PREVENTION AND MANAGEMENT OF ATELECTASES IN INTUBATED AND VENTILATED PATIENTS
RECOMMENDATIONS
Recommendation 1
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 When volume loss is visible on CxR a CPT package of care that includes MHI; gravity assisted positioning if
possible or modified position if contra indicated and suctioning might be initiated. This package should not be
offered less than twice daily (Krause et al 2000) but optimally might be applied hourly for six hours (Stiller et al
1996).
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Weak recommendation: Implementation of this regime provided radiographic evidence of the resolution of areas of
collaps in four RCT’s (Stiller et al 1996; Krause et al 2000; Suh-Hwa Maa 2005; Crowe et al 2006). The effect of this
outcome on LOS or TOV has not been established
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based on low quality evidence: 4 RCT’s (Stiller et al 1996; Krause et al 2000; Suh-Hwa Maa 2005; Crowe et al
2006) providing consistent results but downgraded for imprecision and moderate risk of bias (refer to table 2).
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Recommendation 2
 If kinetic therapy beds are available it might be initiated routinely for unresponsive critically ill patients admitted to
the unit.
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Weak recommendation: The prophylactic use of kinetic beds for all patients admitted to a unit resulted in lower risk
for development of ateIectasis in one RCT (Ahrens et al 2004). No effect was observed in LOS between the two
groups. It is therefore unclear whether the cost of these beds can be justified in terms of savings on LOS and TOV.
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based on moderate quality evidence: One RCT (Ahrens et al 2004) downgraded for moderate risk of bias (refer to
table 2).
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Review question: Is pulmonary physiotherapy more effective than no intervention in the prevention and or
management of lobar atelectasis in intubated and ventilated patients?
Following a systematic review of the literature; critical appraisal of identified studies; the following conclusions were
reached:
SEARCH RESULTS
 Six experimental studies were identified (Crowe et al 2006; Stiller et al 1996; Raoof et al 1999; Krause et al 2000;
Suh-Hwa Maa 2005; Ahrens et al 2004).
 The interventions evaluated include a package of MHI (Crowe et al 2006; Suh-Hwa Maa et al 2005) positioning and
suction (Stiller et al 1996 and Krause et al 2000) and kinetic therapy (Raoof et al 1999; Ahrens et al 2004).
 Five studies investigated the management of patients where atelectasis was already diagnosed (Crowe et al 2006;
Stiller et al 1996; Raoof et al 1999; Krause et al 2000; Suh-Hwa Maa 2005).
 Only one study were identified that evaluated the prevention of atelectasis (Ahrens et al 2004)
 None of the studies compared the intervention to a non intervention control.
SUMMARY OF EVIDENCE
 A package of care should include at least MHI; gravity assisted positioning (modified if contra indicated) and
suctioning in patients where volume loss is visible on CxR (Stiller et al 1996; Krause et al 2000; Suh-Hwa Maa et al
2005).
 The addition of manual techniques in the management of atelectasis is not supported at this time (Stiller et al 1996;
Raooff et al 1999)
 Patients should receive a minimum frequency of two treatment sessions daily (Krause et al 2000) with ideal
frequency hourly for at least six hours (Stiller et al 1996).
 If available, kinetic therapy could be instituted for all patients admitted to a unit to prevent atelectasis (Ahrens et al
2004).
Table 1 Summary of experimental studies identified
Studies
Internal
validity
(Pedro
Score)
7
Sample
size
Population
Intervention and comparison
Study
structure
Outcome measured
35
Patients (intubated
and non intubated) in
ICU presenting with
acute lobar
atelectasis as
observed on CxR.
Factoral
RCT
Mean percentage
resolution compared to
first picture
Raoof et
al 1999
7
24
RCT
Krause et
al 2000
7
17
Respiratory failure &
evidence of
atelectasis on X-rays
Intubated patients
lobar atelectasis as
observed on CxR
MHI; suction compared to
MHI; MPD position; vibration
and suction compared to MHI;
MPD position; suction
compared to MHI; MPD
position; suction hourly for 6
hours compared to MHI; MPD
position; suction once daily
Kinetic therapy compared to
two hourly manual turn and
percussion
PD position; vibration; suction
compared to modified PD
position; vibration; suction
Ahrens et
al 2004
Suh-Hwa
Maa
2005
Crowe et
al 2006
8
234
4
23
multicenter
RCT
multicenter
RCT
7
20
Kinetic therapy compared to
two hourly turn by nursing
MHI and standard CPT (MPD
position;vibration;suction)
compared to standard CPT
MHI (Breath stacking) and
standard CPT (MPD
position;vibration;suction)
compared to standard CPT
(MPDposition;vibration;suction)
Extent of Atelectasis
vissible on CxR
segmental; lobar etc
Number of treatments
needed for complete
resolution of
atelectasis vissible on
CxR
Atelectasis vissible on
CxR (Yes or No)
Improvement vissible
on CxR (Yes or No)
Stiller et
al 1996
Intubated GCS <11;
PaO2:FiO2 <250
>40 intubated > 7
days clinical
diagnosis atelectasis
Intubated with
unilateral or bilat
CxR diagnosis of
atelectasis
RCT
RCT
mean radiology score
based on
predetermined score
SUMMARY OF THE QUALITY OF THE EVIDENCE
All the studies included in this review accepted that some intervention (physiotherapy or positional changes) is
indicated for the management of intubated patients in ICU.
A modified postural drainage position (MPD) was used in four RCT’s evaluating specific CPT techniques (Crowe et al
2006; Stiller et al 1996; Krause et al 2000; Suh-Hwa Maa 2005). One RCT reported a more rapid resolution when
using a gravity assisted drainage position compared to the standard (Krause et al 2000). The quality of this evidence is
downgraded to low quality due to methodological quality and imprecision of data and sample (refer to table 2).
The addition of MHI to a standard protocol of position and suction was specifically investigated in 3 RCT’s (Crowe et al
2006; Stiller et al 1996; Suh-Hwa Maa 2005). Data could not be pooled because different outcomes had been
measured. The addition of MHI improved radiological evidence of atelectases in two RCT’s (Stiller et al 1996; Suh-Hwa
Maa 2005) and had no effect in one study (Crowe et al 2006). The quality of the evidence (from the two studies) is
downgraded to low quality evidence due to poor methodological quality and imprecision of data and sample (refer to
table 2).
The frequency of the physiotherapy intervention used in two RCT’s was twice daily (Crowe et al 2006; Krause et al
2000). An increased frequency of hourly intervention for 6 hours compared to a once daily intervention reported a
significant improved resolution on CxR (Stiller et al 1996). The quality of this evidence is downgraded to low quality due
to methodological quality and imprecision of data and sample (refer to table 2).
One study multicentre RCT reported a significant reduction in the incidence of atelectasis (Ahrens et al 2004). The
quality of this evidence is downgraded to moderate quality for methodological quality (refer to table 2).
Table 2 Factors considered in determining the quality of the evidence
Experimental
Studies
Risk of bias
Heterogeneity
Directness of evidence
Concealed
allocation
LTFO
Stiller et al
1996
No
Raoof et al
1999
Precision
ITT
Intervention
investigated
Sample
investigated
Publication Bias
Data
Sample
Yes
No
Yes
NA
Yes
Yes
Yes
Krause et al
2000
No
Yes
Yes
Yes
Yes
NA
Ahrens et al
2004
Suh-Hwa Maa
2005
No
Yes
Yes
Yes
Yes
NA
No
No
No
Yes
NA
Crowe et al
2006
Yes
Yes
Yes
Yes
No (pt
intubated >
7 days
Yes
Insufficient data
to calculate size
of treatment
effect
No OR
8.57(CI0.8387.83)
Insufficient data
to calculate size
of treatment
effect
Yes OR 0.44
(CI 0.23 – 0.85)
No OR 10.5 (CI
0.83 – 87.83)
No
Yes
No (included
intubated
and non
intubated pt)
Yes
Insufficient data
to calculate size
of treatment
effect
No
Lost to
follow up
NA
NA
No
No
Yes
No