Acute Lobar Atelectasis During Mechanical Ventilation: To Beat, Suck, or Blow?

We describe a patient with lobar atelectasis who was successfully treated with airway pressure release ventilation (APRV) after failed attempts at recruitment with endotracheal suctioning, chest therapy, and bronchoscopy. We review the literature on the effectiveness of the various methods to treat lobar atelectasis. Mechanically ventilated patients have an ineffective cough refl ex and are unable to adequately deal with their respiratory sections. Atelectasis is therefore a common problem in these patients. The risk of atelectasis may be increased with the widespread use of a lung protective strategy utilizing low tidal volumes (6 ml/kg IBW). (1) Atelectasis may worsen hypoxemia through shunting and may predispose to nosocomial pneumonia. Traditionally the treatment of atelectasis in mechanically ventilated patients has centered on chest therapy (slapping, beating and vibrating) and endotracheal suctioning. (2) When this fails, bronchoscopy and/or recruitment maneuvers are attempted. (3) We describe the successful use of airway pressure release ventilation (APRV) for the treatment of atelectasis in a patient who failed the traditional treatment modalities. From the Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA, USA (Christopher Gilbert and Paul E. Marik) and The University of Texas Health Science Center at Houston, The University of Texas Medical Branch at Galveston, and St. Luke’s Episcopal Hospital, Houston, TX, USA (Joseph Varon). Address for correspondence: Paul Marik, MD, FCCP, FCCM Professor of Medicine Chief of Pulmonary and Critical Care Medicine Thomas Jefferson University 834 Walnut Street, Suite 650 Philadelphia, PA, 19107 Case Report A 58-year-old female presented to our hospital with lower extremity weakness. She was intubated and mechanically ventilated for impending respiratory failure. She was placed on assist-controlled ventilation, with a tidal volume of 7 ml/kg PBW, respiratory rate of 16 breaths/minute and a PEEP of 7.5 cmH20. The FiO2 was titrated to keep the arterial saturations greater than 92%. Physical examination revealed an obese female (BMI 48.8 kg/m2) sedated on the ventilator. Vital signs were within normal limits. Lung exam revealed near absent breath sounds and dullness to percussion on the right. A chest radiograph demonstrated right lung collapse. Computed tomography of the thorax showed right lung collapse, a “small” pleural effusion and near complete destruction of the 8th thoracic vertebral body. Chest physiotherapy, endotracheal suctioning and fi beroptic bronchoscopy were attempted without radiologic improvement. This was followed by a recruitment maneuver (performed on the ventilator) followed by chest physiotherapy and suctioning again without success (Figure 1). The patient was then placed on APRV (approximately 24 hours following the failed bronchoscopy). We utilized a pressure high of 20 cmH2O, pressure low of 5 cmH2O, time low of 1 second, a respiratory rate of 14 and FiO2 of 50%. Signifi cant improvement in the chest radiograph was apparent from the chest radiograph obtained approximately four hours after the ventilator change (Figure 2). The patient subsequently underwent anterior spinal fusion with placement of a right sided chest tube.