From the Guidelines
Atelectasis should be managed with higher PEEP levels in adult patients with moderate or severe acute respiratory distress syndrome (ARDS) to reduce lung injury and improve oxygenation, as evidenced by a conditional recommendation with moderate confidence in effect estimates 1.
Causes and Consequences of Atelectasis
Atelectasis is the collapse or closure of a lung or part of a lung, resulting in reduced or absent gas exchange. It occurs when the alveoli (air sacs) become deflated or filled with fluid, leading to reduced lung expansion and surfactant dysfunction, which allows alveolar collapse. Without intervention, this can progress to hypoxemia, pneumonia, and respiratory failure.
Treatment and Management
Treatment depends on the cause and severity but typically includes addressing the underlying condition, encouraging deep breathing exercises, incentive spirometry, chest physiotherapy, and early mobilization. For significant atelectasis, bronchoscopy may be necessary to remove mucus plugs. Supplemental oxygen is often provided to maintain adequate oxygenation. Patients with atelectasis should be positioned with the good lung down to improve ventilation-perfusion matching.
Prevention Strategies
Prevention strategies include early ambulation after surgery, adequate pain control to allow deep breathing, regular position changes for bedridden patients, and smoking cessation. Higher PEEP strategies can reduce atelectasis and increase end-expiratory lung volume, as seen in the IPDMA of higher versus lower PEEP trials 1. Recruitment maneuvers (RMs) can also be used to open collapsed lung and increase the number of alveolar units participating in tidal ventilation, with evidence showing reduced mortality and improved oxygenation 1.
Key Considerations
- Higher PEEP levels are recommended for adult patients with moderate or severe ARDS to reduce lung injury and improve oxygenation 1.
- RMs can be used to reduce atelectasis and improve oxygenation, but may be associated with complications such as hemodynamic compromise and barotrauma 1.
- Prevention strategies, such as early ambulation and adequate pain control, can help reduce the risk of atelectasis.
- Treatment should be individualized based on the underlying cause and severity of atelectasis, with a focus on improving lung expansion and gas exchange.
From the FDA Drug Label
Acetylcysteine is indicated as adjuvant therapy for patients with abnormal, viscid, or inspissated mucous secretions in such conditions as: ... Atelectasis due to mucous obstruction The N-acetylcysteine (INH) drug is indicated for use in patients with Atelectasis due to mucous obstruction, as an adjuvant therapy to help loosen and clear abnormal mucous secretions 2.
From the Research
Definition and Treatment of Atelectasis
- Atelectasis is a condition where a part of the lung collapses or does not inflate properly, often occurring after surgery 3, 4, 5.
- Various treatments have been studied to prevent and manage atelectasis, including intermittent positive pressure breathing (IPPB), incentive spirometry, and positive end-expiratory pressure (PEEP) 3, 4, 5, 6.
Effectiveness of Different Treatments
- A study from 1981 found that face-mask PEEP increased functional residual capacity, while incentive spirometry had little effect, and IPPB may decrease lung volume after treatment 3.
- A 2018 randomized controlled trial found that using 10 cm H2O PEEP reduced the incidence of atelectasis after cardiac surgery, compared to 8 cm H2O PEEP and a control group 4.
- Incentive spirometry has been found to have limited benefits in preventing postoperative pulmonary complications, with clinical practice guidelines advising against its routine use 6.
- A 1977 study found that the Bartlett-Edwards incentive spirometer increased vital capacity in patients after open-heart surgery, but had no effect on arterial oxygen tensions 5.
Prevention of Atelectasis
- The use of PEEP, particularly at a level of 10 cm H2O, has been shown to be effective in reducing the incidence of atelectasis after cardiac surgery 4.
- Incentive spirometry may have some benefits in improving lung function after surgery, but its effectiveness in preventing atelectasis is limited 5, 6.
- Further research is needed to determine the optimal protocols for preventing and managing atelectasis, particularly in postoperative care 4, 6.