What are the treatment options for atelectasis?

Treatment of Atelectasis

Atelectasis should be managed with alveolar recruitment maneuvers combined with PEEP (5-10 cm H2O), airway clearance techniques, and moderate FiO2 (<0.4) to prioritize lung re-expansion and prevent hypoxemia-related morbidity. 1

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
• ARMs are particularly critical in hypoxic patients following intubation or in mechanically ventilated patients with moderate-to-severe ARDS, where they demonstrate mortality benefit. 1
• Always perform ARM before applying PEEP, as PEEP maintains functional residual capacity but does not restore it. 1

Positive End-Expiratory Pressure (PEEP)

• Apply PEEP of 5-10 cm H2O throughout mechanical ventilation after recruitment maneuvers to prevent re-collapse. 1
• Individualize PEEP levels after ARM to avoid alveolar overdistention while preventing cyclic collapse. 1
• Never use zero end-expiratory pressure (ZEEP), as it promotes atelectasis formation in approximately 90% of anesthetized patients and increases driving pressure. 1

Oxygen Therapy Strategy

• Maintain FiO2 <0.4 during emergence from anesthesia and ongoing management when clinically appropriate, as high FiO2 (>0.8) significantly increases atelectasis formation through rapid oxygen absorption behind closed airways. 1, 2
• Do not rely solely on supplemental oxygen without addressing mechanical lung re-expansion. 2

Airway Clearance Techniques

Physical Therapy Interventions

• Implement chest physiotherapy including postural drainage, percussion, and vibration techniques to mobilize secretions. 2
• Teach the forced expiration technique (huffing) for effective airway clearance and patient self-management. 2
• Use positive expiratory pressure (PEP) therapy to open airways while promoting secretion removal. 3

Bronchoscopic Intervention

• Perform flexible bronchoscopy for direct visualization and removal of obstructing mucous plugs in cases of persistent atelectasis that fail conservative measures. 1, 2
• In pediatric patients with persistent atelectasis, flexible bronchoscopy clears most mucous plugging; occasionally rigid bronchoscopy is needed for large resistant plugs. 1

Pharmacological Adjuncts

• Consider nebulized hypertonic saline or inhaled mannitol as adjuncts to airway clearance in persistent cases. 1, 3
• Acetylcysteine (inhaled) is FDA-approved for atelectasis due to mucous obstruction and should be used for abnormal, viscid, or inspissated mucous secretions. 4
• Initiate appropriate antibiotic therapy if fever (≥38.5°C) persists for more than 3 days or confirmed pneumonia/atelectasis appears on chest X-ray. 1

Positioning and Mobilization

• Position patients with head elevated at least 30 degrees to improve lung expansion and reduce diaphragmatic compression. 1, 2, 3
• Encourage early mobilization progressing from sitting to ambulation, as immobility directly contributes to deteriorating lung function. 2, 3
• Consider lateral decubitus positioning with the unaffected lung dependent to improve ventilation-perfusion matching. 1

Breathing Exercises and Lung Expansion

• Prescribe incentive spirometry to encourage deep breathing and maximal inspiration for re-expanding collapsed alveoli. 2, 3
• Implement respiratory muscle strength training to improve ventilatory patterns, lung volumes, and respiratory muscle strength. 2, 3
• Use interventions to increase inspiratory volume when reduced inspiratory capacity contributes to ineffective cough. 1

Postoperative and Post-Extubation Management

• Apply CPAP (7.5-10 cm H2O) immediately post-extubation, especially in obese patients who develop larger atelectatic areas. 1
• Postoperative CPAP may reduce atelectasis, pneumonia, and reintubation rates after major abdominal surgery. 1
• Consider non-invasive ventilation (NIV) for patients with post-operative atelectasis, which improves lung aeration and decreases the need for re-intubation. 1
• Maintain positive pressure until extubation and avoid turning off the ventilator to allow CO2 accumulation, as this causes alveolar collapse. 1

Special Considerations for Compressive Atelectasis

• For pleural effusion causing atelectasis, perform drainage procedures such as thoracentesis or placement of indwelling pleural catheters for recurrent effusions. 1
• Use lung-protective ventilation strategies with appropriate tidal volumes and PEEP for mechanically ventilated patients. 1

Multimodal Physiotherapy Protocol (Postoperative Cases)

• Combine at least three components: breathing exercises, bronchial drainage/coughing techniques, and early mobilization. 1
• Apply manually assisted cough using thoracic or abdominal compression for patients with expiratory muscle weakness. 1
• Reserve oro-nasal suctioning only when other methods fail to clear secretions, and use nasal suctioning with extreme caution in patients on anticoagulation, with facial trauma, or after recent upper airway surgery. 1

Critical Pitfalls to Avoid

• Do not apply PEEP without first performing recruitment maneuvers, as PEEP maintains but does not restore functional residual capacity. 1, 3
• Avoid routine suctioning of the tracheal tube just before extubation, as it reduces lung volume and worsens atelectasis. 1, 3
• Do not use high FiO2 during emergence from anesthesia without clinical indication, as this increases atelectasis formation. 1, 2
• Avoid performing airway clearance techniques without proper instruction, as this significantly reduces effectiveness. 2, 3