What is atelectasis?
If you do a google search on atelectasis, you’ll find that there’s all types of atelectasis and it can get real confusing real quick. Essentially atelectasis refers to a condition where the alveoli or even whole lobes (or the whole lung) are collapsed. And because you’ll likely be writing an atelectasis care plan at some point, it’s good to know how it affects your patients and how you, the nurse, can prevent it. But first, let’s start with the basics!
What are the types of atelectasis?
To start, we have obstructive atelectasis. This one is easy to remember because it is caused by…you guessed it…obstruction! This refers to the patient inhaling a foreign body (like an apricot seed, which I have seen!!!), having an obstructing tumor, or having a mucus plug (really common in patients with cystic fibrosis).
Postoperative atelectasis is likely to be the one you’ll come across the most. This is a pretty common post-op complication, especially in the first few days after surgery. It occurs because general anesthesia changes the patient’s breathing patterns which leads to impaired gas exchange. The result is that those little tiny alveoli deflate, and when they’re deflated they do not participate in gas exchange at all…you can see how this is a vicious cycle! Postoperative atelectasis also occurs due to patients not taking deep breaths after surgery, either due to pain secondary to their surgery or immobility. Your atelectasis care plan will most likely be dealing with this type, and when your instructors ask if your patient has atelectasis, this is likely the type they are talking about.
Another type of atelectasis is called non-obstructive atelectasis. Within this group there are several sub-types, but the ones you typically might see in your Med/Surg clinicals are due to pneumothorax, tumors, pleural effusions and surfactant deficiency.
Though there are a lot of different types of atelectasis, in nursing school you’ll often be talking about collapsed alveoli as a result of the patient not taking deep breaths. Maybe they had surgery, maybe they cracked a rib, or maybe they’re just in pain. So, if the patient isn’t taking deep breaths, those alveoli at the bases aren’t getting air flow. Guess what happens to them? They collapse. See, it’s all making perfect sense now!
Why do we care about a few collapsed alveoli?
Good question! When atelectasis occurs, it’s not just a few alveoli…it’s typically whole lobes or areas of the lung. And, as you recall from your A&P class, it’s that alveolar membrane that allows O2 to enter and CO2 to leave. If the alveolar membrane is collapsed or compromised in some way, we have issues with gas exchange. And that, my friend, is why we care about atelectasis! Even though it is REALLY common, doesn’t mean it’s “no big deal.” The good news is, it is often very treatable and very easy to treat at that! But first, let’s talk about who is at risk.
Who is at risk for developing atelectasis?
- Surgical patients, especially those with procedures involving the chest or abdomen
- Patients with dysphagia (high risk for aspiration here!)
- Patients receiving narcotics, which can lead to shallow breathing
- Anyone with lung disorder such as COPD or asthma
- Cystic fibrosis patients, due to the impaired cilia unable to move mucus effectively
- Patients who are in pain, especially if that pain involves the chest wall…rib fractures are a common reason patients don’t take cough to clear their lungs or take deep breaths.
- Patients with sleep apnea
- Patients who have deconditioned or weak respiratory muscles. This could be your patient who just came off the ventilator or the patient who has a neuromuscular condition such as myasthenia gravis or a spinal cord injury.
- Patients who smoke
- Older patients
- Decreased mobility, which often occurs in conjunction with post-surgical patients or those who are in weakened conditions.
- So basically, pretty much EVERYONE in the hospital (at least it certainly seems that way).
Including assessment in your atelectasis care plan
Patients with atelectasis may have no symptoms at all, but when they do show symptoms they can range from mild to severe.
- The patient may report shortness of breath
- Patient may have wheezing or a cough
- The respiratory rate can be elevated
- Breaths are typically shallow
- Upon auscultation you may hear diminished sounds in the affected area (most often the bases), and when you have the patient take a deeeeep breath you can often hear those alveoli pop back open. It sounds like very faint Rice Krispies (did you love that cereal as much as I did as a kid?)
- Your instructors may tell you that atelectasis causes a low grade fever. If that’s what they’ve told you and it’s on an exam, then go with what they’ve told you. But for your own knowledge, a study done in 1988 concluded that the presence or absence of a fever cannot signify if a patient does or does not have atelectasis. A follow-up study done in 2011 also came to the same conclusions.
What are the complications of atelectasis?
Atelectasis, though common, can have serious consequences if left untreated.
- Hypoxia: When a good number of alveoli are kicking back and not participating in gas exchange, we are at high risk for hypoxia.
- Pneumonia: With a bunch of collapsed alveoli, mucus and any other gunk in the lungs is just going to sit there and not get cleared, putting the patient at high risk for infections like pneumonia.
- And, of course, respiratory failure can occur if things get really bad.
Nursing interventions for atelectasis
When we’re talking about post-op atelectasis or atelectasis from someone not taking deep breaths or getting out of bed and moving around as they should, the remedy is usually pretty simple.
- Cough and deep breathe: If you assess your patient and you notice they are taking shallow breaths, even with or without a lower-than-expected O2 saturation, you want to have them cough and take some deep breaths. If they say their pain level is too high to do so, you’ll need to explore pain management options. This could be medication, heat, ice, positioning…don’t always assume that pain management always means narcotics! Sometimes you’d be surprised what an ice pack, pillow supports and Tylenol can accomplish!
- Ambulate: Getting patients up and moving around is going to increase their respiratory drive and help them keep their lungs inflated.
- Incentive spirometer: If you’re not familiar with this device, it’s a little contraption that patients use to practice taking full deep breaths. It looks like this.
So what would an atelectasis care plan look like?
You will likely include atelectasis in many care plans for patients, especially post-surgical ones. Here’s one way it could look:
Nursing Diagnosis: Impaired gas exchange secondary to shallow respiratory depth as evidenced by O2 saturation 88% on RA.
Nursing Interventions: Teach patient how to use incentive spirometer, pain medication to support deep breathing, ambulate 3x/day, encourage patient to cough/deep breathe, assess O2 saturation, assess lung sounds.
SMART objective: By the end of shift, O2 saturation will be > 95% on RA.
And here’s another one:
Nursing Diagnosis: Risk for infection secondary to decreased respiratory depth and immobility.
Nursing Interventions: Teach patient how to use incentive spirometer, pain medication to support deep breathing, ambulate 3x/day, encourage patient to cough/deep breathe, monitor temperature, monitor WBC, monitor chest X-ray, assess lung sounds, assess respiratory depth.
SMART objective: By post-op day 3, patient will have clear lung x-ray showing no development of pneumonia.
I hope this helps you write an atelectasis care plan or at the very least, answer a few test questions or feel more confident in clinical. Got another topic you’d love to see here? Let me know in the comments below!
Get this on audio in podcast episode 64
AMBOSS. (n.d.). Atelectasis – Knowledge for medical students and physicians. Retrieved from https://www.amboss.com/us/knowledge/Atelectasis
Mavros, M. N., Velmahos, G. C., & Falagas, M. E. (2011). Atelectasis as a Cause of Postoperative Fever: Where Is the Clinical Evidence? CHEST,140(2), 418–424. https://doi.org/10.1378/chest.11-0127
Mayo Clinic. (n.d.). Atelectasis Symptoms and causes, Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/atelectasis/symptoms-causes/syc-20369684
National Heart, Lung, and Blood Institute. (n.d.). Atelectasis. Retrieved from https://www.nhlbi.nih.gov/health-topics/atelectasis
Roberts, J., Barnes, W., Pennock, M., & Browne, G. (1988, March 17). Diagnostic accuracy of fever as a measure of postoperative pulmonary complications. PubMed NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/3350683