ATELECTASIS

Atelectasis is the closure or collapse of alveoli.

It is usually detected by x-ray findings and other clinical signs and symptoms

Atelectasis may also be acute or chronic and may cover a broad range of pathophysiologic changes, from
microatelectasis (which is not detectable on chest x-ray) to macroatelectasis with loss of segmental,
lobar, or overall lung volume.

The most commonly described atelectasis is acute atelectasis, which occurs most often in the
postoperative setting or in people who are immobilized and have a shallow, monotonous breathing
pattern. Excess secretions or mucous plugs may also cause obstruction of airflow and result in
atelectasis in an area of the lung.

Atelectasis also is observed in patients with a chronic airway obstruction that impedes or blocks air flow
to an area of the lung (eg, obstructive atelectasis in the patient with lung cancer that is invading or
compressing the airways). This type of atelectasis is more insidious and slower in onset.

Pathophysiology

Atelectasis may occur in adults as a result of reduced ventilation or any blockage that obstructs passage
of air to and from the alveoli, thus reducing alveolar ventilation. After the trapped alveolar air is
absorbed into the bloodstream, no additional air can enter into the alveoli because of the blockage. As a
result, the affected portion of the lung becomes airless and the alveoli collapse. Possible causes are
altered breathing patterns, retained secretions, pain, alterations in small airway function, prolonged
supine positioning, increased abdominal pressure, reduced lung volumes due to musculoskeletal or
neurologic disorders, restrictive defects, and specific surgical procedures (eg, upper abdominal, thoracic,
or open heart surgery). Patients are at high risk for atelectasis postoperatively because of several
factors. A monotonous, low tidal breathing pattern may cause small airway closure and alveolar
collapse. This can result from the effects of anesthesia or analgesic agents, supine positioning, splinting
of the chest wall because of pain, or abdominal distention. Secretion retention, airway obstruction, and
an impaired cough reflex may also occur, or patients may be reluctant to cough because of pain. Figure
23-1 shows the mechanisms and consequences of acute atelectasis in postoperative patients. Atelectasis
resulting from bronchial obstruction by secretions may also occur in patients with impaired cough
mechanisms (eg, musculoskeletal or neurologic disorders) as well as in those who are debilitated and
bedridden. In addition, atelectasis may develop because of excessive pressure on the lung tissue, which
restricts normal lung expansion on in spiration. Such pressure can be produced by fluid accumulating
within the pleural space (pleural effusion), air in the pleural space (pneumothorax), or blood in the
pleural space (hemothorax). The pleural space is the area between the parietal and the visceral pleurae.
Pressure may also be produced by a pericardium distended with fluid (pericardial effusion), tumor
growth within the thorax, or an elevated diaphragm.

Clinical Manifestations

The development of atelectasis usually is insidious. Signs and symptoms include increasing dyspnea,
cough, and sputum production. In acute atelectasis involving a large amount of lung tissue (lobar
atelectasis), marked respiratory distress may be observed. In addition to the previously mentioned signs
and symptoms, tachycardia, tachypnea, pleural pain, and central cyanosis (a bluish skin hue that is a late
sign of hypoxemia) may be anticipated. Patients characteristically have difficulty breathing in the supine
position and are anxious. In chronic atelectasis, signs and symptoms are similar to those of acute
atelectasis. The chronic nature of the alveolar collapse predisposes patients to infection distal to the
obstruction. Therefore, the signs and symptoms of a pulmonary infection also may be present.

Assessment and Diagnostic Findings

When clinically significant atelectasis develops, it is generally characterized by increased work of

breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area. A
chest x-ray may suggest a diagnosis of atelectasis before clinical symptoms appear; the x-ray may reveal
patchy infiltrates or consolidated areas. Depending on the degree of hypoxemia, pulse oximetry (SpO2)
may demonstrate a low saturation of hemoglobin with oxygen (less than 90%) or a lower-than-normal
partial pressure of arterial oxygen (PaO2).

NOTE: Tachypnea, dyspnea, and mild to moderate hypoxemia are hallmarks of the severity of
atelectasis.