Prevention and Management of Postoperative Atelectasis

Causes and Risk Factors

Surgery, anesthesia, and postoperative pain have deleterious effects on the respiratory system, causing hypoxemia, decreased lung volume, and atelectasis due to diaphragm dysfunction, as reported by the European Respiratory Society 1
Diaphragm dysfunction may persist for up to 7 days after surgery, leading to significant deterioration in arterial oxygenation, according to the European Respiratory Society 1

The British Journal of Anaesthesia recommends applying protective ventilation during surgery with tidal volumes of 6 mL/kg, PEEP, and alveolar recruitment maneuvers to prevent atelectasis 2
The British Journal of Anaesthesia suggests avoiding zero end-expiratory pressure (ZEEP) during induction and emergence from anesthesia 2
The World Journal of Emergency Surgery recommends positioning patients in a head-elevated, semi-seated position to prevent further development of atelectasis and improve oxygenation 3
The Anaesthesia society recommends removing chest tubes, urinary catheters, and arterial/venous catheters as early as possible to facilitate early mobilization 4
The MMWR Recommendations and Reports suggest providing adequate pain control to enable effective breathing exercises and coughing 5

The Anaesthesia society recommends implementing a postoperative multimodal physiotherapy program combining at least three components, including early mobilization, breathing exercises, and bronchial drainage and coughing techniques 6
The Anaesthesia society suggests starting physiotherapy interventions as early as the first postoperative day 4
The World Journal of Emergency Surgery recommends considering CPAP or non-invasive positive pressure ventilation (NIPPV) for patients with postoperative desaturation (SpO₂ <90%) despite supplemental oxygen 3
The European Respiratory Journal suggests using CPAP with caution in patients with hypoxemia, as it may increase the duration and time to detection of apnea/hypopnea 1

The Anaesthesia society recommends considering preoperative prehabilitation programs for high-risk patients (COPD GOLD 3, patients >75 years) 6
The World Journal of Emergency Surgery reports that obese patients are at higher risk for perioperative atelectasis that persists longer compared to normal-weight patients 3
The MMWR Recommendations and Reports suggest that patients undergoing upper abdominal or thoracic surgery are at increased risk due to diaphragmatic dysfunction 5

The European Respiratory Journal reports that CPAP of 10 cm H₂O after thoracoabdominal surgery reduces postoperative pulmonary complications and decreases ICU and hospital stay 1

Supine positioning during anesthesia induction causes cephalad displacement of abdominal contents, forcing the diaphragm upward and compressing dependent lung regions, particularly pronounced in obese patients, according to the British Journal of Anaesthesia 7
Surgical factors, including laparoscopic procedures, thoracic surgery, upper abdominal surgery, pneumoperitoneum insufflation, and prone or Trendelenburg positioning, worsen compression atelectasis, as reported by the British Journal of Anaesthesia and the Annals of Internal Medicine 7, 8

Advanced age (>50 years), BMI >40 kg/m², and ASA class >2 are significant risk factors for postoperative atelectasis, according to the British Journal of Anaesthesia 7
Emergency or urgent surgery increases the risk substantially, as reported by the Annals of Internal Medicine and the World Journal of Emergency Surgery 8, 9
Prolonged surgery (>3 hours), particularly abdominal, thoracic, neurosurgery, head and neck, or vascular procedures, is a risk factor, according to the Annals of Internal Medicine 8
Low serum albumin (<35 g/L) is a powerful marker of increased risk, as reported by the Annals of Internal Medicine 8

The formation of perioperative clinically significant atelectasis is an important risk factor for development of postoperative pulmonary complications, including pneumonia, respiratory failure, and exacerbation of chronic lung disease, as reported by the British Journal of Anaesthesia and the Annals of Internal Medicine 7, 8
These complications contribute equally to cardiac complications in terms of morbidity, mortality, and length of stay, according to the Annals of Internal Medicine 8