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RhDNase may be effective clearing mucinous secretions in refractory mucous plugging in children.
Chest physiotherapy (i.e., percussion, drainage, deep insufflation, and saline lavage) is a common treatment modality in the hospital setting. Caution must be practiced when interpreting the possible positive effects as the number of patients studied is small, the results are not consistent across trials, data on safety are insufficient, and there may be limited applicability to current guidelines.
Application of continuous distending pressure has some benefit in the treatment of preterm infants with respiratory distress syndrome and has the potential to reduce lung damage particularly if applied early (4)[A].
Second Line
Bronchofibroscopy in aspiration of inspissated secretions to improve airway clearance has been efficacious in several studies. However, debate continues regarding its efficacy in the treatment of atelectasis.
Pediatric Considerations
In obstructive atelectasis, bronchoscopy remains controversial. In the presence of a mucus plug or cast, bronchoscopy may be beneficial.
SURGERY/OTHER PROCEDURES
- Appropriate surgical resection for underlying disease (e.g., tumor, severe lymphadenopathy)
- Bronchoscopy
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Ensure adequate oxygenation (may start with 100% FiO2 then taper) and humidification
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Depends on underlying cause and comorbidities
- In uncomplicated cases of atelectasis associated with asthma or infection, outpatient monitoring is appropriate.
PATIENT EDUCATION
Maximize patient mobility and encourage frequent coughing and deep breathing.
PROGNOSIS
- For postoperative atelectasis, spontaneous resolution usually occurs within 24 hours but can persist for days after surgery.
- The prognosis of lobar atelectasis secondary to endobronchial obstruction depends on treatment of the underlying disease or malignancy.
- Surgical therapy is needed only for resectable causes or if chronic infection and bronchiectasis supervene.
COMPLICATIONS
- Pneumonia and pulmonary infections
- Acute atelectasis
- Hypoxemia and respiratory failure
- Postobstructive drowning of the lung
- Chronic atelectasis
- Bronchiectasis
- Pleural effusion and empyema
REFERENCES
11 Hulzebos EH, Smit Y, Helders PP, et al. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev. 2012;(11):CD010118.22 Baltieri L, Santos LA, Rasera IJr, et al. Use of Positive pressure in the bariatric surgery and effects on pulmonary function and prevalence of atelectasis: randomized and blinded clinical trial. Arq Bras Cir Dig. 2014;27(Suppl 1):26-30.33 Freitas ER, Soares BG, Cardoso JR, et al. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev. 2012;(9):CD004466.44 Ho JJ, Henderson-Smart DJ, Davis PG. Early versus delayed initiation of continuous distending pressure for respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2002;(2):CD002975.
ADDITIONAL READING
- Brower RG. Consequences of bed rest. Crit Care Med. 2009;37(10 Suppl):S422-S428.
- Ferreyra G, Long Y, Ranieri VM. Respiratory complications after major surgery. Curr Opin Crit Care. 2009;15(4):342-348.
- Guimar £es MM, El Dib R, Smith AF, et al. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev. 2009;(3):CD006058.
- McCunn M, Sutcliffe AJ, Mauritz W, et al. Guidelines for management of mechanical ventilation in critically injured patients. Trauma Care. 2004;14(4):147-151.
- Mavros MN, Velmahos GC, Falagas ME. Atelectasis as a cause of postoperative fever: where is the clinical evidence? Chest. 2011;140(2):418-424.
- Qaseem A, Snow V, Fitterman N, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006;144(8):575-580.
- Tusman G, B ¶hm SH, Warner DO, et al. Atelectasis and perioperative pulmonary complications in high-risk patients. Curr Opin Anaesthesiol. 2012;25(1):1-10.
- Wu KH, Lin CF, Huang CJ, et al. Rigid ventilation bronchoscopy under general anesthesia for treatment of pediatric pulmonary atelectasis caused by pneumonia: a review of 33 cases. Int Surg. 2006;91(5):291-294.
CODES
ICD10
J98.11 Atelectasis
ICD9
518.0 Pulmonary collapse
SNOMED
- 46621007 Atelectasis (disorder)
- 58525007 Obstructive atelectasis
- 196143003 postoperative atelectasis (disorder)
- 16537000 compression atelectasis (disorder)
- 448370006 round atelectasis (disorder)
CLINICAL PEARLS
- No strong clinical evidence supports atelectasis as an early cause of postoperative fever.
- Anesthesia-induced atelectasis occurs in almost all anesthetized patients.
- Bronchogenic carcinoma, which may present with atelectasis, must be excluded in all patients >35 years.
- In complete atelectasis of an entire lung, the mediastinal ipsilateral shift separates atelectasis from massive pleural effusion.
- Low serum albumin is a powerful predictor of postoperative pulmonary complications, including atelectasis.