What is the treatment for atelectasis?

Treatment of Atelectasis

Atelectasis should be managed with alveolar recruitment maneuvers followed by individualized PEEP (5-10 cm H2O), combined with airway clearance techniques and treatment of underlying causes to prevent respiratory failure and reduce mortality. 1

Primary Treatment Strategy

The cornerstone of atelectasis management involves a systematic approach combining mechanical lung expansion with secretion clearance:

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 beneficial in hypoxic patients following intubation or in mechanically ventilated patients. 1
• Critical pitfall: Never apply PEEP without first performing recruitment maneuvers, as PEEP maintains functional residual capacity but does not restore it. 1

Positive End-Expiratory Pressure (PEEP)

• After successful recruitment, apply PEEP of 5-10 cm H2O to maintain alveolar patency and prevent re-collapse. 1
• Higher PEEP strategies (7.5-10 cm H2O) are recommended for patients with moderate or severe ARDS to reduce atelectasis. 1
• Avoid zero end-expiratory pressure (ZEEP) at all times, as it promotes rapid atelectasis reformation. 1
• Individualize PEEP levels after ARM to avoid alveolar overdistention while preventing collapse. 1

Oxygen Management

• Use FiO2 <0.4 during emergence and recovery when clinically appropriate, as high FiO2 (>0.8) significantly increases atelectasis formation through rapid oxygen absorption behind closed airways. 1, 2
• This is a common pitfall—clinicians often use 100% oxygen during recovery, which worsens atelectasis. 1

Airway Clearance Techniques

Mechanical Clearance

• For mucus plugs causing persistent atelectasis, perform flexible bronchoscopy to directly remove obstructing secretions. 1, 3, 4
• In children or cases with large resistant plugs, rigid bronchoscopy may occasionally be needed. 1
• Bronchoscopy is both diagnostic and therapeutic, allowing direct visualization and restoration of airway patency. 3

Physiotherapy Protocol

• Implement multimodal physiotherapy combining at least three components: breathing exercises to increase inspiratory volume, bronchial drainage with coughing techniques, and early mobilization progressing from sitting to ambulation. 5
• The forced expiration technique (huffing) is effective for increasing airway clearance and can be taught for self-management. 3
• Avoid routine suctioning of the tracheal tube before extubation, as it reduces lung volume and promotes collapse. 1
• Reserve oro-nasal suctioning only when other methods fail to clear secretions. 5

Pharmacological Adjuncts

• Nebulized acetylcysteine (1-10 mL of 20% solution or 2-20 mL of 10% solution every 2-6 hours) is FDA-approved for atelectasis due to mucous obstruction. 6
• The recommended dose for most patients is 3-5 mL of the 20% solution or 6-10 mL of the 10% solution 3-4 times daily. 6
• Nebulized hypertonic saline or inhaled mannitol may be useful adjuncts to airway clearance in patients with persistent atelectasis. 1

Positioning and Ventilation Strategies

Patient Positioning

• Optimize patient positioning with head elevated at least 30 degrees to improve lung expansion and reduce diaphragmatic compression. 1, 5, 3
• Consider lateral decubitus positioning with the unaffected lung dependent to improve ventilation-perfusion matching. 1

Postoperative CPAP

• Apply CPAP (7.5-10 cm H2O) immediately post-extubation, especially in obese patients, as it may reduce atelectasis, pneumonia, and reintubation rates after major abdominal surgery. 1, 5
• Continue positive airway pressure until the patient's respiratory rate and effort return to normal with no episodes of hypopnea or apnea for at least one hour. 7
• CPAP of 10 cm H2O after thoracoabdominal surgery reduces postoperative pulmonary complications and decreases ICU and hospital stay. 5

Lung-Protective Ventilation

• Use tidal volumes of 6-8 mL/kg predicted body weight (not actual body weight) to reduce pulmonary complications. 7
• Maintain PEEP throughout anesthesia and avoid turning off the ventilator to allow CO2 accumulation before extubation, as this causes alveolar collapse. 1

Special Populations and Considerations

Obese Patients

• Obese patients develop larger atelectatic areas and benefit more from CPAP immediately post-extubation. 1
• These patients are at higher risk for perioperative atelectasis that persists longer compared to normal-weight patients. 5

Compressive Atelectasis

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

Postoperative Management

• Start physiotherapy interventions as early as the first postoperative day. 5
• Provide adequate pain control to enable effective breathing exercises and coughing. 5
• Remove chest tubes, urinary catheters, and arterial/venous catheters as early as possible to facilitate early mobilization. 5

Common Pitfalls to Avoid

• Never apply PEEP without first performing recruitment maneuvers—PEEP maintains but does not restore functional residual capacity. 1
• Avoid high FiO2 (>0.8) during emergence from anesthesia, as it increases atelectasis formation. 1
• Do not turn off the ventilator to allow CO2 accumulation before extubation, as this causes alveolar collapse. 1
• Avoid routine suctioning before extubation, as it reduces lung volume. 1
• Do not rely solely on supplemental oxygen without addressing the mechanical aspects of atelectasis. 3
• Use airway clearance techniques with proper instruction to ensure effectiveness. 3