Internal Medicine

P1: SBT

0521779407-04a CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:48

Atelectasis 177

differential diagnosis

■Cardiac: unilateral or bilateral pulmonary edema

■Pulmonary: pneumonia, pleural effusion, interstitial lung disease,

carcinoma, unilateral diaphragm paralysis

management

What to Do First

■Supplemental oxygen

■Ensure adequate analgesia: consider regional anesthesia (epidural,

intercostal blocks)

■Incentive spirometry and/or PEP therapy

■Institute respiratory support with bag-valve mask ventilation if men-

tal status impaired

General Measures

■Tidal volume and FRC recruited through:

➣Enhanced spontaneous ventilation

➣Expectoration of secretions

➣Positive pressure ventilation

■Monitoring in ICU and serial ABG analysis with arterial catheter may

be required if SpO2 remains <90%

specific therapy

Indications

■Therapy should be instituted once diagnosis considered and work-

up initiated

Treatment Options

■Incentive spirometry: q 2–4 h

■Aerosol therapy (saline, N-acetylcysteine) q 2–4 h

■PEP maneuvers by mask q 2–4 h

■Percussion therapyq4h(mosteffective for CF)

■Noninvasive ventilation support with CPAP: start by mask at 5 cm

H 2 O; 15 min q 3–4 h

■BiPAP by nasal or facemask: start at 10 cm H 2 O inspiration/5 cm H 2 O

expiration

■Nasotracheal suctioning q 1–4 h, preferably via nasal airway

■Endotracheal intubation and mechanical ventilation and sighs if

mental status/gag reflex impaired:

➣Initial ventilator settings:

FiO 2 : 1.0

Tidal volume: 10–12 mL/kg