Atelectasis Treatment & Management

Lobar atelectasis is a common problem caused by a variety of mechanisms including resorption atelectasis due to airway obstruction, passive atelectasis from hypoventilation, compressive atelectasis from abdominal distension, and adhesive atelectasis due to increased surface tension. Evidence-based studies on the management of lobar atelectasis are lacking. Assessment of air bronchograms on a chest radiograph may be helpful to determine whether the airway obstruction is proximal or distal. Chest physiotherapy, nebulized dornase alfa (DNase), and, possibly, fiberoptic bronchoscopy might be helpful in patients with mucous plugging of the airways. In passive and adhesive atelectasis, positive end-expiratory pressure might be a useful adjunct to treatment.

Nonpharmacologic therapies for improving cough and clearance of secretions from the airways include chest physiotherapy, including postural drainage, chest wall percussion and vibration, and a forced expiration technique (called huffing). Increased airway clearance as assessed by sputum characteristics (ie, volume, weight, viscosity) and clearance of the radioaerosol from the lung show that the long-term efficacy of these techniques compared with unassisted cough alone is unknown.^[9]

The treatment of atelectasis depends on the underlying etiology. Treatment of acute atelectasis, including postoperative lung collapse, requires removal of the underlying cause.

For postoperative atelectasis, prevention is the best approach. Anesthetic agents associated with postanesthesia narcosis should be avoided; narcotics should be used sparingly because they depress the cough reflex. Early ambulation and use of incentive spirometry are important. Encourage the patient to cough and to breathe deeply. Nebulized bronchodilators and humidity may help liquefy secretions and promote their easy removal. In the case of lobar atelectasis, vigorous chest physiotherapy frequently helps reexpand the collapsed lung. When these efforts are not successful within 24 hours, flexible fiberoptic bronchoscopy should be performed.

When a mechanically obstructed bronchus is suggested but coughing or suctioning is not successful, bronchoscopy should be performed. If bronchoscopy is successful, any underlying infection, if present, is treated.

Prevention of further atelectasis involves (1) placing the patient in such a position that the uninvolved side is dependent to promote increased drainage of the affected area, (2) giving vigorous chest physiotherapy, and (3) encouraging the patient to cough and to breathe deeply.

Patients may require repeat bronchoscopy if atelectasis recurs. This is particularly true in patients with neuromuscular disease and poor cough.

Therapy with a broad-spectrum antibiotic is started and modified appropriately if a specific pathogen is isolated from sputum samples or bronchial secretions.

Postoperative atelectasis is treated with adequate oxygenation and reexpansion of the lung segments. Supplemental oxygen should be titrated to achieve an arterial oxygen saturation of greater than 90%.

Severe hypoxemia associated with severe respiratory distress or hypoxemia should lead to intubation and mechanical support. Intubation not only provides oxygenation and ventilatory support, but also provides access for suctioning of the airways and facilitates performing bronchoscopy, if needed. The positive pressure and larger tidal volumes often help to reexpand collapsed lung segments.

Continuous positive airway pressure delivered via a nasal cannula or facemask may also be effective in improving oxygenation and reexpanding the collapsed lung.

Broad-spectrum antibiotics should be prescribed if evidence of infection is present, such as fever, night sweats, or leukocytosis, because secondary atelectasis usually becomes infected regardless of the cause of obstruction. Obstruction of a major bronchus may cause severe hacking or coughing. Antitussive therapy reduces the cough reflex and may produce further obstruction; thus, it should be avoided.

Fiberoptic bronchoscopy is commonly required for diagnosis, particularly if an endobronchial lesion is suggested. This procedure has a limited role in the management of postoperative atelectasis. Fiberoptic bronchoscopy is not more effective than standard chest physiotherapy, deep breathing, coughing, and suctioning of patients who are intubated. Therefore, simple and standard respiratory therapy techniques should be administered to patients who spontaneously ventilate or patients on mechanical ventilation. Fiberoptic bronchoscopy should be reserved for those situations in which chest physiotherapy is contraindicated (eg, chest trauma, immobilized patient), poorly tolerated, or unsuccessful.

Judicious use of perioperative analgesia is an essential adjunct, permitting patients to breathe deeply, cough forcefully, and participate in chest physiotherapy maneuvers. In patients with underlying pulmonary disease, use of epidural analgesia has been shown to be a very effective pain control measure, thereby aiding aggressive chest physiotherapy.

N -acetylcysteine aerosols commonly are administered in an effort to promote clearance of tenacious secretions; however, their efficacy has not been documented. In addition, N -acetylcysteine may cause acute bronchoconstriction. Its use should be limited to direct instillation at the time of fiberoptic bronchoscopy.

In a study of noncystic fibrosis in children who had atelectasis of infectious origin, treatment with DNase led to rapid clinical improvement observed within 2 hours and radiologic improvement documented within 24 hours. DNase may be an effective treatment for infectious atelectasis in pediatric patients with noncystic fibrosis. Such data does not exist for adult patients, but DNase could be used as a trial of therapy in adults as well.^[10]

Prophylactic maneuvers for reducing the incidence and magnitude of postoperative atelectasis in high-risk patients should be encouraged. These techniques are deep-breathing exercises, coughing exercises, and incentive spirometry.

For maximal benefit, prophylactic measures should be taught and instituted before surgery and used regularly, on an hourly basis, after surgery.

Early ambulation of patients after surgery has also been found to be as effective as physical therapy.

Kato et al reported on the use of the RTX respirator for extensive atelectasis in elderly patients. Patients were placed in the lateral decubitus position, and the RTX respirator was reported to be a useful tool to clear retained sputum in elderly patients.^[11]

Chronic atelectasis is treated with segmental resection or lobectomy.