From the Guidelines
The most appropriate management for this patient is pain management (option D). The patient's clinical presentation suggests atelectasis, which is a common postoperative complication following mastectomy. The shallow breathing with splinting indicates that the patient is limiting her respiratory effort due to pain from the surgical site. This restricted breathing pattern leads to inadequate lung expansion, resulting in atelectasis as confirmed by the chest radiograph showing plate-like opacities in the lung bases. Effective pain management will allow the patient to take deeper breaths, cough more effectively, and clear secretions, which will help resolve the atelectasis. This approach addresses the root cause rather than just treating symptoms. Pain control can be achieved by optimizing the current oral opioid regimen or considering additional modalities such as patient-controlled analgesia, intercostal nerve blocks, or non-opioid adjuncts like acetaminophen or NSAIDs if not contraindicated. Once pain is adequately controlled, the patient should be encouraged to perform deep breathing exercises, incentive spirometry, and early mobilization to further promote lung expansion and prevent pulmonary complications. According to the most recent guidelines, such as those from the European Society for Anaesthesiology and Intensive Care and European Society of Intensive Care Medicine (ESA/ESICM) 1, goal-directed hemodynamic therapy and epidural analgesia have moderate evidence of benefit in the prevention of postoperative pulmonary complications, which supports the importance of adequate pain management in this context.
Some may consider other options like bronchoscopy (option A), inhaled albuterol (option B), or inhaled N-acetylcysteine (option C), but these interventions do not address the primary issue of pain limiting respiratory effort. Bronchoscopy might be considered if there were signs of significant airway obstruction or if the patient failed to improve with initial management, but it is not the first line for atelectasis due to pain. Inhaled medications like albuterol or N-acetylcysteine may have roles in specific contexts, such as bronchospasm or thick secretions, respectively, but they do not directly address the issue of pain-induced atelectasis. The recent study on perioperative care for emergency laparotomy enhanced recovery after surgery (ERAS) society recommendations 1 emphasizes the importance of preventing postoperative pulmonary complications through measures like pain management, which aligns with the chosen management approach for this patient.
From the Research
Management of Atelectasis
The patient's symptoms, including shallow breathing with splinting, diminished breath sounds at the right lung base, dullness on percussion, egophony in the right lower lobe, and rhonchi, are consistent with atelectasis. The chest radiograph showing plate-like opacities in the lung bases also supports this diagnosis.
Treatment Options
- Pain Management: The patient is already experiencing pain, which may be contributing to shallow breathing and splinting. Effective pain management is crucial to prevent atelectasis and promote deep breathing exercises 2, 3.
- Incentive Spirometry: While incentive spirometry may not be recommended for routine use in preventing postoperative pulmonary complications, it can be used with deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent atelectasis 4.
- Deep-Breathing Exercises: Deep-breathing exercises have been shown to reduce atelectasis and improve pulmonary function after surgery 5.
- Bronchoscopy: Bronchoscopy may be necessary to remove persistent mucous plugs, but it is not the first line of treatment for atelectasis 6.
Most Appropriate Management
Based on the evidence, the most appropriate management for this patient would be to optimize pain management to allow for deeper breathing and to prevent further atelectasis. This can be achieved through a combination of pharmacologic and non-pharmacologic interventions, including the use of oral opioids and other analgesics, as well as non-pharmacologic techniques such as deep breathing exercises and incentive spirometry. Therefore, the correct answer is D Pain management 2, 3.