Chest Physical Therapy For
Acute Atelectasis
A Report On Its Effectiveness
WILLY E. HAMMON, BS,
and RICHARD J. MARTIN, MD
Key Words: Atelectasis, Physical therapy.
The term atelectasis is derived from the Greek
words "ateles" (imperfect) and "ektasis" (expansion)
and refers to a condition in which one or more
segments or lobes of the lung are collapsed. Atelectasis, or pulmonary collapse, can be caused by
compression of the lung parenchyma (such as by
increased pleural fluid or pneumothorax) or, more
often, by an obstructed airway (the result of secretions
or tumor). Atelectasis caused by retained secretions is
not an uncommon complication in both the postsurgical and the seriously ill nonsurgical patient. Although
bronchial drainage, percussion, and vibration have
been shown to be effective in reducing the incidence
of postoperative pulmonary complications,1 documentation supporting the use of these modalities in
the treatment of acute atelectasis remains sparse.2 The
purpose of this paper is to report nine episodes of
acute atelectasis in five patients and their resolution
by bronchial drainage, manual percussion, and vibration (BDPV). The technique we used to reexpand the
involved lobes is described.
Fig. 1. Case 1. Pretreatment radiograph shows complete
atelectasis of the left lung.
Case 1
A 19-year-old man with C3 quadriplegia became
diaphoretic and short of breath while recovering from
respiratory failure secondary to pneumonia of his left
lung. Physical examination revealed absent breath
sounds in the left lung and mediastinal shift to the
left. A radiograph showed complete atelectasis of the
left lung (Fig. 1). After BDPV to the involved lung,
Mr. Hammon is Director of Rehabilitative Services, Oklahoma
Memorial Hospital, 800 NE 13th St, Box 26307, Oklahoma City, OK
73190 (USA).
Dr. Martin is Assistant Professor of Medicine, Pulmonary Disease
Section, National Jewish Hospital, Denver, CO 80206.
Address correspondence to Bill Hammon.
This article was submitted November 3, 1978, and accepted June 2,
1980.
Volume 61 / Number 2, February 1981
Fig. 2. Case 1. Posttreatment radiograph indicates resolution by BDPV of atelectasis seen in Fig. 1.
productive of several mucus plugs, good breath
sounds were heard in the left lung. A follow-up
radiograph confirmed resolution of the pulmonary
collapse by this therapy (Fig. 2).
Four mornings later the patient was again
found in respiratory distress, and chest radiography
showed recurrent collapse of the left lung. Arterial
blood gases drawn at this time (with the patient
breathing 40% oxygen) revealed severe hypoxemia
(pH = 7.35, Pao2 = 44, Paco 2 = 60). The left lung
received BDPV. The posttreatment radiograph
217
was hypoxic on arrival and the initial chest radiograph showed atelectasis of the right upper and middle lobes (Fig. 3). Auscultation of the chest indicated
absent breath sounds in these lobes. A treatment
session of BDPV to the involved lobes produced 20
ml of sputum. Auscultation revealed the return of
breath sounds, and a posttreatment radiograph confirmed reexpansion of the atelectatic lobes (Fig. 4).
Two days later a midmorning chest radiograph
indicated recurrent right upper lobe collapse. A radiograph taken immediately after BDPV to the involved lobe confirmed reexpansion of the lung tissue.
Case 3
A 26-year-old woman arrived at the intensive care
unit the morning following laparotomy and repair of
her left renal artery. A radiograph showed her to have
Fig. 3. Case 2. Pretreatment radiograph shows atelec- atelectasis of the right upper lobe. After BDPV, the
follow-up radiograph showed almost complete reextasis of the right upper and middle lobes.
pansion of the involved lobe. Also, an infiltrate was
noted in the right upper lobe and left lower lobe. Two
days later a chest radiograph indicated recurrent atelectasis of the right upper and left lower lobes (Fig.
5). A BDPV treatment was done to both of the lobes,
followed by suctioning. The posttreatment radiograph
confirmed resolution of the atelectasis by the treatment (Fig. 6).
Case 4
A 60-year-old man with chronic obstructive pulmonary disease and left hemiparesis required mechanical ventilation for respiratory failure. The morning following extubation, his chest radiograph showed
infiltrates and atelectasis involving the lingula and
left lower lobe. After three BDPV treatments, the
midafternoon radiograph showed resolution of the
atelectasis. However, the patient was not treated during the night, and by the next morning had developed
Fig. 4. Case 2. Immediately following BDPV the radio- almost complete collapse of the same lung. Immedigraph shows reexpansion of the collapsed lobes seen in ately following a BDPV treatment to the involved
Fig. 3.
lobes, productive of 25 ml of sputum, a radiograph
again showed reexpansion of the left lung.
showed reexpansion of the lung, and arterial oxygenation was improved (pH = 7.37, Pao 2 = 70, Paco 2 = Case 5
55 on 40% oxygen).
A 21-year-old man with C5 quadriplegia required
mechanical ventilation for respiratory failure, secondCase 2
ary to right middle and lower lobe pneumonia. The
A 55-year-old woman was transferred to the inten- evening following extubation, a large amount of musive care unit of the hospital with a one-year history cus obstructed his upper airway, leading to a cardioof progressive muscular weakness. Two days prior to pulmonary arrest. The next morning his chest radiotransfer from another hospital she had suffered a graph showed atelectasis and pneumonia involving
respiratory arrest and was placed on a ventilator. She the right middle and lower lobes. Immediately follow-
218
PHYSICAL THERAPY
ing BDPV, a radiograph showed resolution of the
atelectasis.
The following is our approach to the treatment of
acute atelectasis by the physical therapist.
COMMENTS
These cases illustrate that the techniques of BDPV
can be very effective in resolving atelectasis caused
by retained secretions.
Our examples suggest a relationship between pneumonia and atelectasis in seriously ill patients. There
was clinical and radiographic evidence of pneumonia
prior to the development of atelectasis in six of the
nine described episodes. In all but one of the above
cases, pulmonary collapse occurred in individuals
with weakness or paralysis of the muscles of respiration. This muscular weakness greatly impaired the
strength of the patients' coughs, predisposing them to
mucus plugging and atelectasis. In cases 1 and 5, these
complications proved to be life threatening. Also,
these patients are at risk to develop recurrent atelectasis, as did four of the examples.
It appears that an acute pneumonia in individuals
with weakened or paralyzed respiratory muscles
places them at significant risk for developing atelectasis. They should be treated vigorously, receiving
BDPV every four hours, with emphasis given to the
lobes involved with the atelectasis or pneumonia.
This treatment should be continued for at least three
or four days, to reduce the potential for recurrent
atelectasis. One study using BDPV, combined with
deep breathing exercise and incentive spirometry every four hours, reduced the mortality rate from respiratory failure in patients with acute quadriplegia
from 41 percent to 0 percent.3 Such a treatment
regimen seems justified not only in patients with
paralysis, but those with weakened respiratory muscles as well.
Physicians not aware of the effectiveness of BDPV
will often first request that fiberoptic bronchoscopy
be performed to treat the acute atelectasis. However,
a recent study found aggressive respiratory therapy
and BDPV to be as effective as fiberoptic bronchoscopy in the resolution of acute atelectasis.2 Further,
pulmonary collapse did not recur or advance in the
group of patients that received respiratory therapy
and BDPV every four hours.
When a patient develops acute atelectasis at our
hospital, the chest physical therapist is called. If the
patient does not improve with one or two treatments
and he is experiencing significant respiratory distress,
then he may undergo a bronchoscopy. However, because of the expense of the procedure, the limited
availability of bronchoscopists, and the transient hypoxemia encountered during the procedure, we believe that a bronchoscopy should not be routinely
performed prior to a trial of BDPV.
Volume 61 / Number 2, February 1981
Chart Examination
Examine the medical chart to determine the patient's underlying medical conditions. Note specific
lobes of the lung that are involved with pneumonia
or atelectasis, according to the chest radiograph reports. Determine if there are any contraindications or
precautions that should be taken when doing the
requested treatment.
Chest Radiograph Examination
In many hospitals, it takes several hours for
the chest radiograph interpretation to be written
Fig. 5. Case 3. Pretreatment radiograph shows atelectasis of the right upper and left lower lobes.
Fig. 6. Case 3. Reexpansion of the atelectatic lobes seen
in Fig. 5 after BDPV. An infiltrate can be seen in the right
upper lobe.
219
and posted in the medical chart. Ideally, you
should be able to examine this chest radiograph to
visualize the area of involvement. Making mental
notes of anatomical landmarks and their relation to
the atelectatic lobe is useful for identifying the precise
area on which to concentrate percussion and vibration.
Patient Explanation
Explain to the patient the treatment his physician
has requested to help clear his lungs of "congestion"
or "phlegm." Tell him the importance of proper
positioning, what percussion and vibration are, what
the treatment will feel like, and about how long the
treatment will take.
Physical Examination of the Chest
Check for symmetrical blateral expansion of the
chest. Usually the patient with atelectasis has diminished chest movement over the involved lobe. Auscultation of the chest is very useful to establish a baseline before treatment, because the involved lung tissue
will have absent breath sounds. During the treatment,
the expectoration of sputum and the return of breath
sounds to the involved lobe are reliable signs that
your efforts have been successful.
Patient Positioning
Assist the patient in assuming the most ideal
drainage position for his involved lobe,4 being
certain all attached lines and tubes have sufficient
slack.
Percussion and Vibration
Percuss over the involved lobe at a rate of about
100/min for four minutes. Then ask the patient to
take a deep breath and do the vibration as he exhales.
Repeat this procedure for six consecutive breaths. If
the patient is being mechanically ventilated, you can
deliver a deeper breath by triggering the "sigh" button
on the machine. Then do the vibration as the patient
exhales and before the therapist triggers another
"sigh." This series of percussion and vibration continues until auscultation of the involved lobe reveals the
return of breath sounds, usually within 10 minutes.
Patient's Tolerance to Treatment
Although patients infrequently manifest signs of
poor tolerance to treatment, it is important that the
therapist be alert to recognize them. When present,
they usually occur in more seriously ill patients. They
are almost always associated with the Trendelen-
220
burg's position and the treatment of the middle lobe,
lingula, or lower lobes.
Cardiac arrhythmias may be one of the first indications of poor tolerance to treatment. Hence, it is
important to observe the cardiac monitor of seriously
ill patients to determine the pretreatment heart rate
and rhythm. During BDPV, note any abnormal or
increase in abnormal heart rhythms that represent a
change from the base-line. A second indication we
have observed on occasion is that some critically ill
patients receiving BDPV have a worrisome and unexplained fall in arterial oxygen level.5 Patients experiencing these signs of poor tolerance to treatment often
complain of irregular or increased heart rate, orthopnea, or shortness of breath. If these persist, it may be
advisable to modify or end the treatment. Useful
modifications for patients in the Trendelenburg's position are 1) to lower the foot of the bed to an almost
horizontal position or 2) to seek authorization to
increase temporarily the percentage of oxygen delivered to the patient during BDPV. If these measures
are not effective, it may be best to terminate the
treatment and confer with the referring physician
before treating the patient again.
Cough or Suction
Following treatment, the patient should be coughed
or suctioned to clear the airways of mucus drained
during BDPV.
CONCLUSION
The physical therapist should play an important
role in the prevention and treatment of acute atelectasis. He should be aware that in seriously ill patients,
a pneumonia frequently precedes the development of
atelectasis. This is especially true in patients with
weak or paralyzed respiratory muscles. Frequent and
aggressive BDPV focused on the area of involvement
is recommended to treat and prevent the occurrence
or recurrence of atelectasis.
REFERENCES
1. Stein M, Cassara E: Pre-operative pulmonary evaluation and
therapy for surgery patients. JAMA 211:787-790, 1970
2. Marini JJ, Pierson DJ, Hudson LD: Acute lobar atelectasis:
A prospective comparison of fiberoptic bronchoscopy and
respiratory therapy. Am Rev Respir Dis 119:971 -978,1979
3. McMichan JC, Michel L, Westbrook PR: Pulmonary dysfunction following traumatic quadriplegia: Recognition, prevention, and treatment. JAMA 243:528-531, 1980
4. Frownfelter DL: Postural drainage. In Frownfelter DL (ed):
Chest Physical Therapy and Pulmonary Rehabilitation: An
Interdisciplinary Approach. Chicago, IL, Year Book Medical
Publishers, Inc, 1978, pp 201-215
5. Connors AF, Hammon WE, Martin RJ, et al: Chest physical
therapy: The immediate effect on oxygenation in acutely ill
patients. Chest 78:559-564, 1980
PHYSICAL THERAPY