Pulmonary Atelectasis Treatment & Management

Evidence based studies to guide therapy in pediatric atelectasis are lacking. ^[9] The following treatment modalities are described in the literature:

• Chest physiotherapy
• Medications including inhaled bronchodilators, DNase and surfactant
• Fiberoptic bronchoscopy
• Positive end-expiratory pressure
• Treatment of underlying infections
• Treatment of underlying condition

Bedside chest physiotherapy has been used for children on mechanical ventilation. A four-step procedure for treatment of various degree of lung collapse is described in literature. ^[10] The technique involves bagging with 100% oxygen, instillation of 0.25-0.5 mL/kg sterile saline endotracheally, followed by bagging with momentary inspiratory hold, then release of the hold and simultaneous forced exhalation and vibration to simulate cough, and endotracheal suctioning. In this study 84% of ventilated children had successful improvement in lung expansion.

Medications including inhaled bronchodilators, DNase, and surfactant (see Medications section).

Dornase alfa (DNase) is a mucolytic therapy and can be administered as nebulized or direct tracheal application. DNase fragments extracellular DNA molecules in tracheobronchial secretions and improves flow properties and clearance of mucus. ^[11] DNase has been successfully used in patients with cystic fibrosis and others with acute atelectasis. In a retrospective case series involving 25 non-cystic fibrosis children with infectious atelectasis, the administration of DNase showed clinical and radiologic improvement. However, the success of the medication depends on the amount of DNA in the secretions, and neutrophil counts in the affected area. ^[12]

 Although N-acetyl cysteine has been used as a mucolytic both in nebulizer and bronchoscope forms, success has not been validated in controlled studies. Furthermore, it has the potential to cause significant bronchospasm.

If the patient is severely affected by the atelectasis and response to therapy of the underlying disorder is suboptimal, bronchoscopic removal of secretions, mucous plugs, or both may be helpful.

A pediatric pulmonologist may help diagnose and treat the underlying disorder and may also be helpful if bronchoscopy is necessary.

Bronchoscopy has both a diagnostic and therapeutic value. Flexible bronchoscopy may help distinguish intrinsic obstruction from extrinsic compression. Direct bronchoscopic inspection can also better define the nature of any intrinsic obstructing lesion. A retrospective study by Bar-Zohar et al in one hundred consecutive infants and children hospitalized in a PICU showed that treatment of atelectasis by flexible fiber optic bronchoscopy was successful in 26 of 35 cases (74.3%) without any procedure-related mortality or life-threatening complications. ^[13] Repeat bronchoscopic examination can be performed for removal of secretions reexpansion of atelectatic segment. ^[14]

Rigid bronchoscopy  has been used for treatment of pediatric pulmonary atelectasis for removal of mucus plugs, thick secretions  and removal of a foreign body. Rigid bronchoscope is safe but requires general anesthesia. ^[15]

Bronchoscopy should be used with caution in patients in a pediatric intensive care unit, who may not be able to tolerate the changes in partial pressure of oxygen and partial pressure of carbon dioxide in arterial blood that often accompany the procedure. Caution is also warranted in patients with traumatic brain injury because of the increase in intracranial pressure that can be associated with bronchoscopy, despite the use of adequate sedation. ^[16]

Bronchoscopic surfactant administration was found to be successful in opening the areas of atelectasis and helping wean children from mechanical ventilation. ^[17]

Mechanical ventilation of pediatric patients is discussed elsewhere.

A randomized controlled trial by Roncin et al showed that continuous positive airway pressure delivered via a nasal cannula or facemask is effective in improving oxygenation and re-expanding the collapsed lung. ^[18]

Antibiotics are not necessary in patients with asthma. Oral corticosteroids, together with frequent inhaled bronchodilators and  inhaled corticosteroids, would address any underlying inflammation and bronchospasm.

If the child with atelectasis has cystic fibrosis, aggressive antibiotic therapy is indicated in conjunction with chest physical therapy and postural drainage. A mucus plug from other causes may respond to chest physical therapy and postural drainage. See Cystic Fibrosis for a more detailed discussion of the therapy for this disorder. Instillation of DNase (see above) and N-acetyl cysteine and rhDNase have been used with some success in facilitating the removal of mucus plugs in the airways. Both have been used in patients with cystic fibrosis and have had some success in patients without cystic fibrosis as well.

Children with neuromuscular disease, children who have undergone surgery, and children with chest pain benefit from chest physical therapy to reduce the likelihood of developing further atelectasis; whether these procedures treat the existing atelectasis is not clear. In children with neuromuscular disease, the mechanical ex-insufflator (Cough Assist Device) is helpful in preventing atelectasis and produces enough of a cough to adequately clear the airways.

If pain is causing the atelectasis, adequate pain therapy is mandatory.

If the patient is severely affected by the atelectasis and response to therapy of the underlying disorder is suboptimal, bronchoscopic removal of secretions, mucous plugs, or both may be helpful. Both N-acetyl cysteine and rhDNase have been used with some success in facilitating the removal of mucous plugs in the airways. Both have been used in patients with cystic fibrosis and have had some success in patients without cystic fibrosis as well.

DNAse has been used in cystic fibrosis to facilitate transport of the abnormal secretions. DNAse has been successfully used in other patients with acute atelectasis. However, the success of the medication depends on the amount of DNA in the secretions, which is generally not known beforehand. In mechanically ventilated children who had undergone cardiac surgery, ^[12] nebulized DNAse was able to ameliorate atelectasis after 10 doses. It was more effective in children with high neutrophil counts in the affected area. Bronchoscopic installation of surfactant ^[17] was successful in opening the areas of atelectasis and helping wean children from mechanical ventilation. Although N -acetyl cysteine has been used as a mucolytic both in nebulizer and bronchoscope forms, success has not been validated in controlled studies. Furthermore, it has the potential to cause significant bronchospasm.

The appropriate long-term management of asthma should reduce the likelihood of the child developing atelectasis.

In children with cystic fibrosis, adequate use of the airway clearance mechanisms, sometimes in conjunction with antibiotics, can reduce the likelihood of atelectasis developing.

In children with neuromuscular disease, using a mechanical ex-insufflator (CoughAssist Device) can mobilize those secretions that predispose to atelectasis.

Routine use of chest physical therapy and postural drainage after extubation has not been shown to reduce the incidence of atelectasis.