Atelectasis

The primary treatment for atelectasis involves alveolar recruitment maneuvers (30-40 cm H2O for 25-30 seconds) followed by individualized PEEP titration, combined with airway clearance techniques and avoidance of high oxygen concentrations (FiO2 >0.8). 1, 2

Immediate Mechanical Interventions

Alveolar Recruitment Maneuvers (ARM)

• Perform recruitment maneuvers as the first-line intervention 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 critical in hypoxic patients following intubation 1
• In mechanically ventilated patients with ARDS and atelectasis, recruitment maneuvers combined with higher PEEP show mortality benefit in moderate to severe cases 1

PEEP Optimization

• Apply PEEP only AFTER performing recruitment maneuvers, as PEEP maintains functional residual capacity but does not restore it 1
• Use higher PEEP strategies for patients with moderate or severe ARDS to reduce atelectasis 1, 2
• Titrate PEEP individually after ARM to prevent alveolar overdistention or re-collapse 1, 2

Airway Clearance Strategies

Bronchoscopic Intervention

• Perform flexible bronchoscopy for persistent mucous plugs that do not respond to conservative measures 1, 2, 3
• Bronchoscopy allows direct visualization and removal of obstructing secretions 2
• In children with persistent atelectasis, flexible bronchoscopy can clear most mucus plugging; occasionally rigid bronchoscopy is needed for large resistant plugs 1

Physiotherapy Techniques

• Implement airway clearance techniques taught by trained respiratory physiotherapists for patients with chronic productive cough 1
• Consider nebulized hypertonic saline or inhaled mannitol as useful adjuncts to airway clearance in persistent atelectasis 1

Positioning and Supportive Care

Patient Positioning

• Elevate the head of bed to at least 30 degrees to improve lung expansion and reduce diaphragmatic compression 1, 2, 4
• Encourage early mobilization and physical activity, as immobility contributes to deterioration in lung function 2, 4

Postoperative CPAP

• Apply CPAP (7.5-10 cm H2O) immediately post-extubation, especially in obese patients who develop larger atelectatic areas 1, 2
• Postoperative CPAP may reduce atelectasis, pneumonia, and reintubation rates after major abdominal surgery 1, 2

Oxygen Management

FiO2 Considerations

• Avoid high FiO2 (>0.8) during emergence from anesthesia as it significantly increases atelectasis formation 1, 2
• Use FiO2 <0.4 during emergence when clinically appropriate to reduce atelectasis 1, 2
• After recruitment maneuvers, ventilate with moderate FiO2 rather than 100% oxygen to prevent rapid re-collapse 5

Pharmacological Interventions

Antibiotic Therapy (When Indicated)

• Initiate appropriate antibiotic therapy for fever (≥38.5°C) persisting >3 days or confirmed pneumonia/atelectasis on chest X-ray 1
• In children under 3 years, use beta-lactams (amoxicillin, amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil) 1

Special Population Considerations

Compressive Atelectasis

• For pleural effusion causing atelectasis, perform drainage procedures such as thoracentesis or place indwelling pleural catheters for recurrent effusions 1
• Consider non-invasive ventilation (NIV) or CPAP for post-operative atelectasis to improve lung aeration 1

Pediatric and Neonatal Patients

• In children, perform flexible bronchoscopy for persistent atelectasis, unexplained cyanosis, or respiratory distress 2
• Newer flexible bronchoscopes with improved suction channels allow therapeutic aspiration of mucous plugs in neonates 2

Critical Pitfalls to Avoid

• Never apply PEEP without first performing recruitment maneuvers, as this approach is ineffective for restoring functional residual capacity 1
• Do not routinely suction the tracheal tube just before extubation, as this reduces lung volume 1
• Avoid turning off the ventilator to allow CO2 accumulation before extubation, as this causes alveolar collapse 1
• Do not use zero end-expiratory pressure (ZEEP) in the postoperative period 1