Efficacy of selective intrabronchial air insufflation in acute lobar collapse

doi:10.1016/S0002-9610(05)81189-4

The American Journal of Surgery

Volume 164, Issue 5, November 1992, Pages 501-505

https://doi.org/10.1016/S0002-9610(05)81189-4 Get rights and content

Flexible fiberoptic bronchoscopy (FFB) to remove mucous plugs followed by selective intrabronchial air insufflation (SII) to expand the atelectatic lung was used in 17 surgical intensive care unit (SICU) patients with pulmonary lobar collapse. Thirteen patients were admitted for acute trauma, and the remainder were elderly postoperative patients. Lobar collapses occurred on SICU days 1 to 18 (mean±SEM: 5±1 days), and duration ranged from 4 to 258 hours (mean: 77±18 hours). Indications for FFB with SII included critical hypoxemia in 5 patients, worsening collapse in 2, and failure to respond to aggressive respiratory care in 10 (59%). FFB with SII was effective in 14 (82%) patients: 10 achieved full lung re-expansion, and 4 partial lung re-expansion. When lobar collapse was of less than 72 hours' duration, 92% (12 of 13) of patients had lungs re-expanded compared with 50% (2 of 4) whose collapse existed for more than 72 hours. The mean Pao₂/Flo₂ (fraction inspired oxygen) ratio was 135±18 prior to FFB with SII and increased to 205±21 after FFB with SII. Complications were minor and clinically insignificant. In conclusion, SII appears to be a simple, safe, effective adjunct to FFB in the treatment of SICU patients with pulmonary lobar collapse.

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Acute Lobar Atelectasis
2019, Chest
Citation Excerpt :
Well-established atelectasis often proves refractory to quick re-expansion, even after the blocked passage has been cleared. Aggressive instrumentation that selectively occludes the involved airway and sustains a high regional airway inflation pressure that meets or exceeds those associated with total lung capacity may reverse atelectasis, with variable impact on gas exchange.102-107 The indications that mandate such aggressive measures and the relative safety of such maneuvers have not been convincingly delineated or verified.
Lobar atelectasis (or collapse) is an exceedingly common, rather predictable, and potentially pathogenic companion to many forms of acute illness, postoperative care, and chronic debility. Readily diagnosed by using routine chest imaging and bedside ultrasound, the consequences from lobar collapse may be minor or serious, depending on extent, mechanism, patient vulnerability, abruptness of onset, effectiveness of hypoxic vasoconstriction, and compensatory reserves. Measures taken to reduce secretion burden, assure adequate secretion clearance, maintain upright positioning, reverse lung compression, and sustain lung expansion accord with a logical physiologic rationale. Both classification and logical approaches to prophylaxis and treatment of lobar atelectasis derive from a sound mechanistic knowledge of its causation.
Blunt Thoracic Trauma
2008, Mechanical Ventilation: Clinical Applications and Pathophysiology
Selective lobar collapse for video-assisted thoracic surgery
2004, Annals of Thoracic Surgery
Citation Excerpt :
As previously noted, we sustain a positive pressure inspiratory hold through the endotracheal tube to both lungs after each procedure to reduce residual pleural air and postoperative atelectasis. We have thus far not explored the possibility of introducing air or oxygen through our suction catheter at positive pressures to selectively reexpand the target lobe although a similar selective intrabronchial air insufflation procedure has been previously reported to reduce pulmonary lobar collapse after chest trauma or surgery [13]. A potential pitfall of our technique is that the suction catheter does not necessarily achieve an airtight occlusion of the target lobar bronchus (compared for example with the Fogarty balloon technique).
Video-assisted thoracic surgery (VATS) is conventionally performed under single-lung ventilation. A small proportion of patients are often excluded from undergoing VATS because of their inability to tolerate single-lung ventilation. We describe a simple technique of selective lobar lung collapse that may help to recruit additional, selected patients for VATS.
We use a standard suction catheter placed under bronchoscopic guidance to the target lobar bronchus through a single-lumen endotracheal tube. The catheter is left open to air, or suction can be applied to facilitate lobar collapse. The remaining lobe of the same lung can be ventilated throughout surgery. Surgery is performed using standard VATS techniques.
Using this technique we have successfully performed VATS on 63 chest sides in 35 patients. The procedures performed included thoracodorsal sympathectomies (n = 28), mechanical pleurodesis procedures (n = 3), mediastinal and pleural biopsies (n = 2), and lung wedge resections (n = 2). We encountered no mortality or morbidity in all cases.
This technique is simple and safe and requires no expensive disposable devices. Although not essential for most patients undergoing VATS, it deserves to be in the armamentarium of the thoracic surgeon. Further studies will be required to better define its application in clinical practice.
Bronchoscopy for atelectasis in the ICU: A case report and review of the literature
2003, Chest
Citation Excerpt :
This procedure was utilized in two other studies with equally good success. Haenel et al11 used a similar apparatus to deliver oxygen-enriched gas to a pressure of 40 cm H2O. They noted partial or complete reexpansion in 14 of their 17 patients (82%).
Fiberoptic bronchoscopy has become a commonplace procedure in ICUs. Despite the fact that one of the most common indications for bronchoscopy is the presence of retained secretions and atelectasis, there is little research dedicated to its safety and utility in this clinical situation. This article presents a case of an intubated trauma victim who had undergone numerous bronchoscopic procedures, with varying degrees of success, for retained secretions and atelectasis. This review then seeks to answer the following three main questions regarding bronchoscopy in critically ill patients: (1) Is bronchoscopy effective in resolving atelectasis? (2) Is bronchoscopy superior to other means of resolving atelectasis? (3) Is bronchoscopy safe in critically ill patients? The patient was a 28-year-old man with no significant medical history who presented to the emergency department after his car was hit by a dump truck. He was found to have multiple leg fractures and a splenic rupture, and he was taken to the operating room for an exploratory laparotomy, splenectomy, and reduction of his fractures. He was then brought to the surgical ICU intubated, sedated, and receiving mechanical ventilation. Over the next 6 h, he developed progressive hypoxemia and diffuse, bilateral alveolar infiltrates on a chest radiograph (CXR). Four days postoperatively, a routine CXR revealed total atelectasis of his right upper lobe (RUL). Emergent bronchoscopy was performed, and a large mucus plug obscuring the RUL bronchus was removed. Follow-up CXR demonstrated resolution of the atelectasis. The next day, RUL atelectasis was again seen on his CXR. A repeat bronchoscopic examination and BAL failed to reveal any plug. A follow-up CXR showed continued atelectasis. Over the next week, the patient underwent daily bronchoscopy for atelectasis with variable degrees of improvement. Over the next 3 weeks, his pulmonary status improved until he was eventually extubated, and 1 month after hospital admission he was discharged to rehabilitation.
Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients
1999, Chest
Some critically ill patients have difficulty in mobilizing their respiratory secretions. These patients can develop pulmonary atelectasis that may result in hypoxemia. There are some data to show that atelectasis may be prevented by turning a patient from side to side utilizing special beds.
To determine the role of kinetic therapy (KT) combined with mechanical percussion (P) in the resolution of established atelectasis of the lungs and hypoxemia in critically ill, hospitalized patients. (KT was defined as rotation of a patient along the longitudinal axis of ≥ 40° to each side continuously.)
Prospective and randomized study (2:1 test to control group).
Twenty-four patients with respiratory failure, either mechanically ventilated or spontaneously breathing, who demonstrated segmental, lobar, or unilateral entire lung atelectasis were studied.
Medical ICU and adult respiratory ward in a county hospital in New York.
Seventeen patients were treated with KT combined with mechanical P using a KT system (Triadyne Kinetic Therapy System; KCI; San Antonio, TX). Seven patients received manual repositioning and manual P every 2 h. Both groups received similar conventional therapy with inhaled bronchodilators and suctioning.
Partial or complete resolution of atelectasis was seen in 14 of 17 patients (82.3%) in the test group as compared with 1 of 7 patient (14.3%) in the control group. The median duration to resolution of atelectasis was 4 days in the test group. Bronchoscopy was performed in 3 of 7 patients in the control group, but in none of the patients in the test group. A cost of $720 was incurred per patient for utilizing the specialty beds for a mean duration of 4 days. An improvement in oxygenation index occurred in the test group (change in baseline Pao₂/fraction of inspired oxygen from 207.4 ± 106.7 mm Hg to 318 ± 100.7 mm Hg) at the end of therapy, while the control group showed a reduction over a similar duration of time (181.3 ± 96.3 mm Hg to 112 ± 21.2 mm Hg).
KT and mechanical P therapy resulted in significantly greater partial or complete resolution of atelectasis as compared with conventional therapy. There was a generalized trend toward statistical significance in the improvement of oxygenation and a reduced need for bronchoscopy in the group receiving KT and P therapy.
Aspiration-induced lung injury
2011, Critical Care Medicine
Citation Excerpt :
Hence, routine bronchoscopy with lavage is not indicated. However, in the event that the aspirate is predominantly particulate in nature with clear radiographic evidence of lobar collapse or major atelectasis, therapeutic bronchoscopy is helpful (64). The other major advantage of bronchoscopy is the sampling of the lower respiratory tract.
Aspiration of oropharyngeal or gastric contents into the lower respiratory tract is a common event in critically ill patients and can lead to pneumonia or pneumonitis. Aspiration pneumonia is the leading cause of pneumonia in the intensive care unit and is one of the leading risk factors for acute lung injury and acute respiratory distress syndromes. Despite its frequency, it remains largely a disease of exclusion characterized by ill-defined infiltrates on the chest radiograph and hypoxia. An accurate ability to diagnose aspiration is paramount because different modalities of therapy, if applied early and selectively, could change the course of the disease. This article reviews definitions, diagnosis, epidemiology, pathophysiology, including animal models of aspiration-induced lung injury, and evidence-based clinical management. Additionally, a review of current and potential biomarkers that have been tested clinically in humans is provided.
Data were obtained from a PubMed search of the medical literature. PubMed “related articles” search strategies were used.
Aspiration in the intensive care unit is a clinically relevant problem requiring expertise and awareness. A definitive diagnosis of aspiration pneumonitis or pneumonia is challenging to make. Advances in specific biomarker profiles and prediction models may enhance the diagnosis and prognosis of clinical aspiration syndromes. Evidence-based management is supportive, including mechanical ventilation, bronchoscopy for particulate aspiration, consideration of empiric antibiotics for pneumonia treatment, and lower respiratory tract sampling to define pathogenic bacteria that are causative.

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^*: Presented at the 44th Annual Meeting of the Southwestern Surgical Congress, Scottsdale, Arizona, April 26–29, 1992.

¹: From the Department of Surgery, Denver General Hospital, University of Colorado Health Science Center, Denver, Colorado.

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Efficacy of selective intrabronchial air insufflation in acute lobar collapse*

Chest

Ann Thorac Surg

Chest

Chest

Ann Thorac Surg

Chest

Prevention of postoperative pulmonary complications

Surg Gynecol Obstet

Postoperative atelectasis: pathophysiology, clinical importance, and principles of management

Resp Care

Mechanical aids to lung expansion in nonintubated surgical patients

Am Rev Resp Dis

The evaluation of the incentive spirometer in the management of postoperative abdominal operations

Br J Surg

Respiratory therapy to prevent pulmonary complications of surgery

Resp Care

Flail chest/pulmonary contusion: a surgical critical care challenge