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Atelektasis 1 PDF
Atelektasis 1 PDF
Key points Atelectasis is derived from the Greek words pneumonitis, or neonatal respiratory distress
ateles and ektasis, meaning incomplete expan- syndrome.
Atelectasis during general
anaesthesia (GA) is common, sion. It is also referred to as collapse of the lung. Cicatrizing: this occurs due to scar tissue
but usually does not cause Atelectasis is the loss of lung volume, either a formation as a result of granulomatous
clinically significant problems. part or all of a lung with or without mediastinal disease or necrotizing pneumonia.
Persistent prolonged atelectasis shift. This is in contrast to consolidation where
The above types of atelectasis are most often
after GA increases the lung volume is normal. In clinical practice,
perioperative respiratory described in the chronic setting, but in this article,
there is often a combination of both. Atelectasis
complications. we focus on the mechanisms, pathophysiology,
is common in the setting of anaesthesia and critic-
Risk factors contributing to diagnosis, and management of pulmonary atelec-
al care. Atelectasis can be broadly classified into
atelectasis include: obesity, tasis in the settings of general anaesthesia (GA)
obstructive and non-obstructive, each having a
chronic lung disease, thoracic or and critical care.
upper gastrointestinal surgery, particular radiological pattern. Obstructive atelec-
and prolonged use of tasis is by far the most common cause of lung col-
high-inspired oxygen lapse, in both adult and paediatric populations.
concentration. Atelectasis related to GA
The aetiology and significance of Atelectasis is common during anaesthesia and is
atelectasis in critically ill patients Types of atelectasis frequently noted in critically ill patients with dif-
is different from that seen in
patients undergoing GA. In the context of chest medicine, several types of ferent underlying aetiologies and pathophysi-
atelectasis can be categorized according to aeti- ology.1,2 Uneventful anaesthesia can lead to the
The treatment and prevention
of atelectasis varies according to ology (Table 1). development of collapse in 10 15% of lung
the aetiology, severity, and tissue. The following mechanisms have been
clinical context. proposed to contribute to atelectasis during GA.
Obstructive
Komal Ray MBBS FRCA Bronchial obstruction is a frequent cause of atel-
Consultant in Anaesthesia ectasis. This is usually due to a neoplasm, Compression atelectasis
Leeds General Infirmary mucus plug, or foreign body. Progressive airway
Great George Street In a normal healthy adult in the upright position,
Leeds LS1 3EX collapse develops distal to the obstruction.
UK the functional residual capacity (FRC) is 3
litres. This decreases by 0.70.8 litres in the
Andrew Bodenham MBBS FRCA FICM
Consultant in Anaesthesia and Intensive
Non-obstructive supine position as abdominal contents push the
Care Medicine diaphragm cephalad. This is further accentuated
Leeds General Infirmary
Various types exist:
with anaesthesia and paralysis, as abdominal pres-
Great George Street
Leeds LS1 3EX Compressive: a large peripheral tumour, sure is easily transmitted to the thoracic cavity.
UK bullae, or extensive air trapping (emphyse- The loss of intercostal muscle function also con-
Tel: 44 113 392 2321
ma) compresses adjacent normal lung tissue. tributes to FRC reduction, particularly in children.
Fax: 44 113 392 5682
E-mail: andy.bodenham@leedsth.nhs.uk Passive: this is also referred to as relaxation Surgical manipulation during thoraco-abdominal
(for correspondence) atelectasis, and it is caused by the loss of procedures may worsen atelectasis caused by GA.
Elankumaran Paramasivam MBBS MRCP contact between parietal and visceral Other factors accentuating compression atelec-
FICM pleura, for example, due to pleural effusion, tasis include morbid obesity, laparoscopic proce-
Consultant in Intensive Care and Respiratory pneumothorax, or pleural malignancy. dures, and head-down and lateral positioning.
Medicine
St Jamess University Hospital Adhesive: this is caused by a lack of or in- During one-lung anaesthesia, the lung on the side
Beckett Street activation of surfactant and can be seen in of surgery is typically deliberately collapsed to
Leeds LS9 7TF
UK
severe acute lung injury (ALI), radiation allow surgical access on that side.
doi:10.1093/bjaceaccp/mkt064 Advance Access publication 23 December, 2013
236 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 14 Number 5 2014
& The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
Pulmonary atelectasis
Table 1 Causes of lung collapse in anaesthesia and atelectasis leads to increased neutrophil activation. This leads to an
critical care
inflammatory response causing localized lung injury alongside sys-
Obstructive temic and distant organ dysfunction due to systemic release of in-
Large airway obstruction flammatory mediators (cytokines, proteases, and reactive oxygen
Tumour: bronchial, metastatic
Inflammatory: tuberculosis, sarcoidosis species).3 It will therefore take time to resolve, unlike the usually
Other: foreign body, malpositioned tracheal tube fairly rapid resolution after uncomplicated GA and surgery.
Small airway obstruction
Mucus plugs
Inflammation Surfactant depletion
Bronchopneumonia, bronchitis, bronchiectasis Surfactant is a lipoprotein complex secreted by Type II alveolar
Non-obstructive
Compressive
cells which forms an inner coating for alveoli. It reduces surface
Peripheral tumour tension within a theoretically spherical structure like an alveolus,
Interstitial disease: sarcoidosis, lymphoma and so may be considered to follow Laplaces law ( pressure2
Air trapping in adjacent lung: emphysema
Passive
tension/radius). This equation indicates that smaller alveoli will
Bibasal collapse under anaesthesia contain higher pressure than larger ones, and so would quickly
Thoracic and abdominal surgery empty into the larger alveoli, and so collapse. Surfactant reduces
Pneumothorax, pleural effusions
Diaphragmatic hernia
surface tension in all alveoli, and to a greater extent in smaller ones,
Adhesive thereby maintaining alveolar stability. The lack of surfactant func-
Smoke inhalation tion therefore leads to atelectasis. Also, lung tissue deficient in sur-
Cardiopulmonary bypass
factant is difficult to inflate leading to increased work of breathing
and so likelihood of respiratory failure. This situation can be seen in
premature neonates who may require artificial surfactant. In
Absorption atelectasis adults, surfactant function may be impaired by lung infection or
This can occur by two different mechanisms: inflammation.
Impaired oxygenation
Atelectasis in the critical care setting Atelectasis can significantly affect systemic oxygenation by the loss
Atelectasis is a common cause of impaired gas exchange and X-ray of adequate ventilation to perfused lung units. This was first
opacification of lung regions in critically ill patients. It may be identified during GA and the effect was reversed by passive
encountered in the presence or absence of ALI. The incidence is hyperinflation.
likely to be high if the patient is immobile, has had a general anaes-
thetic, or if they have pre-existing lung disease, a smoking history, Increased pulmonary vascular resistance
obesity, or advanced age. Its pathophysiology is multifactorial: ob-
Regional hypoxia in atelectatic lung units leads to hypoxic pulmon-
structive, non-obstructive, or both. Most cases are likely to be multi-
ary vasoconstriction due to decreased alveolar and mixed venous
factorial in origin with prolonged immobility and infection probably
oxygen tension. If extensive, this phenomenon may lead to right
being the most common contributors.
ventricular dysfunction and increased microvascular fluid leakage in
susceptible patients.
Acute lung injury
Extensive evidence exists regarding the maintenance of lung volume
Clinical presentation
in the prevention of lung injury. Atelectasis in patients with ALI
differs from atelectasis related to GA. During lung injury, atelectasis This depends on the extent of atelectasis and rapidity with which it
is accompanied by inflammatory fluid filling up the alveoli and a develops. Small and slowly developing areas of collapse may be
phenomenon of cyclical collapse is seen. Also, repetitive lung asymptomatic or present as a non-productive cough. Rapidly
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 5 2014 237
Pulmonary atelectasis
Investigations
Chest X-ray
The radiological signs of collapse will depend upon the aetiology,
degree of collapse, and associated consolidation or pleural pathology.
Signs may be direct (related to loss of lung volume and collapsed
lobes) or indirect (occurring as result of compensatory changes due to
volume loss), leading to shift of the mediastinal structures.
Direct signs Fig 1 Total lung collapse due to obstructive pathology causing a white out of
the right hemithorax. Note the trachea is pulled towards the collapsed lung.
These include:
Increased opacification in the area of atelectasis. Air broncho-
grams are normally a feature of consolidation but may also be
present in lobar collapse.
Displacement of fissures. This occurs with large degree of col-
lapse.
Loss of aeration. If the collapsed lung is adjacent to the medias-
tinum or diaphragm, then loss of definition of these structures
indicates loss of aeration (the silhouette sign).
Vascular signs. In partial collapse, crowding of vessels may be
seen.
Indirect signs
These include:
238 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 5 2014
Pulmonary atelectasis
Fig 3 (A) RUL collapse (PA view). The minor fissure and hilum are displaced upwards. The mediastinal border is obscured. The trachea is deviated to the right.
(B) RUL collapse (lateral view). The minor and major fissures (arrows) are pulled upwards causing a triangular opacity with well-defined margins. (C) Golden S
sign. This is seen in RUL collapse due to a mass lesion. The superior portion of the S is from the displaced minor fissure (arrow), while the inferior portion
results from the mass itself (arrowhead).
posterioranterior view. The right horizontal and oblique fissures compared with the RUL. It appears as a veil-like opacity
move towards each other leading to a wedge-shaped opacity on extending from the hilum and fading inferiorly. On the lateral
the lateral view. A chronically collapsed RML is often associated view, the major fissure displaces anteriorly and the lower lobe
with bronchiectasis and is known as RML syndrome. is hyper-expanded. LUL collapse also causes a hyper-expanded
Right lower lobe (RLL) collapse (Fig. 5A and B) is seen as a superior segment of the left lower lobe (LLL), which is posi-
triangular opacity adjacent to the right heart border. There is tioned between the atelectatic upper lobe and the aortic arch in
obliteration of the right hemidiaphragm and it may appear half of cases. This gives the appearance of a crescent of aerated
elevated. However, the right heart border is clearly seen. On lung, called the Luftsichel sign (Fig. 6A).
lateral projection, the right hemidiaphragm outline is lost LLL collapse (Fig. 7A and B) is seen as an increased retrocardiac
posteriorly and the lower thoracic vertebrae appear more dense. opacity, which silhouettes the left hemidiaphragm. On the lateral
Left upper lobe (LUL) collapse (Fig. 6A and B). Owing to the view, the left hemidiaphragm outline is lost posteriorly and the
lack of a minor fissure, LUL collapse appears different lower thoracic vertebrae appear denser than normal.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 5 2014 239
Pulmonary atelectasis
Fig 4 (A) RML collapse (PA view). The minor fissure is displaced downwards. There is an ill-defined opacity adjacent to the right heart border, and loss of the
right heart border. (B) RML collapse (lateral view). There is a wedge-shaped opacity extending from the hilum.
In clinical practice, particularly in the sicker patient, many of endobronchial lesions and any tumour spread, and differentiation of
these patterns of collapse can co-exist, and bibasal collapse is com- obstructive lesions from other forms of atelectasis.
monly seen after major anaesthesia and surgery, or in a critically ill
patient with impending respiratory failure. Ultrasound
Rounded atelectasis. This unusual type of collapse appears as a Obstructive atelectasis on ultrasound shows as an area of homogen-
homogenous mass on a plain film. This is due to segmental or ous low echogenicity. An important role for ultrasound is to distin-
subsegmental atelectasis, and occurs secondary to visceral guish basal lung collapse from a loculated pleural effusion (Fig. 9).
pleural thickening and entrapment of lung tissue. An affected segment of collapse resembles liver (so-called hepatiza-
tion of the lung). Echogenic bands may be visible as a result of a
fluid bronchogram. No reinflation of the lung is seen during inhal-
CT scan ation. On using colour-flow Doppler, increased flow signals relative
to the liver are seen. Also the lung pulse may be used as a dynamic
Atelectasis on CT has been defined as pixels with attenuation values lung ultrasound sign described as absent lung sliding with the per-
of 2100 to 100 Hounsfield units. The Hounsfield unit is a ception of heart activity at the pleural line, associated with complete
measure of X-ray attenuation used in CT scan interpretation. It char- atelectasis (e.g. during endobronchial intubation).5
acterizes the relative density of a substance, that is, air: 21000, fat:
250, water: 0, muscle: 40, calculus: 100 to 400, bone:
Other investigations
1000. Features of lobar collapse and effusions are more obvious
on CT than plain radiographs (Fig. 8) and it is useful for more atyp- These include bronchoscopy, thoracoscopy, and open surgery, but
ical forms of collapse. CT aids identification and localization of these are often more treatment based than purely for diagnosis.
240 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 5 2014
Pulmonary atelectasis
Fig 5 (A) RLL collapse (PA view). There is a well-defined opacity adjacent to the right heart border with the loss of definition of the right hemidiaphragm. The
right heart border is still visible. (B) RLL collapse (lateral view). There is a well-defined posterior opacity, with the oblique fissure displaced. There is loss of the
normal darkening of the thoracic vertebral bodies inferiorly.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 5 2014 241
Pulmonary atelectasis
Fig 6 (A) LUL collapse (PA view). There is a veil-like opacity over the left lung field with Luftsichel sign (arrow), and the trachea is deviated to left, sometimes
with an elevated left hilum. (B) LUL collapse (lateral view). There is an opacity with a sharply defined posterior border due to anterior displacement of major
fissure (arrow).
spontaneous breaths in longer cases rather that have a patient fully Postoperative period
paralysed is unknown. Overall, ventilation strategies should follow Atelectasis is one of the most common pulmonary complications in
those advocated in critical care (see below) with limited tidal the postoperative period, although it is often clinically insignificant.
volumes and peak inspiratory pressures.7 The altered compliance of lung tissue, impaired regional ventilation,
Recruitment of atelectasis should be attempted if it is suspected and retained airway secretions contribute to the development of atel-
clinically or in high-risk patients. Research has shown that recruit- ectasis. Postoperative pain interferes with spontaneous deep breath-
ment of lung units follows a Gaussian distribution; hence, different ing and coughing resulting in decreases in FRC, leading to
units recruit at different pressures, range 10 45 cm H2O. In addition atelectasis. In addition to general measures, a variety of lung expan-
to this critical opening pressure, lung recruitment requires time to sion exercises may reduce postoperative pulmonary complications in
allow the delivered gas volume to redistribute. selected patients, including chest physical therapy, deep breathing
Suggested recruitment manoeuvres include: exercises, incentive spirometry, intermittent positive pressure
breathing, and CPAP. Good postoperative pain control may help to
Vital capacity manoeuvre using an inflation pressure of 40 cm minimize postoperative pulmonary complications by enabling
H2O sustained for 10 15 s. earlier ambulation and improving the patients ability to take deep
Increasing PEEP to 15 cm H2O and then increasing tidal breaths.8
volumes to achieve peak inspiratory pressure of 40 cm H2O for
10 breaths before then returning to standard ventilator settings.
Management in critical care
Higher levels of PEEP are generally not beneficial as the shunt does
not improve due to redistribution of blood flow in the lung, and the Treatment of atelectasis in critically ill patients differs from anaes-
high intra-thoracic pressure leads to decreased venous return and thesia in that there is commonly a presence of background ALI or in-
haemodynamic compromise. fection. The open-lung approach to ventilating patients with severe
242 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 5 2014
Pulmonary atelectasis
Fig 7 (A) LLL collapse (PA view). There is a triangular opacity visible through the heart, with the loss of the medial border of the diaphragm. (B) LLL collapse
(lateral view). There is increased retrocardiac opacity, with downward displacement of the fissure.
ALI consists of recruitment manoeuvres with high sustained airway point on the pressure volume curve is suggested to decrease mortal-
pressures to open atelectatic alveoli, followed by application of ity, length of intensive care unit (ICU) stay, and days on ventilator.9
PEEP to maintain alveolar patency.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 14 Number 5 2014 243
Pulmonary atelectasis
Table 2 Other strategies which may be used in the management of artificial ventilation
in patients with atelectasis. FRC, functional residual capacity
strategies are more likely to be used in ICUs and are not commonly
required or used in theatre. There is no strong evidence to support
the application of these techniques and so their use should be pre-
ceded by an individual risk benefit analysis for each patient.
Conclusion
Atelectasis is commonly encountered in the perioperative and critic-
al care settings and may lead to hypoxaemia and respiratory failure.
Fig 9 Lung ultrasound. There is a large pleural effusion causing underlying
lung collapse. Timely diagnosis and management is crucial for a good outcome.
Prevention is better than cure when dealing with patients at high risk
of developing atelectasis.
Muscle tone during artificial ventilation can also affect gas ex-
change. Allowing spontaneous breathing up to 10 20% of total ven-
tilation improves gas exchange by redistribution of ventilation and Acknowledgement
end-expiratory gas to dependent areas, thus promoting alveolar re-
The authors would like to thank Medical illustration at St James
cruitment. This can be achieved with airway pressure release ventila-
Hospital Leeds for producing the line diagrams.
tion or biphasic positive airway pressure.11
High-frequency oscillation ventilation (HFOV) may be consid-
ered and facilitates lung inflation and recruitment by maintaining Declaration of interest
mean airway pressure at a constant elevated level while using a
piston to cycle the ventilation rate at several hundred times per We thank Medical illustration at St James Hospital Leeds for produ-
minute. This results in tidal volumes that are smaller than the cing the line diagrams.
anatomical dead space of lungs with the potential to reduce
volutrauma-related lung injury. HFOV minimizes cyclical alveolar
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