Atelectasis

Prepared by zeyad H. Al kahlout. (BSN, RN, MPH)

Definition:
Atelectasis is a condition in which one or more areas of your lungs collapse or don't inflate properly. If only a small area or a few small areas of the lungs are affected, you may have no signs or symptoms. If a large area or several large areas of the lungs are affected, they may not be able to deliver enough oxygen to your blood. This can cause symptoms and complications.

Overview
To understand atelectasis, it helps to understand how the lungs work. Your lungs are organs in your chest that allow your body to take in oxygen from the air. They also help remove carbon dioxide (a waste gas that can be toxic) from your body. When you breathe, air passes through your nose and mouth into your windpipe. The air then travels to your lungs' air sacs. These sacs are called alveoli. Small blood vessels called capillaries run through the walls of the air sacs. When air reaches the air sacs, the oxygen in the air passes through the air sac walls into the blood in the capillaries. At the same time, carbon dioxide moves from the capillaries into the air sacs. This process is called gas exchange. The air sacs must remain open and filled with air for this process to work right. Surfactant, a liquid that coats the inside of the lungs, helps the air sacs stay open. Deep breathing and coughing also help keep the air sacs open. (Coughing helps clear mucus and other substances from your airways.) In atelectasis, part of the lung collapses or doesn't inflate. The air sacs in that part of the lung are no longer filled with air. As a result, they can't take part in gas exchange.

If only a small area or a few small areas of the lungs are affected, you may have no signs or symptoms. This is because the rest of the lung can bring in enough oxygen to make up for the collapsed part of the lung. If atelectasis affects a large area or several large areas of the lungs, your body's organs and tissues may not get enough oxygen-rich blood. Conditions and factors that keep the lungs from properly expanding and filling with air can cause atelectasis. For example, atelectasis is very common after surgery. The medicine used during surgery to temporarily put you to sleep can decrease or stop your normal effort to breathe and urge to cough. Sometimes, especially after chest or abdominal surgery, pain may keep you from wanting to take deep breaths. As a result, part of your lungs may collapse or not inflate right.

Outlook The outlook for atelectasis depends on its cause. In adults, atelectasis often is short term. The collapsed air sacs slowly refill with air once the cause of the atelectasis is resolved. If atelectasis persists, it may prevent the lung from properly clearing mucus. This can lead to infections (such as pneumonia). Atelectasis usually isn't life threatening. However, if it affects a large area of the lungsespecially in a baby, small child, or someone who has another lung disease or illnessit can be fatal if not treated quickly.

Other Names for Atelectasis

Closed lung Partial lung collapse

Causes:
If the lungs can't properly expand and fill with air, atelectasis may occur. Atelectasis has a number of causes. Conditions and Factors That Prevent Deep Breathing and Coughing Conditions and factors that prevent deep breathing and coughing can cause atelectasis. For example, if you're taking shallow breaths or breathing with the help of a ventilator, your lungs don't fill with air in the normal way. Normally, when you take a deep breath, the base (bottom) and the back of your lungs fill with air first. However, if you're taking shallow breaths or using a ventilator, air may not make it all the way to the air sacs at the bottom of your lungs. Thus, these air sacs won't inflate properly. Atelectasis is very common after surgery. The medicine used during surgery to temporarily put you to sleep can decrease or stop your normal effort to breathe and urge to cough. Sometimes, especially after chest or abdominal surgery, pain may keep 3

you from wanting to take deep breaths. As a result, part of your lung may collapse or not inflate right. Pressure from outside the lungs also may make it hard to take deep breaths. A number of factors can cause pressure outside the lungs. Examples include a tumor, a tight body cast, a bone deformity, or pleural effusion (fluid buildup between the ribs and the lungs). Lung conditions and other medical disorders that affect your ability to breathe deeply or cough and clear mucus from your lungs also may lead to atelectasis. One example is respiratory distress syndrome (RDS). RDS is a breathing disorder that affects some newborns. It's more common in premature infants because their lungs aren't able to make enough surfactant. Surfactant is a liquid that coats the inside of the lungs and helps keep the air sacs open. Without enough surfactant, part of the lungs may collapse. Other lung conditions and medical disorders that can cause atelectasis include pneumonia, lung cancer, and neuromuscular diseases. Rarely, asthma, COPD (chronic obstructive pulmonary disease), and cystic fibrosis are associated with atelectasis. Migrating atelectasis in newborns is rare and may be caused by neuromuscular diseases. Migrating means that the part of the lung that collapses will change depending on the position of the baby. An Airway Blockage An airway blockage also can cause atelectasis. A blockage may be due to a foreign object (such as an inhaled peanut), a mucus plug, lung cancer, or a poorly placed breathing tube from a ventilator. When a blockage occurs, the air that's already in the air sacs is absorbed into the bloodstream. New air can't get past the blockage to refill the air sacs, so the affected area of lung deflates.

Risky people:
You may be at risk for atelectasis if you're unable to take deep breaths or cough. You also may be at risk if you have a blockage in your airway. Conditions that can increase your risk of developing atelectasis include:

Surgery in which you're given medicine to temporarily put you to sleep. This medicine can decrease or stop your normal effort to breathe and urge to cough.

Any condition or factor that causes pain when you breathe. Examples include surgery on your chest or abdomen, trauma, broken ribs, or pleurisy (inflammation of the membrane that surrounds your lungs and lines your chest cavity).

Being on a ventilator. A blockage in your airway from a foreign object, a mucus plug, lung cancer, or a poorly placed breathing tube.

Lung conditions and other medical disorders that affect your ability to breathe deeply or cough. Examples include respiratory distress syndrome, pneumonia, lung cancer, and neuromuscular diseases. Rarely, asthma, COPD (chronic obstructive pulmonary disease), and cystic fibrosis are associated with atelectasis.

People who have one of the conditions above and who smoke or are obese are at greater risk for atelectasis than people who don't smoke and aren't obese. Infants and toddlers (aged 13 years old) who have risk factors for atelectasis seem to develop the condition more easily than adults.

Signs and symptoms:

If only a small area of lung is affected, atelectasis likely won't cause signs or symptoms. If atelectasis affects a large area of lung, especially if it occurs suddenly, it may cause a low level of oxygen in your blood.

As a result, you may feel short of breath. Your heart rate and breathing rate may increase, and your skin and lips may turn blue. Other symptoms may be related to the underlying cause of the atelectasis (for example, chest pain due to surgery). If your child has atelectasis, you may notice that he or she seems agitated, anxious, or scared.

Diagnosis:
Atelectasis is diagnosed based on your signs and symptoms and the results from tests and procedures. Often, atelectasis is detected by chest x rays done for an underlying lung condition. Atelectasis usually is diagnosed by a radiologist, pulmonologist (lung specialist), emergency medicine physician, or a primary care doctor (such as a pediatrician, internal medicine specialist, or family practitioner). Diagnostic Tests and Procedures The most common test used to diagnose atelectasis is a chest x ray. A chest x ray is a painless test that creates pictures of the structures inside your chest, such as your heart, lungs, and blood vessels. Your doctor also may recommend a chest computed tomography scan, or chest CT scan. This test creates precise images of the structures in your chest. A chest CT scan is a type of x ray. However, the pictures from a chest CT scan show more details than pictures from a standard chest x ray. Atelectasis often resolves without treatment. But if the condition is severe or lasts a long time and your doctor thinks it's caused by an airway blockage, he or she may use bronchoscopy. This is a procedure used to look inside your airway. During the procedure, your doctor passes a thin, flexible tube called a bronchoscope through your nose (or sometimes your mouth), down your throat, and into your

airway. If you have a breathing tube, the bronchoscope can be passed through the tube to your airway. A light and small camera on the bronchoscope allow your doctor to see inside your airway so he or she can remove blockages.

Treatment:
The main goals of treating atelectasis are to treat the cause of the condition and to reexpand the collapsed lung tissue. Treatment may vary based on the underlying cause of the atelectasis. Atelectasis Caused by Surgery If atelectasis is caused by surgery, your doctor may recommend that you take the following steps to fully expand your lungs:

Perform deep breathing exercises. This is very important after surgery. While in the hospital, you may use a device called an incentive spirometer. This device measures how much air you're breathing in and how fast you're breathing in. Using this device encourages you to breathe in deeply and slowly.

Change your position. Sit up or walk around as soon as possible after surgery with your doctor's permission.

Make an effort to cough. Coughing helps clear mucus and other substances from your airways.

Your doctor also may suggest using positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). Both devices use mild air pressure to help keep the airways and air sacs open. Atelectasis Caused by Pressure From Outside the Lungs If pressure from outside the lungs causes atelectasis, your doctor will treat the cause of the pressure. For example, if the cause is a tumor or fluid buildup, your doctor will remove the tumor or fluid. This will allow your lung to fully expand.

Atelectasis Caused by a Blockage If a blockage causes atelectasis, you'll receive treatment to remove the blockage or relieve it. If the blockage is from an inhaled object, such as a peanut, your doctor will remove it during bronchoscopy. (For more information, go to How Is Atelectasis Diagnosed?) If a mucus plug is blocking your airways, your doctor may use suction to remove it. Other treatments also can help clear excess mucus from the lungs, such as:

Chest clapping or percussion. This treatment involves pounding your chest and back over and over with your hands or a device to loosen the mucus from your lungs so you can cough it up.

Postural drainage. For this treatment, your bed may be tilted so that your head is lower than your chest. This allows mucus to drain more easily.

Medicines. Your doctor may prescribe medicines to help open your airways or to loosen mucus.

Atelectasis Caused by a Lung Condition or Other Medical Disorder If a lung condition or other medical disorder causes atelectasis, your doctor will treat the underlying cause with medicines, procedures, or other therapies.

Prevention:
People who smoke and are scheduled to have surgery can lower their risk of atelectasis by not smoking before the surgery. Talk with your doctor about how far in advance of your surgery you should quit smoking. After surgery, your doctor may recommend that you take the following steps to fully expand your lungs:

Perform deep breathing exercises. This is very important after surgery. While in the hospital, you may use a device called an incentive spirometer. This device measures how much air you're breathing in and how fast you're

breathing in. Using this device encourages you to breathe in deeply and slowly.

Change your position. Sit up or walk around as soon as possible after surgery with your doctor's permission.

Make an effort to cough. Coughing helps clear mucus and other substances from your airways.

If deep breathing is painful, your doctor may prescribe medicines to control the pain. This may make it easier for you to take deep breaths and fully expand your lungs. Your doctor also may suggest using positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). Both devices use mild air pressure to help keep the airways and air sacs open.