Atelectasis


Article Author:
Kelly Grott


Article Editor:
Julie Dunlap


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
8/22/2019 9:49:08 PM

Introduction

The word "atelectasis" is Greek in origin; It is a combination of the Greek words atelez (ateles) and ektasiz (ektasis) meaning "imperfect" and "expansion" respectively. It results from the partial or complete, reversible collapse of the small airways leading to an impaired exchange of CO2 and O2 - i.e., intrapulmonary shunt. The incidence of atelectasis in patient's undergoing general anesthesia is 90%.[1]

Etiology

The mechanism by which atelectasis occurs is due to one of three processes: compression of lung tissue (compressive atelectasis), absorption of alveolar air (resorptive atelectasis), or impaired pulmonary surfactant production or function.[2]

Atelectasis can categorize into obstructive, non-obstructive, postoperative, and rounded atelectasis. 

Nonobstructive atelectasis can further classify into compression, adhesive, cicatrization, relaxation, and replacement atelectasis.  Compression atelectasis is secondary to increased pressure exerted on the lung causing the alveoli to collapse. In other words, there is a decreased transmural pressure gradient (transmural pressure gradient = alveolar pressure - intrapleural pressure) across the alveolus resulting in alveolar collapse. In an awake, spontaneously-ventilating patient, caudad excursion of the diaphragm during contraction causes a subsequent decrease in intrapleural pressure and alveolar pressure. The decrease in pressure allows for passive movement of air into the lungs. This process is inhibited by general anesthesia due to diaphragm relaxation. Patients lying supine have cephalad displacement of the diaphragm further decreasing the transmural pressure gradient and increasing the likelihood of atelectasis. Adhesive atelectasis is often the result of a surfactant deficiency or dysfunction as seen in ARDS or RDS in premature neonates. Surfactant functions to decrease alveolar surface tension and prevent alveolar collapse; therefore, any alterations to surfactant production and function often manifest as an increase in the surface tension of the alveoli leading to instability and collapse.  Cicatrization atelectasis is often the result of parenchymal scarring of the lung, leading to contraction of the lung. Processes that lead to cicatrization atelectasis include tuberculosis, fibrosis, and other chronic destructive lung processes. Relaxation atelectasis involves the loss of contact between parietal and visceral tissue as seen in pneumothoraces and pleural effusions. Replacement atelectasis is one of the most severe forms and occurs when all of the alveoli in an entire lobe are replaced by tumor. This is typically seen in bronchioalveolar carcinoma and results in complete lung collapse. 

Obstructive atelectasis is often referred to as resorptive atelectasis and occurs when alveolar air gets absorbed distal to an obstructive lesion. The obstruction either partially or completely inhibits ventilation to the area. Perfusion to the area is maintained; however, so gas uptake into the blood continues. Eventually, all of the gas in that segment will be absorbed and, without return of ventilation, the airway will collapse. Resorption atelectasis can be secondary to numerous pathologic processes, including intrathoracic tumors, mucous plugs, and foreign bodies in the airway. Children are especially susceptible to resorption atelectasis in the presence of an aspirated foreign body because they have poorly developed collateral pathways for ventilation.

In contrast, adults with COPD have extensive collateral ventilation secondary to airway destruction and thus are less likely to develop resorption atelectasis in the presence of an obstructing lesion (i.e., intrathoracic tumor). The use of high inspiratory oxygen concentration (high FiO2) during induction and maintenance of general anesthesia also contributes to atelectasis via absorption atelectasis. Room air is 79% nitrogen; nitrogen is slowly absorbed into the blood and therefore helps maintain alveolar patency. In contrast, oxygen is rapidly absorbed into the blood. 

Postoperative atelectasis typically occurs within 72 hours of general anesthesia and is a well-known postoperative complication. 

Rounded atelectasis is less common and often seen in asbestosis.  The pathophysiology involves the folding of the atelectatic lung tissue to the pleura.

While all of the mechanisms mentioned above may contribute to the formation of perioperative atelectasis, absorption and compression mechanisms are the two most commonly implicated.[3]

Middle lobe syndrome involves recurrent or fixed atelectasis of the right middle lobe and lingula. Extraluminal and intraluminal bronchial obstruction can result in middle lobe syndrome. Nonobstructive causes include inflammatory processes, defects in bronchial anatomy, and collateral ventilation. Fiberoptic bronchoscopy and bronchoalveolar lavage are the treatment of choice for this syndrome. Long term consequences of chronic atelectasis include bronchiectasis. Sjogren syndrome has associations with middle lobe syndrome and treatment with glucocorticoids has been favorable.

Epidemiology

Atelectasis does not preferentially affect either sex. There is also no increased incidence of atelectasis in patients with COPD, asthma, or increased age.[4] It is more common in patient's who recently underwent general anesthesia, with the incidence being as high as 90% in this patient population.[1] Research has shown that atelectasis appears in the dependent regions of both lungs within five minutes of induction of anesthesia.[5]  Atelectasis is more prominent after cardiac surgery with cardio-pulmonary bypass than after other types of surgery, including thoracotomies; however, patients undergoing abdominal and/or thoracic procedures are at increased risk of developing atelectasis.[3] Obese and/or pregnant patients are more likely to develop atelectasis due to cephalad displacement of the diaphragm (see the section on epidemiology).  

Pathophysiology

Administration of general anesthesia, use of muscle relaxants, obesity, pregnancy, inadequate pain control, and thoracic or cardiopulmonary procedures increase the risk of developing atelectasis in the perioperative period.

The incidence of atelectasis in patient's undergoing general anesthesia is 90%.[1] Studies have demonstrated that up to 15 to 20% of the lung at its base collapses during uneventful anesthesia before any surgical intervention. Atelectasis is seen with general anesthesia regardless of whether or not muscle paralysis is used. Ketamine, when used as a sole agent, is the only anesthetic agent that does not increase the risk for developing atelectasis.[6] The use of high inspiratory oxygen concentration (high FiO2) during induction and maintenance of general anesthesia also contributes to atelectasis via absorption atelectasis. 

Obese patients have an increased incidence of atelectasis due to decreased FRC (functional residual capacity) and compliance. Atelectasis development in pregnant patients is by this same mechanism.

Inadequate pain control can contribute to the development of atelectasis by inducing shallow breathing ("splinting") and/or inhibiting coughing.

History and Physical

Typically, atelectasis is asymptomatic. However, a patient might also present with decreased or absent breath sounds, crackles, cough, sputum production, dyspnea, tachypnea, and/or diminished chest expansion.

Evaluation

Atelectasis is usually a clinical diagnosis in a patient with known risk factors. If imaging is warranted, a chest X-ray, chest CT, and/or thoracic ultrasonography are useful in the diagnosis of atelectasis. A chest x-ray will reveal platelike, horizontal lines in the area of atelectatic lung tissue. Atelectasis is not typically evident on convention chest radiographs until it is significant. 

On chest X-ray, atelectasis will result in the displacement of interlobar fissures, pulmonary opacification, and/or tracheal shift toward the affected side.[7]

Chest CT often reveals dependent lung densities and loss of volume in the affected side of the chest.   

Atelectasis may also be directly visible with fiberoptic bronchoscopy.   Fiberoptic bronchoscopy can be both diagnostic and therapeutic, often revealing the cause of any obstruction contributing to the atelectasis (i.e., tumor, mucous plug, or foreign body).

An arterial blood gas may reveal arterial hypoxemia and respiratory alkalosis. The PaCO2 is often normal; however, it may be lower secondary to increased minute ventilation, which often accompanies atelectasis. 

Treatment / Management

Most atelectasis that appears during general anesthesia leads to transient lung dysfunction that resolves within 24 hours after surgery.  Nevertheless, some patients develop significant perioperative respiratory complications that can lead to increased morbidity and mortality if not treated. Atelectasis is preventable through avoidance of general anesthesia, early mobilization, adequate pain control, and minimizing parenteral opioid administration. When general anesthesia use is unavoidable, the use of continuous positive airway pressure, the lowest possible FiO2 during induction and maintenance, PEEP (positive end-expiratory pressure), lung recruitment maneuvers, and low tidal volumes will help prevent the development of atelectasis.[8] One study showed that intraoperative alveolar recruitment with a vital capacity maneuver followed by PEEP 10 cm H2O is effective at preventing lung atelectasis in morbidly obese patients; this also correlated with better oxygenation, shorter PACU stay, and fewer pulmonary complications in the postoperative period.[9]

Changing position from supine to upright increases FRC and decreases atelectasis.[10] Encouraging patients to take deep breaths, early ambulation, incentive spirometry, use of an acapella device, chest physiotherapy, tracheal suctioning (in intubated patients), and/or positive pressure ventilation has been shown to decrease atelectasis. The mechanism behind all of these measures is a transient increase in transmural pressure that allows for reexpansion of collapsed lung segments. Prophylactic measures, such as incentive spirometry, should be taught and instituted before surgery and continued on an hourly basis following surgery until discharge to obtain the maximal benefit.

Additional pharmacologic treatment options include mucolytic agents (acetylcysteine) and recombinant human DNase (dornase alpha) in patients with cystic fibrosis. The aforementioned nebulized medications are particularly beneficial in patients with atelectasis secondary to mucous plugging of the airways. 

Fiberoptic bronchoscopy also has a role in the management of atelectasis. In one study single-suction, fiberoptic bronchoscopy led to improved lung function and reversal of atelectasis in 76% of cases.  Bronchoscopy should always be the intervention when there is a high suspicion for a mechanically obstructed bronchus and coughing/suctioning have not been successful. Bronchoscopy is also indicated when less invasive efforts, such as early ambulation, incentive spirometry, bronchodilators, and humidity,  have not been successful within 24 hours of their initiation. 

Employing early preventative strategies and valuing prompt recognition/diagnosis will not only improve patient outcomes, but it will also significantly decrease cost.[11]

Differential Diagnosis

The differential diagnosis of atelectasis should include the following:

  • Neoplasm
  • Pneumonia
  • Pleural effusion
  • Pulmonary embolism
  • Foreign body

Prognosis

For patients with atelectasis, the prognosis varies greatly, and the primary determination is the underlying etiology and patient co-morbidities. 

Complications

Atelectasis is one of the most common respiratory complications in the perioperative period, and it may contribute to significant morbidity and mortality, including the development of pneumonia and acute respiratory failure. 

Postoperative and Rehabilitation Care

Postoperative fever has historically been attributed to atelectasis, but there is no evidence supporting the finding that atelectasis is a causative mechanism for fever.[12]

Deterrence and Patient Education

The definition of atelectasis is a partial collapse of the lung. It can cause people to feel short of breath. It can be a consequence of several different processes, most commonly when there is a poor inspiratory effort, an obstruction blocking airflow into the lung, extra pressure exerted on the outside of the lung, or deficient production or function of a specific protein in the lung. Treatment aims at the underlying cause of the condition, but mainly involves supportive measures, such as deep breathing exercises, incentive spirometry, and supplemental O2. 

Enhancing Healthcare Team Outcomes

Prevention of atelectasis is vital to improving patient outcomes in the postoperative period. Despite employing these strategies, atelectasis is not always preventable and, therefore, early recognition and treatment are equally important. Ultimately, this will decrease the length of hospital stay, cost, and improve patient outcomes.

Both prevention and treatment of atelectasis need to be an interprofessional team effort. Physicians, and especially surgeons and anesthesiologists, need to be aware of the role of anesthesia in atelectasis. Nursing will be monitoring the patient both during and after the procedure. In the event of medical management, the pharmacist can provide recommendations on opioids and mucolytics. The nursing staff will be administering these and can report to the physicians on the effectiveness of therapy as well as any adverse events, which may lead to dose or agent changes, or other interventions. The nursing staff should assist the clinicians in the education of the patient and family in incentive spirometry and other techniques to minimize risk. In summary, atelectasis management needs to be an interprofessional team collaboration to optimize patient outcomes. [Level V]


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Attributed To: Image courtesy Dr Chaigasame

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Atelectasis - Questions

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The radiologist has just read an adult's chest radiograph and notes the presence of a "sail sign." What is the most likely etiology?



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A 71-year-old smoker underwent a left hip replacement. On the first postoperative day, he complains of difficulty breathing. His pulse oximeter reads 93% on room air. Auscultation of breath sounds reveals a few coarse rales. What is the next best step in the management of this patient?



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A 76-year old male undergoes elective surgery for a ventral hernia. On post-operative day 1, he reports that his abdominal pain is tolerable and he is eating solid foods. However, he develops some shortness of breath and her oxygen level drops down to 90% on room air. On physical exam, his breath sounds are clear to auscultation but diminished at the right base. The wound is margins are healing with no evidence of infection. The surgical procedure and anesthesia were both performed without any adverse events. Which of the following is true regarding the cause of the patient's dyspnea?



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On postoperative day three following abdominal surgery, a 65-year-old patient complains of a cough. Breath sounds are clear to auscultation bilaterally. Vital signs at presentation include BP 134/74 mmHg, HR 67 bpm, and RR 16/min. A right basilar opacity is found on a chest x-ray. Which of the following treatments is indicated?



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Which of the following is the most effective way to prevent atelectasis after surgery?



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A 65-year-old female with a past medical history significant for smoking, chronic obstructive pulmonary disease (on 3 liters supplemental oxygen at home), ischemic cardiomyopathy, osteoporosis, and well-controlled diabetes underwent intramedullary nail placement in the left femur for the treatment of a fracture. She refuses to wear sequential compression devices, and her participation with physical therapy has been minimal. On postoperative day 4, she develops shortness of breath. Her vital signs are significant for blood pressure 138/72 mmHg, heart rate 70/min, respiratory rate 14/min, oxygen saturation 93% on 3 liters of supplemental oxygen via nasal cannula, and temperature of 98.7 degrees Fahrenheit. Which of the following increases her risk of developing atelectasis?



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Preoperative evaluation is done for a 19-year-old female who is preparing to undergo general anesthesia for an elective surgical procedure. She is also considering a future career in healthcare. Preoperatively, she states that she has been researching the complications that can occur in the postoperative period. She specifically asks about atelectasis. Postoperative atelectasis is most often associated with which of the following?



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A 47-year-old male with a past medical history significant for obstructive sleep apnea, hypertension, obesity, and pre-diabetes is evaluated following an ankle fusion. He reports that he feels short of breath and has a cough. He has not been able to get out of bed secondary to ankle pain. Blood pressure is 130/65 mmHg, heart rate 77 bpm, respiratory rate 14/min, and oxygen saturation 97%. He has developed atelectasis. Which of the following physical findings would support this diagnosis?



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A 54-year old female presents for an emergent exploratory laparotomy for a suspected small bowel obstruction. The surgical procedure is uneventful, and the patient is extubated and taken to the post-anesthesia care unit. The patient's oxygen saturations are consistently 84 to 86 percent. Which of the following is likely to be the cause of her desaturation postoperatively?



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What term is used for inadequate lung expansion?



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A postoperative client is on the medical-surgical floor following exploratory laparotomy. On day 1 the client has difficulty breathing and the chest x-ray reveals atelectasis. What interventions might help this client recover? Select all that apply.



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A patient returns to the medical floor after a lung biopsy. The physician recommends taking steps to prevent atelectasis. What statements below are true regarding atelectasis? Select all that apply.

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A patient in the medical-surgical unit develops atelectasis on the second postoperative day. What features may be present on a physical exam during a nursing assessment? Select all that apply.



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A 66-year-old male with a 90 pack year smoking history, chronic obstructive pulmonary disease (COPD), hypertension, coronary artery disease (status-post CABG 3 years ago), and arthritis, is being prepared for a partial right lung lobectomy. His preoperative vital signs are within normal limits. Which of the following contributes the most to an increased risk of developing atelectasis in the perioperative period?



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A 27-year-old male in the postoperative ICU is complaining of difficulty breathing. He underwent an open reduction and internal fixation of the right femur two days ago. He was involved in a motor vehicle accident three days ago and suffered a displaced right femur fracture, three fractured ribs on the right side, a pulmonary contusion, a grade 1 liver laceration, and a 5 cm laceration on the forehead. He has a history of asthma for which he takes albuterol as needed. His vital demonstrate a blood pressure of 142/83 mmHg, heart rate 88/min, SpO2 97%, and respiratory rate 24/min. On examination, he is taking rapid, shallow breaths. His lungs are clear to auscultation bilaterally, and his heart rate is regular. Which of the following is the next best step in the management of this patient?



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A 45-year old, 70 kg female who was involved in a motor vehicle accident 4 hours ago is brought in for an open reduction and fixation of a femur fracture. The procedure is performed under general anesthesia. The ventilator settings are adjusted at 100% fraction of inspired oxygen (FiO2), 550 mL tidal volume, respiratory rate of 14/min, and positive end-expiratory pressure (PEEP) of 5 mm Hg. The patient's vital signs are stable, and her SpO2 remains 100% throughout the case. As the case nears completion, the team requests a chest x-ray to evaluate for a possible rib fracture seen on the portable chest x-ray earlier. The chest x-ray is negative for a rib fracture, but it shows atelectasis. Which of the following is the most likely cause of the x-ray findings in this patient?



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A 6-month old infant is brought to the operating room for a hypospadias repair. Following a mask induction with 100% O2 and 8% sevoflurane, an intravenous catheter is placed, and 2 mg/kg of propofol is given in preparation for intubation. The first intubation attempt is unsuccessful, and the patient's oxygen saturations fall to 50%. The patient is manually ventilated with oxygen saturations improving to 100%. A second attempt at intubation is successful. Following intubation, the patient's O2 saturation is 91 mm Hg, and the peak airway pressures are 28 cm H20. What is the most appropriate intervention to improve oxygen saturation and decrease peak airway pressures?



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Atelectasis - References

References

Lundquist H,Hedenstierna G,Strandberg A,Tokics L,Brismar B, CT-assessment of dependent lung densities in man during general anaesthesia. Acta radiologica (Stockholm, Sweden : 1987). 1995 Nov;     [PubMed]
Tokics L,Hedenstierna G,Strandberg A,Brismar B,Lundquist H, Lung collapse and gas exchange during general anesthesia: effects of spontaneous breathing, muscle paralysis, and positive end-expiratory pressure. Anesthesiology. 1987 Feb;     [PubMed]
Gunnarsson L,Tokics L,Gustavsson H,Hedenstierna G, Influence of age on atelectasis formation and gas exchange impairment during general anaesthesia. British journal of anaesthesia. 1991 Apr;     [PubMed]
Craig DB,Wahba WM,Don HF,Couture JG,Becklake MR,     [PubMed]
Mavros MN,Velmahos GC,Falagas ME, Atelectasis as a cause of postoperative fever: where is the clinical evidence? Chest. 2011 Aug;     [PubMed]
Hartland BL,Newell TJ,Damico N, Alveolar recruitment maneuvers under general anesthesia: a systematic review of the literature. Respiratory care. 2015 Apr;     [PubMed]
Peroni DG,Boner AL, Atelectasis: mechanisms, diagnosis and management. Paediatric respiratory reviews. 2000 Sep     [PubMed]
Magnusson L,Spahn DR, New concepts of atelectasis during general anaesthesia. British journal of anaesthesia. 2003 Jul     [PubMed]
Brismar B,Hedenstierna G,Lundquist H,Strandberg A,Svensson L,Tokics L, Pulmonary densities during anesthesia with muscular relaxation--a proposal of atelectasis. Anesthesiology. 1985 Apr     [PubMed]
Woodring JH,Reed JC, Types and mechanisms of pulmonary atelectasis. Journal of thoracic imaging. 1996 Spring     [PubMed]
Talab HF,Zabani IA,Abdelrahman HS,Bukhari WL,Mamoun I,Ashour MA,Sadeq BB,El Sayed SI, Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery. Anesthesia and analgesia. 2009 Nov     [PubMed]
Restrepo RD,Braverman J, Current challenges in the recognition, prevention and treatment of perioperative pulmonary atelectasis. Expert review of respiratory medicine. 2015 Feb     [PubMed]

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