Atelectasis

Original Editor - Hing Long Yip

Lead Editors  

Introduction

Atelectasis is the collapse of the lung. It is most commonly seen in post-operative patient whose breathing mechanism is impacted by the procedure, pain and prolonged recumbency. Less commonly, atelectasis is seen in people with conditions signify chronic sputum production or airway obstruction, such as COPD, bronchiectasis and cystic fibrosis.

It is normally mistaken atelectasis as a diagnosis, instead it is a clinical sign shown on chest x-ray.

Common types of atelectasis

Atelectasis can be divided into two main types, obstructive and non-obstructive atelectasis.

Obstructive atelectasis[1]: causes by blockage of the an airways or multiple airways which reduces the amount of air going into deep lung tissue. This type of atelectasis happens with acute pneumonia and chronic sputum production. Airways are blocked due to accumulation of secretion in the airway, which limits airflow to the alveoli resulting collapse of the lung. Other conditions, such as malignancy and COPD, which impact on the patency of the airway can also cause obstructive atelectasis.

Obstruction atelectasis can impact parts of the lung or the entire depending on the location of the blockage. For example, when obstruction locates higher up or in bigger airways, larger area of the lung would be affected due to the anatomy of the lung.

Non-obstructive atelectasis[2][3]: is an umbrella term for other types which does not involve of blockage of the airways. For example, compressive atelectasis, post surgical atelectasis, round atelectasis, adhesive atelectasis and replacement atelectasis. Amongst those, physiotherapy interventions can only be effective in treating compressive and post-surgical atelectasis.

Compressive atelectasis - When there is an external force acting on the lung tissue preventing alveoli from expanding, such as pleural effusion.

Post-surgical atelectasis - Usually due to the impaired breathing pattern due to post-operative pain. Other contributing factors including effects of anaesthetics, type of surgery (usually abdominal or chest surgery), history of smoking, high BMI, prolonged recumbency and increased sputum production.

Clinical Presentation

  • Shortness of breath
  • Shallow breathing pattern
  • Reduced chest expansion
  • Increased respiratory rate
  • Increased work of breathing
  • Reduced breath sound on auscutation
  • Hypoxia/hypoxaemia
  • CXR

Management / Interventions

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Airway clearance techniques

As atelectasis can be caused by blockage of bigger airways, physiotherapy treatment to assist in airway clearance can improve atelectasis

Example of airway clearance technique: active cycle breathing techniques[4][5], supported cough[5], positioning[4], postural drainage[4]

Breathing exercise

Incentive spirometry

Sustained maximal inspiration: is often used to prevent and management atelectasis in abdominal and thoracic surgery patients.[6] It's effects are often compared with incentive spirometry, and interestingly evidence has shown similar effects in SMI in improving breathing patterns, chest expansion and thoracoabdominal asynchrony.[7] Hence, it could be an alternative where incentive spirometry is unavailable.

Early mobilisation[4]

This fits in the picture of both post-operative patients and population with acute respiratory conditions, such as acute pneumonia. When a patient is medically stable enough, physiotherapist should assist with mobilisation in accordance to patient's status. Mobilisation can include sitting up in bed, sitting over the edge of the bed, standing, marching at a spot, ambulation with/without aids.

References

  1. Raman TS, Mathew S, Garcha PS. Atelectasis in children. Indian pediatrics. 1998 May;35(5):429-35.
  2. CULINER MM. The right middle lobe syndrome, a non-obstructive complex. Diseases of the Chest. 1966 Jul 1;50(1):57-66.
  3. SUTNICK AI, SOLOFF LA. Atelectasis with pneumonia: a pathophysiologic study. Annals of internal medicine. 1964 Jan 1;60(1):39-46.
  4. 4.0 4.1 4.2 4.3 Stiller K, Geake T, Taylor J, Grant R, Hall B. Acute lobar atelectasis: a comparison of two chest physiotherapy regimens. Chest. 1990 Dec 1;98(6):1336-40.
  5. 5.0 5.1 Schindler MB. Treatment of atelectasis: where is the evidence?. Critical Care. 2005 Aug;9(4):341.
  6. Tan AK. Incentive spirometry for tracheostomy and laryngectomy patients. The Journal of otolaryngology. 1995 Oct;24(5):292-4.
  7. Mendes LP, Teixeira LS, da Cruz LJ, Vieira DS, Parreira VF. Sustained maximal inspiration has similar effects compared to incentive spirometers. Respiratory physiology & neurobiology. 2019 Mar 1;261:67-74.