DRG Category: 205
Mean LOS: 5.5 days
Description: Medical: Other Respiratory System Diagnoses With Major Complication or Comorbidity
Atelectasis means “incomplete expansion” (from the Greek words ateles and ektasis) and is defined as the collapse of lung tissue because of airway obstruction, an abnormal breathing pattern, or compression of the lung tissue. Obstructive atelectasis is the most common type. When the airway becomes completely obstructed, the gas distal to the obstruction becomes absorbed into the pulmonary circulation and the lung collapses. When gas is removed from portions of the lungs, unoxygenated blood passes unchanged through capillaries (a process called shunting), and hypoxemia results.
The obstruction, which occurs at the level of the larger or smaller bronchus, can be caused by a foreign body, a tumor, or mucous plugging. When the obstruction is removed, the lungs return to normal unless infection persists.
Nonobstructive atelectasis is caused by loss of contact between the parietal and the visceral pleurae, as well as compression, loss of surfactant, and replacement of parenchymal tissue by scarring or infiltrative disease. Pleural effusions, pneumothorax, blunt trauma, and acute respiratory distress syndrome all are nonobstructive conditions. Abnormal breathing patterns, such as hypoventilation following surgical procedures, can also lead to atelectasis. In such cases, the lung does not fully expand, which causes the lower airways to collapse. Complications of atelectasis include pneumonia and sepsis, bronchiectasis, hypoxemia, pleural effusion, and empyema.
Atelectasis occurs most frequently after surgery and is a major concern for acute care nurses. Patients with abdominal and/or thoracic surgery are the most susceptible, especially in the older age group. The duration of the surgery is also a risk factor. Patients in surgery for more than 4 hours have a 50% incidence of severe atelectasis, compared with a 19% incidence for those in surgery for 2 hours. Other causes of atelectasis are mucous plugs in patients who smoke heavily and inflammation from inflammatory lung disease. Atelectasis also occurs in patients with central nervous system depression following a drug overdose or a critical cerebral event, such as a cerebrovascular accident.
Atelectasis may be seen as a feature of a number of inherited disorders with pulmonary components, including cystic fibrosis.
Premature infants with idiopathic respiratory distress syndrome develop atelectasis. Atelectasis, however, can occur at any age and equally in men and women. It can occur with a complete obstruction of the lung because of a foreign object, although foreign body aspiration is more common in children under age 4 years than in adults. Generally, however, atelectasis occurs most often in older adults because the aging lung is less compliant.
Ethnicity, race, and sexual/gender minority status have no known effect on the risk for atelectasis.
While atelectasis occurs around the world, no data are available on incidence.
PLANNING AND IMPLEMENTATION
Collaborative
Prevention of postoperative atelectasis is the ultimate goal, which can be met through pain control, early ambulation, adequate fluid intake, coughing and deep-breathing protocols, and the use of incentive spirometry. Patients in pain, especially following abdominal and thoracic surgery, tend to breathe shallowly to decrease their discomfort. Pain medications allow them to breathe more deeply and expand their lungs. Use caution in overmedicating patients, however, because that will reduce respiratory excursion. In the immediate postoperative period, narcotic analgesia is often prescribed because it is readily reversible by naloxone (Narcan).
Incentive spirometry, chest percussion and vibration, and postural drainage may be prescribed by the physician to increase gas exchange and to decrease the risk of atelectasis. Oxygen may be delivered with humidification to improve clearance of mucus. Nebulized bronchodilators and humidity may help liquefy secretions and promote easy removal. If atelectasis lasts more than 24 hours, flexible fiberoptic bronchoscopy will likely be used. If atelectasis persists and hypoxemia becomes life-threatening, noninvasive ventilation or endotracheal intubation and mechanical ventilation with positive-pressure ventilation and positive end-expiratory pressure (PEEP) may be necessary, but these aggressive therapies are usually not needed.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Bronchodilators such as albuterol, metaproterenol | Varies with drug | Beta2 agonists | Dilate bronchioles, stimulate cilia, facilitate in removal of secretions |
Other: Broad-spectrum antibiotics (cefuroxime, cefaclor) to treat an underlying infection
Independent
Instruct the preoperative patient on coughing and deep-breathing exercises before incisional pain makes learning difficult. Teach the patient breathing exercises, such as pursed-lip breathing and abdominal breathing, to expand the lungs. As soon as the patient is awake and alert after surgery, with a patent airway and adequate breathing, encourage the patient to cough and breathe deeply to help expand the lung. If the patient has abdominal or thoracic incisions, use a pillow to splint the incision to reduce discomfort during breathing exercises. Encourage the patient to use the incentive spirometer at the bedside every 2 hours when the patient is awake. Determine the patient's appropriate level of hydration to ensure liquidation of secretions.
Encourage the patient to ambulate as soon as possible to reduce complications of immobility, which cause retention of secretions and decreased lung volumes. Seating the patient upright allows the patient to breathe more deeply because the lungs can expand better. Turn patients on bedrest at least every 2 hours.
Encourage patients who can expectorate secretions to cough; place a paper bag on the side rails of the bed for sanitary tissue disposal. If the patient is not on fluid restriction, explain that the patient should drink at least 2 to 3 L of fluid a day to liquefy secretions. If the patient is unresponsive, suction the patient endotracheally to remove sputum and to stimulate coughing.
If a child has developed atelectasis because of foreign body obstruction, teach the parents to maintain a safe environment. The most commonly aspirated objects are safety pins and hard foods such as corn, raisins, and peanuts. Parents should not allow children to run or walk while eating because activity predisposes the child to aspiration. Teach the patient and family to evaluate all toys for removable parts; explain that coins are commonly aspirated and should not be given to children. Explain to parents that they should not allow a young child to play with baby powder during diaper changes because if the top is altered and powder spills onto the child's face, the child can inhale it.
Evidence-Based Practice and Health Policy
Sagar, A., Sabath, B., Eapen, G., Song, J., Marcoux, M., Sarkiss, M., Arain, M., Grosu, H., Ost, D., Jimenez, C., & Casal, R. (2020). Incidence and location of atelectasis developed during bronchoscopy under general anesthesia: The I-LOCATE trial. CHEST, 158, 2658–2666.
- The authors determined the incidence, anatomic location, and risk factors for developing atelectasis during bronchoscopy under general anesthesia. In 57 patients, they captured images in the right and left bronchi and categorized them as either being aerated lung (snowstorm pattern) or nonaerated (atelectatic pattern). They evaluated eight lung segments.
- Fifty-one patients (89%) had atelectasis in at least one lung segment. Forty-five patients (79%) had atelectasis in at least three segments, 41 patients (72%) had atelectasis in four segments, 33 patients (58%) had atelectasis in five segments, and 18 patients (32%) had atelectasis in at least six segments. The authors concluded that the incidence of atelectasis during bronchoscopy under general anesthesia in dependent lung zones is high. Risk factors were prolonged time under anesthesia and increased body mass index.