Intervention
Medical care
The treatment of atelectasis depends on the underlying etiology. The 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 to reexpand the collapsed lung. When these efforts are not successful within 24 hours, flexible fiberoptic bronchoscopy should be performed.
Bronchoscopy
When a mechanically obstructed bronchus is suspected and when coughing or suctioning is not successful, bronchoscopy should be performed. If bronchoscopy is successful, any underlying infection should be treated.
Prevention of further atelectasis involves (1) placing the patient in a position such that the uninvolved side is dependent to promote increased drainage of the affected area, (2) providing 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 a poor cough. Bronchoscopy is the most important diagnostic procedure in the evaluation of atelectasis; this procedure is useful not only in detecting and localizing an obstructive lesion, but also in obtaining tissue samples for the histologic confirmation of bronchogenic carcinoma. Bronchoscopy has therapeutic value in obstructive lesions other than tumors, and it is urgently indicated in patients with hypoxemia or respiratory distress. A pulmonary specialist performs the bronchoscopic procedure.
Flexible fiberoptic bronchoscopy can be a useful diagnostic and therapeutic procedure. Bronchoscopy helps in evaluating the cause of bronchial obstruction. In addition, bronchoscopy helps clear mucus plugs when they cause bronchial obstruction. However, bronchoscopy has limitations; because only the subsegmental bronchi are visualized, a distal endobronchial lesion is not accessible by means of this procedure.
Airway stenting
Patients with obstructing airway lesions either secondary to benign or malignant lesions can be treated with the use of airway stents. Initially designed to relieve tracheal stenosis, these stents have proven to be beneficial in lobar collapses secondary to large airway obstruction.
The nature of the underlying pathologic condition and the location of the obstructing lesion influences the stenting methods and the techniques. Airway obstructions caused by malignant lesions are best treated by a multimodality approach utilizing debridement and/or stenting of the lesion. Debridement of malignant endobronchial lesions provides effective short-term relief of the obstruction and reexpansion of the collapsed lobe. The presence of significant residual luminal narrowing requires placement of a stent.
Primary airway stenting is used in cases in which the lesions are caused by external compression without endobronchial obstruction because in such situations, the role of debridement is limited. Other treatment modalities such as adjuvant radiotherapy, either external beam or brachytherapy, may also be applied in these conditions. Subsequent mechanical or laser debridement can be employed if the tumor overgrowth occurs after the stenting.
For benign tracheobronchial stenoses that cannot be treated with endoscopic debridement, these conditions are best managed with tracheobronchial stents. Either the Y-stents or the straight silicone stents of the Hood or Dumon variety are selected for patients with distal tracheal or mainstem bronchial lesions that invade the carina. The stents are generally well tolerated and have been shown to offer significant palliation of symptoms.
A variety of stents are available; these include silicone, metallic, and mixed stents. The silicone stents are easy to place but require rigid bronchoscopy with general anesthesia.20 The advantages of metallic stents are that flexible fiberoptic bronchoscopy and local anesthetic are utilized in their placement; the disadvantages are the difficult removal and occlusion from tissue proliferation. The other complications of silicone stents are migration, granuloma formation, obstruction, cough, mucociliary alteration, and rupture. Metallic stents can cause complications such as cough, hemoptysis, bronchial obliteration, and occlusion by tumor growth.
Medicolegal Pitfalls
- Failure to consider lobar or segmental collapse when a loss of volume is observed on chest radiographs
- Failure to exclude an endobronchial abnormality when evaluating a patient with lobar collapse
- Failure to recognize that the lung collapse is a medical emergency because patients may develop respiratory distress and hypoxemia
- Failure to consider bronchoscopy as a diagnostic and therapeutic procedure for patients with lung collapse
Related Medscape topic:
Resource Center Medical Malpractice and Legal Issues
The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Dr Sean Tsuyuki to the development and writing of this article.
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Further Reading
Keywords
obstructive atelectasis, nonobstructive atelectasis, platelike atelectasis, discoid atelectasis, subsegmental atelectasis postoperative atelectasis, cicatrization atelectasis, rounded atelectasis, folded-lung syndrome, Blesovsky syndrome, Blesovsky's syndrome, replacement atelectasis, incomplete expansion, diminished lung volume, pulmonary volume deficiency, lung foreign body, lung tumor, mucus plugging, pleural effusion, right middle lobe syndrome, atelectatic lung tissue, bronchial obstruction, pneumothorax lobar collapse, pneumothorax, airless lung
