What medications are given for atelectasis?

Management of Atelectasis: Pharmacological and Non-Pharmacological Interventions

Atelectasis should be managed primarily with airway clearance techniques (chest physiotherapy, bronchoscopy for mucus removal) and alveolar recruitment strategies rather than medications, as no specific pharmacological agents directly treat atelectasis itself. 1, 2

Primary Treatment Approach: Airway Clearance

Mechanical Clearance Techniques

• Flexible bronchoscopy is the definitive intervention for removing mucus plugs causing atelectasis, with most cases responding to this approach 3, 1
• Rigid bronchoscopy may occasionally be needed for large resistant mucus plugs that cannot be cleared with flexible bronchoscopy 3
• Chest physiotherapy techniques (including postural drainage, percussion, and vibration) should be implemented to mobilize secretions and prevent further collapse 3, 2

Adjunctive Mucolytic Agents

• Nebulized hypertonic saline or inhaled mannitol may offer benefit in selected patients with persistent mucus plugging, though evidence is extrapolated from other conditions 3
• Nebulized acetylcysteine (Mucomyst) can be administered at doses of 3-5 mL of 20% solution or 6-10 mL of 10% solution 3-4 times daily via nebulizer to help thin secretions 4
• For direct instillation into airways, 1-2 mL of 10-20% acetylcysteine solution may be given as often as every hour through tracheostomy or bronchoscopy 4

Important caveat: Nebulized DNase (dornase alfa) is likely ineffective for atelectasis when extrapolating from non-cystic fibrosis bronchiectasis studies 3

Ventilatory Management Strategies

Alveolar Recruitment Maneuvers

• Perform recruitment maneuvers with transient elevation of airway pressures (30-40 cm H₂O for 25-30 seconds) to re-expand collapsed lung tissue, particularly beneficial in hypoxic intubated patients 1
• Always perform recruitment maneuvers BEFORE increasing PEEP, as PEEP maintains functional residual capacity but does not restore it 1

Positive End-Expiratory Pressure (PEEP)

• Apply individualized PEEP after recruitment maneuvers to prevent re-collapse while avoiding overdistention 1
• Avoid zero end-expiratory pressure (ZEEP) during mechanical ventilation, as this promotes atelectasis 1, 5

Oxygen Therapy Considerations

• **Use FiO₂ <0.4 during emergence from anesthesia when clinically appropriate**, as high FiO₂ (>0.8) significantly increases atelectasis formation through absorption atelectasis 1
• Balance oxygen delivery needs against the risk of absorption atelectasis behind closed airways 6

Postoperative and Supportive Management

Positioning and Mobilization

• Position patients with head elevated at least 30 degrees to reduce diaphragmatic compression and improve lung expansion 1, 5
• Encourage early mobilization and deep breathing exercises to prevent further collapse 5

Non-Invasive Ventilatory Support

• Consider CPAP (7.5-10 cm H₂O) immediately post-extubation, especially in obese patients who develop larger atelectatic areas 1, 5
• CPAP after thoracoabdominal surgery reduces pulmonary complications and decreases ICU/hospital stay 5

Bronchodilator Therapy

• Bronchodilators may be indicated if concurrent reversible airflow obstruction contributes to mucus retention 3
• Pretreatment with beta-agonists is recommended before administering local anesthetics or other potentially bronchospastic nebulized medications 3

When Antibiotics Are Indicated

• Antibiotics should only be given if there is confirmed pneumonia or bacterial infection, not for atelectasis alone 1
• For fever ≥38.5°C persisting >3 days with confirmed pneumonia/atelectasis on chest X-ray, initiate appropriate antibiotic therapy 1
• In children under 3 years with confirmed bacterial infection, beta-lactams (amoxicillin, amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil) are recommended 1

Critical pitfall: The diagnosis of "atelectatic pneumonia" should be based on clinical signs, symptoms, and identification of pathogenic bacteria—not on radiographic atelectasis alone 7

Anti-Inflammatory Considerations

• Nebulized corticosteroids (budesonide 500 mcg twice daily) may be tried for stridor or radiation pneumonitis, though evidence is limited 3
• Systemic steroids (equivalent to hydrocortisone 100 mg every 6 hours) reduce inflammatory airway edema from direct injury but have no effect on mechanical compression 3
• Steroids should be started early in high-risk patients and continued for at least 12 hours; single-dose steroids immediately before extubation are ineffective 3

Common Pitfalls to Avoid

• Do NOT routinely suction the tracheal tube just before extubation, as this reduces lung volume and promotes collapse 1
• Do NOT turn off the ventilator to allow CO₂ accumulation before extubation, as this causes alveolar collapse 1
• Do NOT apply PEEP without first performing recruitment maneuvers, as PEEP alone will not re-expand collapsed alveoli 1
• Do NOT prescribe antibiotics for atelectasis without evidence of bacterial infection, as atelectasis itself is not an infectious process 1, 7