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Atelectasis

by Başak Çoruh, MD, Brian Pomerantz, MD; Alexander S. Niven, MD

Atelectasis is collapse of lung tissue with loss of volume. Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Pleuritic chest pain may be present with certain causes of atelectasis. Diagnosis is by chest x-ray. Treatment includes maintaining coughing and deep breathing and treating the cause.

The natural tendency for open air spaces such as the alveoli to collapse is countered by the following:

  • Surfactant (which maintains surface tension)

  • Continuous breathing (which keeps the alveoli open)

  • Intermittent deep breathing (which releases surfactant into the alveoli)

  • Periodic coughing (which clears the airways of secretions)

  • Major consequences of atelectasis include under ventilation (with hypoxia and ventilation/perfusion [V/Q] mismatch) and pneumonia.

Etiology

The most common factors that can cause atelectasis include the following:

  • Intrinsic obstruction of airways (eg, by foreign body, tumor, mucous plug)

  • Extrinsic compression of airways (eg, by tumor, lymphadenopathy)

  • Suppression of respiration or cough (eg, by general anesthesia, oversedation, severe pleuritic pain)

  • Supine positioning, particularly in obese patients

  • Compression or collapse of lung parenchyma (eg, by large pleural effusion or pneumothorax)

Thoracic and abdominal surgeries are very common causes because they involve general anesthesia, opioid use (with possible secondary respiratory depression), and often painful respiration. A malpositioned endotracheal tube can cause atelectasis by occluding a mainstem bronchus.

Less common causes of atelectasis include surfactant dysfunction and lung parenchymal scarring or tumor.

Symptoms and Signs

Atelectasis itself is asymptomatic unless hypoxemia or pneumonia develops. Symptoms of hypoxemia tend to be related to acuity and severity of atelectasis. With rapid, extensive atelectasis, dyspnea or even respiratory failure can develop. With slowly developing, less extensive atelectasis, symptoms may be mild or absent.

Pneumonia may cause cough, dyspnea, and pleuritic pain. Pleuritic pain may also be due to the disorder that caused atelectasis (eg, chest trauma or surgery).

Signs are often absent. Decreased breath sounds in the region of atelectasis and possibly dullness to percussion and decreased chest excursion are detectable if the area of atelectasis is large.

Diagnosis

  • Chest x-ray

Atelectasis should be suspected in patients who have any unexplained respiratory symptoms and who have risk factors, particularly recent major surgery. Atelectasis that is clinically significant (eg, that causes symptoms, increases risk of complications, or meaningfully affects pulmonary function) is generally visible on chest x-ray; findings can include lung opacification and/or loss of lung volume. If the cause of atelectasis is not clinically apparent (eg, if it is not recent surgery or pneumonia seen on chest x-ray) or another disorder is suspected (eg, pulmonary embolism, tumor), other tests, such as bronchoscopy or chest CT, may be necessary.

Treatment

  • Maximizing cough and deep breathing

  • If obstruction by tumor or foreign body is suspected, bronchoscopy

Evidence for the efficacy of most treatments for atelectasis is weak or absent. Nonetheless, commonly recommended measures include chest physiotherapy to help maintain ventilation and clearance of secretions, and encouragement of lung expansion techniques such as directed cough, deep breathing exercises, and use of an incentive spirometer. For patients who are not intubated and do not have excessive secretions, continuous positive airway pressure may help. For patients who are intubated, positive end-expiratory pressure and/or higher tidal volume ventilation may help.

Avoiding oversedation helps ensure ventilation and sufficient deep breathing and coughing. However, severe pleuritic pain may impair deep breathing and coughing and may be relieved only with opioids. Thus, many clinicians prescribe opioid analgesics in doses sufficient to relieve pain and advise patients to consciously cough and take deep breaths periodically. In certain postoperative patients, epidural analgesia or an intercostal nerve block may be used to relieve pain without causing respiratory depression. Antitussive therapy should be avoided.

Most importantly, the cause of atelectasis (eg, mucous plug, foreign body, tumor, mass, pulmonary effusion) should be treated. For persistent mucous plugging, nebulized dornase alfa and sometimes bronchodilators are tried. N -Acetylcysteine is usually avoided because it can cause bronchoconstriction. If other measures are ineffective or if a cause of obstruction other than mucus plugging is suspected, bronchoscopy should be done.

Prevention

Smokers can decrease their risk of postoperative atelectasis by stopping smoking, ideally 6 to 8 wk before surgery. Drug treatment for patients with chronic lung disorders (eg, COPD) should be optimized before surgery. Preoperative inspiratory muscle training (including incentive spirometry) should be considered for patients scheduled for thoracic or upper abdominal surgery. After surgery, early ambulation and lung expansion techniques (eg, coughing, deep breathing exercises, incentive spirometry) may also decrease risk.

Key Points

  • Atelectasis is reversible collapse of lung tissue with loss of volume; common causes include intrinsic or extrinsic airway compression, hypoventilation, and a malpositioned endotracheal tube.

  • A large area of atelectasis may cause symptomatic hypoxemia, but any other symptoms are due to the cause or a superimposed pneumonia.

  • Diagnosis is by chest x-ray; if the cause is not clinically apparent, bronchoscopy or chest CT may be needed.

  • Treatment involves maximizing coughing and deep breathing.

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