How should bi‑basilar atelectasis be managed?

Management of Bi-Basilar Atelectasis

Bi-basilar atelectasis should be managed with alveolar recruitment maneuvers (30-40 cm H₂O for 25-30 seconds) followed by individualized PEEP (5-10 cm H₂O), combined with multimodal physiotherapy including breathing exercises, airway clearance techniques, and early mobilization. 1

Initial Assessment and Immediate 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 basilar lung tissue 1
• ARMs are particularly beneficial in hypoxic patients and should be performed before increasing PEEP, as PEEP maintains functional residual capacity but does not restore it 1
• After ARM, apply individualized PEEP (5-10 cm H₂O) to prevent re-collapse and avoid alveolar overdistention 1

Oxygen Therapy Optimization

• Avoid high FiO₂ (>0.8) as it significantly increases atelectasis formation due to rapid oxygen absorption behind closed airways 1
• Use FiO₂ <0.4 when clinically appropriate to reduce further collapse 1
• Never use zero end-expiratory pressure (ZEEP), as this promotes atelectasis formation and fails to maintain functional residual capacity 1

Multimodal Physiotherapy Protocol

Core Components (All Three Required)

The European Respiratory Society mandates combining at least three components for effective treatment: 1

1. Breathing exercises to increase inspiratory volume, particularly when reduced inspiratory capacity contributes to ineffective cough 1

2. Bronchial drainage and coughing techniques with manually assisted cough using thoracic or abdominal compression for patients with respiratory muscle weakness 1

3. Early mobilization progressing from sitting to ambulation as tolerated 1

Airway Clearance Techniques

• For mucus plugs causing persistent atelectasis, flexible bronchoscopy should be performed to remove obstructing secretions 1, 2, 3
• Nebulized hypertonic saline or inhaled mannitol may be useful adjuncts to airway clearance 1
• Reserve oro-nasal suctioning only when other methods fail to clear secretions 1
• Avoid routine suctioning before extubation as it reduces lung volume 1

Patient Positioning and Ventilation

Positioning Strategies

• Position patients with head elevated at least 30 degrees to improve lung expansion and reduce diaphragmatic compression 1
• This is particularly critical for obese patients who develop larger atelectatic areas 1
• Consider lateral decubitus positioning with the unaffected lung dependent to improve ventilation-perfusion matching 1

Positive Pressure Support

• Apply CPAP (7.5-10 cm H₂O) immediately post-extubation, especially in obese patients, as this may reduce atelectasis, pneumonia, and reintubation rates 1
• Continue CPAP/BiPAP treatment in patients using it preoperatively to reduce the risk of apnea and other complications 1
• Use non-invasive ventilation (NIV) or CPAP for patients with post-operative atelectasis to improve lung aeration 1

Treatment of Underlying Causes

Compressive Atelectasis

• For pleural effusion causing atelectasis, perform drainage procedures such as thoracentesis or placement of indwelling pleural catheters for recurrent effusions 1
• Address external compression from masses or other thoracic pathology 4

Obstructive Atelectasis

• Remove mucus plugs with flexible bronchoscopy using large-volume saline instillation in aliquots and repeated suctioning 1, 2
• In children with persistent atelectasis, flexible bronchoscopy can clear most mucus plugging; occasionally rigid bronchoscopy is needed for large resistant plugs 1

Pharmacological Considerations

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

Common Pitfalls to Avoid

Critical errors that worsen outcomes: 1

• Never apply PEEP without first performing recruitment maneuvers, as PEEP maintains but does not restore functional residual capacity 1
• Never use high FiO₂ during emergence from anesthesia (increases atelectasis formation) 1
• Never turn off the ventilator to allow CO₂ accumulation before extubation (causes alveolar collapse) 1
• Never perform routine suctioning before extubation (reduces lung volume) 1
• Never use ZEEP (zero end-expiratory pressure) during or after mechanical ventilation 1

Special Populations

Obese Patients

• Develop larger atelectatic areas that persist longer compared to normal-weight patients 1
• Benefit more from CPAP immediately post-extubation 1
• Require head-elevated or ramped positioning during anesthesia induction 1

High-Risk Patients

• Use the STOP-BANG questionnaire preoperatively to identify patients with high risk of obstructive sleep apnea 1
• Extend observation in the PACU, as most dangerous hypoxic events occur near discontinuation of anesthesia or after opioid administration 1
• Minimize systemic opioid use to reduce apnea/hypopnea episodes 1