1. Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 44 Postoperative Atelectasis Figure 44-1. Alveoli in postoperative atelectasis. A, Total alveolar collapse. B, Partial alveolar collapse. A B A B

2. Copyright © 2006 by Mosby, Inc. Slide 2 Anatomic Alterations of the Lungs  Alveoli of primary lobules (micro-atelectasis or subsegmental atelectasis)—very common  Lung segment—fairly common  Lung lobe—less common  Entire lung—rare

3. Copyright © 2006 by Mosby, Inc. Slide 3 Etiology Decreased Lung Expansion  Thoracic and upper abdominal procedures  Considered high risk for atelectasis

4. Copyright © 2006 by Mosby, Inc. Slide 4 Etiology Decreased Lung Expansion  Other precipitating factors  Anesthesia  Postoperative pain  Supine position  Obesity  Advanced age  Inadequate tidal volumes during mechanical ventilation  Malnutrition  Ascites  Diaphragmatic apraxia  The presence of a restrictive lung disorders

5. Copyright © 2006 by Mosby, Inc. Slide 5 Etiology Alveolar Degassing Atelectasis associated with airway secretions and mucus plugs  Precipitating factors  Decreased mucociliary transport  Excessive secretions  Inadequate hydration  Weak or absent cough  General anesthesia  Smoking history  Gastric aspiration  Certain preexisting conditions (e.g., chronic bronchitis, asthma)

6. Copyright © 2006 by Mosby, Inc. Slide 6 Overview of the Cardiopulmonary Clinical Manifestations Associated with POSTOPERATIVE ATELECTASIS The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Atelectasis (see Figure 9-7)—the major anatomic alterations of the lungs associated with postoperative atelectasis (see Figure 44-1)

7. Copyright © 2006 by Mosby, Inc. Slide 7 Figure 9-7. Atelectasis clinical scenario.

8. Copyright © 2006 by Mosby, Inc. Slide 8 Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

9. Copyright © 2006 by Mosby, Inc. Slide 9 Clinical Data Obtained at the Patient’s Bedside  Cyanosis  Cough, sputum production, and hemoptysis  Chest assessment findings  Increased tactile and vocal fremitus  Dull percussion note  Bronchial breath sounds  Diminished breath sounds (when mucus plugs present)  Crackles  Whispered pectoriloquy

10. Copyright © 2006 by Mosby, Inc. Slide 10 Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

11. Copyright © 2006 by Mosby, Inc. Slide 11 Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

12. Copyright © 2006 by Mosby, Inc. Slide 12 Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

13. Copyright © 2006 by Mosby, Inc. Slide 13 Clinical Data Obtained from Laboratory Tests and Special Procedures

14. Copyright © 2006 by Mosby, Inc. Slide 14 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or  FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or 

15. Copyright © 2006 by Mosby, Inc. Slide 15 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC N or     N VC IC ERV RV/TLC%    N V T RV FRC TLC N or     N VC IC ERV RV/TLC%    N

16. Copyright © 2006 by Mosby, Inc. Slide 16 Arterial Blood Gases Small or Localized Postoperative Atelectasis  Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly)  pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

17. Copyright © 2006 by Mosby, Inc. Slide 17 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

18. Copyright © 2006 by Mosby, Inc. Slide 18 Arterial Blood Gases Widespread Postoperative Atelectasis  Acute ventilatory failure with hypoxemia pH Pa CO 2 HCO 3 - Pa O 2    (Slightly)  pH Pa CO 2 HCO 3 - Pa O 2    (Slightly) 

19. Copyright © 2006 by Mosby, Inc. Slide 19 Time and Progression of Disease 100 50 30 80 0 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Acute Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Figure 4-7. PaO 2 and PaCO 2 trends during acute ventilatory failure.

20. Copyright © 2006 by Mosby, Inc. Slide 20 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2   Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2  

21. Copyright © 2006 by Mosby, Inc. Slide 21 Radiologic Findings Chest radiograph  Increased density in areas of atelectasis  Air bronchograms  Elevation of the hemidiaphragm on the affected side  Mediastinal shift toward the affected side

22. Copyright © 2006 by Mosby, Inc. Slide 22 General Management of Postoperative Atelectasis  Precipitating factors for postoperative atelectasis should be identified  High-risk patients should be monitored closely  Preventive measures should be prescribed for high-risk patients  Incentive spirometry  Chest physical therapy  Whenever possible, treatment of the underlying cause of atelectasis should be prescribed immediately

23. Copyright © 2006 by Mosby, Inc. Slide 23 General Management of Postoperative Atelectasis Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Hyperinflation therapy protocol  Mechanical ventilation protocol