Atelectasis
- A closure or collapse of alveoli and often described in relation to CXR findings and
clinical S/S
o One of the most commonly found Dx on CXR
- Can be acute or chronic
- Can see microatelectasis (not detectable on CXR) to macroatelectasis w/ loss of
segmental, lobar, or overall lung volume
- Most common form of Dx is acute atelectasis
o Usually happens postop following thoracic and upper ABD procedures or in pts
who are immobile who have a shallow, monotonous breathing pattern
o Excess secretions or mucus plugs may also cause obstruction of airflow and
result in atelectasis in an area of the lung
- Also seen in pts w/ a chronic airway obstruction that impedes/blocks flow of air to an
area of the lung (obstructive atelectasis in pt w/ lung cancer that is invading or
compressing the airways)
o This form more insidious (progressive but more harmful) and slower onset
Pathophysiology
- Dx can be obstructive or nonobstructive
o Nonobstructive – occurs in adults as a result of reduced ventilation
o Obstructive – results from any blockage that impedes the passage of air to and
from the alveoli, reducing alveolar ventilation
Most common type and results from reabsorption of gas (trapped
alveolar air is absorbed into the bloodstream); no more air can enter into
the alveoli b/c of the blockage
Results in the affected portion of the lung becoming airless alveolar
collapse
- Causes of Dx include foreign body, tumor/growth in an airway, altered breathing
patterns, retained secretions, pain, alteration in small airway function, prolonged
supine positioning, increased ABD pressure, reduced lung volumes r/t musculoskeletal
or neuro disorders, and specific surgical procedures (upper ABD, thoracic, or open-heart
surgery)
- Pts at high-risk postop b/c of
o Monotonous, low tidal breathing pattern may cause small airway closure and
alveolar collapse
This can result from effects of anesthesia or analgesic agents, supine
positioning, splinting of chest wall b/c of pain, or ABD distension
o Secretion retention, airway obstructions, and an impaired cough reflex may
also occur, or pts reluctant to cough b/c of pain
- Atelectasis resulting from bronchial obstruction by secretions may also occur in pts w/
impaired cough mechanisms (musculoskeletal or neuro Dx as well as pts who are
bedbound
- May also develop b/c of excessive pressure on the lung tissue (compressive atelectasis)
which restricts normal lung expansion on inspiration
, o Excess pressure can be prod. by a pleural effusion (fluid accumulating within
the pleural space), a pneumothorax (air in pleural space), or a hemothorax
(blood in the pleural space)
Pleural space = area between the parietal and visceral pleurae; normally a
potential rather than an actual space
o Pressure may also be prod. by a pericardial effusion (pericardium distended w/
fluid), tumor growth within the thorax, or an elevated diaphragm
Clinical Manifestations
- Dx process is usually insidious (gradual but still harmful)
- S/S – increasing dyspnea (SOB), cough, and sputum production
o Tachycardia, tachypnea, pleural pain, and central cyanosis (late sign of
hypoxemia) may be anticipated (middle-late S/S)
- Pts have a harder time breathing supine; also anxious
- In acute atelectasis involving a large amount of lung tissue (lobar atelectasis), marked
resp. distress may be seen
- S/S of chronic Dx similar to acute
o Chronic alveolar collapse predisposes pts to infection distal to obstruction
o S/S of pulmonary infection may also be present
Assess/Diagnostic
- When clinically significant atelectasis develops increased effort of breathing and
hypoxemia (decreased O2 tension in arterial blood)
- Decreased breath sounds and crackles heard over affected area
, - CXR may suggest diagnosis of atelectasis before S/S appear
o CXR may show patchy infiltrates or consolidated areas
- Depending on degree of hypoxemia a pulse-ox may show low saturation of hemoglobin
***Quality Nursing – tachypnea, dyspnea, and mild-moderate hypoxemia are hallmarks of
the severity of atelectasis***
Prevention
- Frequent turning, early mobilization, and strategies to expand the lungs and to
manage secretions
o Especially change position from supine to upright to promote ventilation and
prevent secretions from accumulating
- Voluntary deep-breathing maneuvers (at least every 2hr) helps in preventing and
treating atelectasis
o Pt must be alert and cooperative
o Deep breathing & coughing to mobilize secretions and prevent from
accumulating
- Incentive spirometry or voluntary deep breathing enhances lung expansion,
decreasing potential for airway closure and may generate a cough
o Incentive spirometry is a method of deep breathing that provides visual feedback
to encourage pts to inhale slowly and deeply to maximize lung inflation and
prevent or reduce atelectasis
o Purpose is to ensure that the volume of air inhaled is increased gradually as pts
breaths get deeper and deeper
- Incentive spirometers available in 2 types – volume or flow
o Volume – the tidal volume is set using manufacturer instructions
Pt takes a deep breath through the mouthpiece, pauses at peak lung
inflation, and then relaxes and exhales
Breathe normally in between attempts to minimize fatigue
Volume is increased as tolerated
o Flow – volume is not preset
Spirometer contains balls that are pushed up by force of the breath and
held suspended in air while the pt inhales
Amount of air inhaled and flow of air are estimated by how long and how
high the balls are suspended
- Secretion management techniques include directed cough, suctioning, aerosol
nebulizer treatments followed by chest physiotherapy (CPT), and bronchoscopy
o May use pressurized metered-dose inhaler (pMDI) to give bronchodilator instead
of aerosolized, small-volume nebulizer (SVN)
CHART 19-1 – PERFORMING INCENTIVE SPIROMETRY (I remember being tested on
how to perform incentive spirometry)
Inspired air helps inflate the lungs; the ball rises in response to the intensity of the intake of air;
the deeper the breath the higher the ball goes
Instructions
, - Place pt in semi-Fowler or upright position before starting
- Use diaphragmatic breathing
- Place the mouthpiece firmly in mouth, inspire slowly through the mouth and hold the
breath at the end of inspiration for ~3sec to maintain the ball between the lines
- Exhale through the mouthpiece
- Cough during and after each session; splint the incision when coughing postop
- Perform exercise ~10 times in succession, repeating the 10 breaths with the spirometer
each hour during waking hours
Management
- Goal of Tx is to improve ventilation and remove secretions
- Prevention strategies – frequent turning, early ambulation (post-op) lung volume
expansion maneuvers (deep breathing & incentive spirometry), and coughing serve as
first line measures to minimize or treat atelectasis by improving ventilation
- ICOUGH prevention program
o I – incentive spirometry
o C – coughing and deep breathing
o O – oral care (brush teeth, use mouthwash 2xdaily
o U – understanding (pt/staff education)
o G – getting out of bed at least 3xdaily
o H – head of bed elevation
- If pts don’t respond to first line Tx or can’t perform deep breathing exercises or other
Tx such as positive end-expiratory pressure (PEEP; simple mask and one-way valve
system that provides varying amounts of expiratory resistance; usually 10-15cm H2O)
continuous positive airway breathing, or bronchoscopy may be used
- Before moving on to more $$$/laborious measures, make sure ICOUGH has been
sufficiently executed
- If the cause of the atelectasis is bronchial obstruction from secretions, the secretions
must be removed by coughing or suctioning to allow air to reenter the affected portion
of the lung
o CPT and postural drainage may also be used to mobilize secretions
- SVN Tx w/ a bronchodilator may be used to help pts expectorate secretions
- If resp. care measures fail to remove obstruction, bronchoscopy is performed
o Although bronchoscopy is very effective, nurse MUST assist pt w/ maintaining
patency of airways using traditional techniques (deep breathing, coughing, and
suctioning) after bronchoscopy
- Severe or massive atelectasis may acute resp. failure, especially in pts w/
underlying lung Dx
o Endotracheal (ET) intubation and mechanical ventilation may be necessary
- If the cause of Dx is compression of lung tissue, the goal is to decrease the compression
o W/ a large pleural effusion that is compressing lung tissue and causing alveolar
collapse, Tx may include thoracentesis (removal of fluid by needle aspiration) or
insertion of a chest tube
o Also take measures to increase lung expansion (already typed them out)
- A closure or collapse of alveoli and often described in relation to CXR findings and
clinical S/S
o One of the most commonly found Dx on CXR
- Can be acute or chronic
- Can see microatelectasis (not detectable on CXR) to macroatelectasis w/ loss of
segmental, lobar, or overall lung volume
- Most common form of Dx is acute atelectasis
o Usually happens postop following thoracic and upper ABD procedures or in pts
who are immobile who have a shallow, monotonous breathing pattern
o Excess secretions or mucus plugs may also cause obstruction of airflow and
result in atelectasis in an area of the lung
- Also seen in pts w/ a chronic airway obstruction that impedes/blocks flow of air to an
area of the lung (obstructive atelectasis in pt w/ lung cancer that is invading or
compressing the airways)
o This form more insidious (progressive but more harmful) and slower onset
Pathophysiology
- Dx can be obstructive or nonobstructive
o Nonobstructive – occurs in adults as a result of reduced ventilation
o Obstructive – results from any blockage that impedes the passage of air to and
from the alveoli, reducing alveolar ventilation
Most common type and results from reabsorption of gas (trapped
alveolar air is absorbed into the bloodstream); no more air can enter into
the alveoli b/c of the blockage
Results in the affected portion of the lung becoming airless alveolar
collapse
- Causes of Dx include foreign body, tumor/growth in an airway, altered breathing
patterns, retained secretions, pain, alteration in small airway function, prolonged
supine positioning, increased ABD pressure, reduced lung volumes r/t musculoskeletal
or neuro disorders, and specific surgical procedures (upper ABD, thoracic, or open-heart
surgery)
- Pts at high-risk postop b/c of
o Monotonous, low tidal breathing pattern may cause small airway closure and
alveolar collapse
This can result from effects of anesthesia or analgesic agents, supine
positioning, splinting of chest wall b/c of pain, or ABD distension
o Secretion retention, airway obstructions, and an impaired cough reflex may
also occur, or pts reluctant to cough b/c of pain
- Atelectasis resulting from bronchial obstruction by secretions may also occur in pts w/
impaired cough mechanisms (musculoskeletal or neuro Dx as well as pts who are
bedbound
- May also develop b/c of excessive pressure on the lung tissue (compressive atelectasis)
which restricts normal lung expansion on inspiration
, o Excess pressure can be prod. by a pleural effusion (fluid accumulating within
the pleural space), a pneumothorax (air in pleural space), or a hemothorax
(blood in the pleural space)
Pleural space = area between the parietal and visceral pleurae; normally a
potential rather than an actual space
o Pressure may also be prod. by a pericardial effusion (pericardium distended w/
fluid), tumor growth within the thorax, or an elevated diaphragm
Clinical Manifestations
- Dx process is usually insidious (gradual but still harmful)
- S/S – increasing dyspnea (SOB), cough, and sputum production
o Tachycardia, tachypnea, pleural pain, and central cyanosis (late sign of
hypoxemia) may be anticipated (middle-late S/S)
- Pts have a harder time breathing supine; also anxious
- In acute atelectasis involving a large amount of lung tissue (lobar atelectasis), marked
resp. distress may be seen
- S/S of chronic Dx similar to acute
o Chronic alveolar collapse predisposes pts to infection distal to obstruction
o S/S of pulmonary infection may also be present
Assess/Diagnostic
- When clinically significant atelectasis develops increased effort of breathing and
hypoxemia (decreased O2 tension in arterial blood)
- Decreased breath sounds and crackles heard over affected area
, - CXR may suggest diagnosis of atelectasis before S/S appear
o CXR may show patchy infiltrates or consolidated areas
- Depending on degree of hypoxemia a pulse-ox may show low saturation of hemoglobin
***Quality Nursing – tachypnea, dyspnea, and mild-moderate hypoxemia are hallmarks of
the severity of atelectasis***
Prevention
- Frequent turning, early mobilization, and strategies to expand the lungs and to
manage secretions
o Especially change position from supine to upright to promote ventilation and
prevent secretions from accumulating
- Voluntary deep-breathing maneuvers (at least every 2hr) helps in preventing and
treating atelectasis
o Pt must be alert and cooperative
o Deep breathing & coughing to mobilize secretions and prevent from
accumulating
- Incentive spirometry or voluntary deep breathing enhances lung expansion,
decreasing potential for airway closure and may generate a cough
o Incentive spirometry is a method of deep breathing that provides visual feedback
to encourage pts to inhale slowly and deeply to maximize lung inflation and
prevent or reduce atelectasis
o Purpose is to ensure that the volume of air inhaled is increased gradually as pts
breaths get deeper and deeper
- Incentive spirometers available in 2 types – volume or flow
o Volume – the tidal volume is set using manufacturer instructions
Pt takes a deep breath through the mouthpiece, pauses at peak lung
inflation, and then relaxes and exhales
Breathe normally in between attempts to minimize fatigue
Volume is increased as tolerated
o Flow – volume is not preset
Spirometer contains balls that are pushed up by force of the breath and
held suspended in air while the pt inhales
Amount of air inhaled and flow of air are estimated by how long and how
high the balls are suspended
- Secretion management techniques include directed cough, suctioning, aerosol
nebulizer treatments followed by chest physiotherapy (CPT), and bronchoscopy
o May use pressurized metered-dose inhaler (pMDI) to give bronchodilator instead
of aerosolized, small-volume nebulizer (SVN)
CHART 19-1 – PERFORMING INCENTIVE SPIROMETRY (I remember being tested on
how to perform incentive spirometry)
Inspired air helps inflate the lungs; the ball rises in response to the intensity of the intake of air;
the deeper the breath the higher the ball goes
Instructions
, - Place pt in semi-Fowler or upright position before starting
- Use diaphragmatic breathing
- Place the mouthpiece firmly in mouth, inspire slowly through the mouth and hold the
breath at the end of inspiration for ~3sec to maintain the ball between the lines
- Exhale through the mouthpiece
- Cough during and after each session; splint the incision when coughing postop
- Perform exercise ~10 times in succession, repeating the 10 breaths with the spirometer
each hour during waking hours
Management
- Goal of Tx is to improve ventilation and remove secretions
- Prevention strategies – frequent turning, early ambulation (post-op) lung volume
expansion maneuvers (deep breathing & incentive spirometry), and coughing serve as
first line measures to minimize or treat atelectasis by improving ventilation
- ICOUGH prevention program
o I – incentive spirometry
o C – coughing and deep breathing
o O – oral care (brush teeth, use mouthwash 2xdaily
o U – understanding (pt/staff education)
o G – getting out of bed at least 3xdaily
o H – head of bed elevation
- If pts don’t respond to first line Tx or can’t perform deep breathing exercises or other
Tx such as positive end-expiratory pressure (PEEP; simple mask and one-way valve
system that provides varying amounts of expiratory resistance; usually 10-15cm H2O)
continuous positive airway breathing, or bronchoscopy may be used
- Before moving on to more $$$/laborious measures, make sure ICOUGH has been
sufficiently executed
- If the cause of the atelectasis is bronchial obstruction from secretions, the secretions
must be removed by coughing or suctioning to allow air to reenter the affected portion
of the lung
o CPT and postural drainage may also be used to mobilize secretions
- SVN Tx w/ a bronchodilator may be used to help pts expectorate secretions
- If resp. care measures fail to remove obstruction, bronchoscopy is performed
o Although bronchoscopy is very effective, nurse MUST assist pt w/ maintaining
patency of airways using traditional techniques (deep breathing, coughing, and
suctioning) after bronchoscopy
- Severe or massive atelectasis may acute resp. failure, especially in pts w/
underlying lung Dx
o Endotracheal (ET) intubation and mechanical ventilation may be necessary
- If the cause of Dx is compression of lung tissue, the goal is to decrease the compression
o W/ a large pleural effusion that is compressing lung tissue and causing alveolar
collapse, Tx may include thoracentesis (removal of fluid by needle aspiration) or
insertion of a chest tube
o Also take measures to increase lung expansion (already typed them out)
