Category: Lung

DISCUSSION

Collapsed lung is one of the important problems in critically ill patients, and the clinical condition may worsen rapidly. Treatment with a therapeutic fiber­optic bronchoscopic procedure at the bedside was introduced and good results were reported in many studies. This therapeutic procedure includes repet­itive sputum suctioning and bronchial washing with normal saline solution; complete or partial re-expan­sion of atelectasis was attained in 60 to 90 percent of the cases.

When the lung volume decreases, the alveolar radius will decrease and the alveolar pressure rise according to Laplace relationship: Рт = 2 T/r (Рт-alveolar pres­sure, T-alveolar surface tension, r-alveolar radius). In these conditions, the surfactant will work to lower the alveolar surface tension; this reduction in surface tension offsets the reduction in alveolar radius and prevents alveolar pressure from rising. But if the atelectasis is profound, the reduction in surface ten­sion can not overcome the reduction in alveolar radius, and the alveolar pressure will rise and create a higher critical opening pressure in the atelectatic alveoli and lower lung compliance. The above findings are espe­cially common in cases with a small area of collapse. In these cases, the transpulmonary pressure of the atelectatic alveoli is often too low to overcome the critical pressure. These refractory atelectasis do not easily re-expand even after the above broncho­scopic procedures. It would be useful if we could introduce positive pressure ventilation directly into the collapsed area to overcome the critical opening pressure. But if we can not sufflate the air directly into the atelectatic alveoli, the insufflated air will tend to be distributed into the noncollapsed areas because of lower airway resistance and higher lung compliance. This will result in a hyperinflated normal lung area which in turn will compress the collapsed area.

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After 12 of the 14 procedures, the chest x-ray film showed complete reexpansion; in the remaining two, case 5 and the secondary procedure in case 12, the x-ray film showed partial re-expansion. In case 5 the collapsed lung reexpanded completely after six days of continuous, intensive, pulmonary care. In case 12, a third bronchoscopic procedure was performed with immediate full re-expansion (Table 1).

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Twelve patients were admitted to the medical or surgical ICU for the different critical conditions (Table 1). The duration of lung collapse ranged from 24 to 120 hours. All had received intensive respiratory care since admission to prevent atelectasis. When the lung collapsed, another 24 hours of respiratory therapy was per­formed before the fiberoptic bronchoscope procedure.

A fiberoptic bronchoscope was used. A three-way adaptor was connected to the suction channel of the bronchoscope. One port was used to introduce room air by Ambu bag, the other port was connected to a pressure gauge to monitor the peripheral airway pressure during air insufflation (Fig 1).

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Treatment for Collapsed Lung in Critically III Patients

Collapsed lung is a common problem in critically ill patients. Although respiratory therapy is a pri­mary and effective method of treatment, it is not suitable for some patients, such as those with rib fractures, hemothorax, or pneumothorax. Other pa­tients are too critical to wait for the results of repetitive respiratory care or cannot tolerate vigorous therapy. In 1973, a bedside procedure was introduced to re- expand the collapsed lung using a fiberoptic broncho­scope.1 This procedure includes repetitive sputum suctioning and bronchial washing with normal saline solution. Although most of the lung collapse was re- expanded with the above procedure, some were re­fractory. This may be due to a lower lung compliance and higher critical opening pressure in the collapsed lung. If the collapse is left untreated it may become chronic and a secondary infection may occur.

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