Canadian Anaesthetists’ Society Journal

, Volume 28, Issue 4, pp 305–313 | Cite as

Pulmonary atelectasis after anaesthesia: Pathophysiology and management

  • John R. A. Rigg


The pathophysiological basis of pulmonary atelectasis is reviewed and risk factors that enhance lung collapse are discussed. Management strategies to reduce or eliminate risk factors and to prevent collapse are discussed and the rational bases of these strategies are identified.

Instability of lung alveoli is a consequence of surface tension and regional differences in alveolar size. The inherent tendency of alveoli to collapse is enhanced by the following risk factors; low lung volume, high closing volume, oxygen therapy, a rapid shallow ventilatory pattern, chronic lung disease, smoking, obesity, postoperative pain following abdominal or thoracic surgery, narcotic induced ventilatory depression, and neurological, neuromuscular, muscular and musculoskeletal diseases associated with mechanical impairment of respiratory function. The primary goal of perioperative respiratory management is prevention of atelectasis. Appropriate management strategies include physiotherapy and delay of elective surgery if substantial improvement in respiratory status can be achieved by specific treatments such as antibiotics, bronchodilators, steroids, and reduction of tobacco use and caloric intake. In selected cases, elective postoperative controlled ventilation may be indicated.

Key Words

Anaesthesia Complications atelectasis Lung atelectasis 


Ce travail présente une discussion des mécanismes physiopathologiques de l’atélectasie pulmonaire ainsi que des facteurs de risque prédisposant au collapsus pulmonaire. Les différentes approaches en vue d’éliminer ou d’atténuer les effets des facteurs de risque et de prévenir le collapsus pulmonaire sont également discutées dans l’pptique de leur mécanisme d’action.

L’instabilité de l’alvéole pulmonaire est la conséquence naturelle des phénomènes de tension de surface associés aux différences régionales de diamètre alvéolaire. Cette tendance naturelle au collapsus alvéolaire est amplifiée en présence des facteurs de risque suivants: bas volumes pulmonaires, hauts volumes de fermeture, oxygénothérapie, ventilation rapide et superficielle, pathologies pulmonaires chroniques, tabac, obésité, douleurs post-opératoires en chirurgie abdominale ou thoracique, atteintes neurologiques, neuro-musculaires ou musculo-squelettiques avec répercussions sur la ventilation.

Les soins respiratoires péri-opératoires sont axés sur la prévention de l’atélectasie pulmonaire. A cet effet on recommande la physiothérapie et la remise à plus tard des cas de chirurgie élective lorsqu’une amélioration significative de la fonction respiratoire est possible avec une thérapie spécifique (antibiotiques, broncho-dilatateurs, stéroïdes, diminution du tabac et de l’apport calorique). Dans certains cas particuliers un support ventilatoire post-opératoire avec respiration contrôlée peut être indiqué.


  1. 1.
    James, O.F., Mills, R.M. &Allen, K.M. Acute respiratory failure in a regional respiratory unit. Anaesth. Intens. Care5: 372–377 (1977).Google Scholar
  2. 2.
    Pierce, A.K. &Robertson J. Pulmonary complications of general surgery. Ann. Rev. Med.28: 211–221 (1977).PubMedCrossRefGoogle Scholar
  3. 3.
    Fraser, R.G. &Pare, J.A. Diagnosis of diseases of the chest. W.B. Saunders, Toronto,1: 301–302, (1970).Google Scholar
  4. 4.
    West, J.B. Respiratory physiology - the essentials. Williams and Wilkins, Baltimore, Chapter 7 (2nd ed.) (1979).Google Scholar
  5. 5.
    West, J.B. &Dollery, C.T. Distribution of blood flow and ventilation-perfusion ratio in the lung measured with radioactive CO2. J. Appl. Physiol.15: 405–410 (1960).PubMedGoogle Scholar
  6. 6.
    Ball, W.C., Stewart, P.B., Newsham, L.G.S. &Bates, D.V. Regional pulmonary function studied with Xenon. J. Clin. Invest.41: 519–531 (1962).PubMedCrossRefGoogle Scholar
  7. 7.
    Kaneko, K, Milic-Emili, J., Dolovich, M.B., Dawson, A. &Bates, D.V. Regional distribution of ventilation and perfusion as a function of body position. J. Appl. Physiol.21: 767–777 (1966).PubMedGoogle Scholar
  8. 8.
    Milic-Emili, J., Henderson, J.A.M., Dolovich, M.B., Trop, D. &Kaneko, K. Regional distribution of inspired gas in the lung. J. Appl. Physiol.21: 749–759 (1966).PubMedGoogle Scholar
  9. 9.
    Gale, G.P., Teasdale, S.J., Sanders, D.E., Bradwell, P.J., Russell, A., Solarie, B. &York, J.E. Pulmonary atelectasis and other respiratory complications after cardiopulmonary bypass and investigation of aetiological factors. Can. Anaesth. Soc.26: 15–21 (1979).Google Scholar
  10. 10.
    West, J.B. Respiratory physiology - the essentials. Williams and Wilkins, Baltimore, Chapter 9 (2nd ed.) (1979).Google Scholar
  11. 11.
    Farhi, L. Atmospheric nitrogen and its role in modern medicine. J. Am. Med. Assoc.188: 984–993 (1964).Google Scholar
  12. 12.
    Husfeld, E. &Wandall, H.H. Experimental investigations into ventilation of the lung. Acta. Med. Scand.108: 603–609 (1941).Google Scholar
  13. 13.
    Dale, W.A. &Rhan, H. Rate of gas absorption during atelectasis. Am. J. Physiol.170: 606–615 (1952).PubMedGoogle Scholar
  14. 14.
    Comroe, J.H. Jnr. &Dripps, R.D. Physiological basis for oxygen therapy. Charles C. Thomas, Springfield, Illinois (1960).Google Scholar
  15. 15.
    Rahn, H. &Farhi, L.E. Gaseous environment and atelectasis. Fed. Proc.22: 1035–1041 (1963).PubMedGoogle Scholar
  16. 16.
    Ernsting, J. Some effects of oxygen breathing in man. Proc. Roy. Soc. Med.53: 96–98 (1960).PubMedGoogle Scholar
  17. 17.
    Langdon, D.E. &Reynolds, G.E. Post flight respiratory symptoms associated with 100% oxygen and G forces. Aerospace Med.32: 713–718 (1961).PubMedGoogle Scholar
  18. 18.
    Bendixen, H.H., Hedley-White, J., Chir, B. &Laver, M.B. Impaired oxygenation in surgical patients during general anaesthesia with controlled ventilation: a concept of atelectasis. N. Engl. J. Med.269: 911–996 (1963).Google Scholar
  19. 19.
    Robertson, W.G. &Farhi, L.E. Effect of ambient pressure on rate of collapse of rat lung. Physiologist 4: 95 (1961).Google Scholar
  20. 20.
    Mead, J. &Collier, C. Relation of volume history of lungs to respiratory mechanics in anaesthetized dogs. J. Appl. Physiol.14:669–678 (1959).Google Scholar
  21. 21.
    Meneely, G.R. &Ferguson, J.L. Pulmonary evaluation and risk in patient preparation for anesthesia and surgery. J. Am. Med. Assoc.175: 1074–1080 (1961).Google Scholar
  22. 22.
    Stein, M., Koota, G.M., Simon, M. &Frank, H.A. Pulmonary evaluation of surgical patients. J. Am. Med. Assoc.181: 765–770 (1962).Google Scholar
  23. 23.
    Lattimer, R.G., Dickman, M., Day, W.G., Gunn, M.L. &Schmidt, C.D. Ventilatory patterns and pulmonary complications after upper abdominal surgery determined by preoperativeand postoperative computerized spirometry and blood gas analysis. Am. J. Surg.122: 622–63 (1971).CrossRefGoogle Scholar
  24. 24.
    Anscombe, D.R. &Buxton, R. St. J. Effect of abdominal operations on total lung capacity and its subdivisions. Br. Med. J.2: 85–86 (1958).Google Scholar
  25. 25.
    Lewis, F.J. &Welch, J.A. Respiratory mechanics in postoperative patients. Surg. Gynecol. Obstet.120: 305–314 (1965).PubMedGoogle Scholar
  26. 26.
    Pierce, J.A. &Garofolo, M.L. Preoperative medication and its effect on blood gases. J. Am. Med. Assoc.194: 99–102 (1965).CrossRefGoogle Scholar
  27. 27.
    Egbert, L.D. &Bendixen, H.H. Effect of morphine on breathing pattern, a possible factor in atelectasis. J. Am. Med. Assoc.188: 485–487 (1964).Google Scholar
  28. 28.
    Bendixen, H.H., Smith, G.M. &Mead, J. Pattern of ventilation in young adults. J. Appl. Physiol.19: 195–198 (1964).PubMedGoogle Scholar
  29. 29.
    Rigg, J.R.A. Ventilatory effects and plasma concentration of morphine in man. Br. J. Anaesth50: 759–765 (1978).PubMedCrossRefGoogle Scholar
  30. 30.
    Rigg, J.R.A. Low ventilatory response to carbon dioxide is not associated with increased ventilatory depression by morphine. Br. J. Anaesth.50: 767–771 (1978).PubMedCrossRefGoogle Scholar
  31. 31.
    Rigg, J.R.A. &Goldsmith, C.H. Recovery of ventilatory responses to CO2 after thiopentone, morphine and fentanyl in man. Canad. Anaesth. Soc. J.23: 370–382 (1976).PubMedGoogle Scholar
  32. 32.
    Bunker, J.P., Bendixen, H.H., Sykes, M.K., Todd, D.P. &Surtesses, A.D. A comparison of ether anaesthesia with thiopental-nitrous oxidesuccinylcholine for upper abdominal surgery. Anesthesiology20: 745–752 (1959).PubMedCrossRefGoogle Scholar
  33. 33.
    Eldridge, F.L. &Davis J.M. Effect of Mechanical factors on respiratory work and ventilatory responses to CO2. J. Appl. Physiol.14: 721–726 (1959).PubMedGoogle Scholar
  34. 34.
    Lourenco, R.V., Cherniack N.S., Malm J.R. &Fishman A.P. Nervous output from the respiratory centre during obstructed breathing. J. Appl. Physiol21: 527–533 (1966).PubMedGoogle Scholar
  35. 35.
    Stanley, N.N., Cunningham E.L., Altose M.D., Kelsen S.G., Levinson R.S. &Cherniack N.S. Evaluation of breath holding in hypercapnia as a simple clinical test of respiratory chemosensitivity. Thorax30: 337–343 (1975).PubMedGoogle Scholar
  36. 36.
    Cherniack R.M. &Snidal D.P. The effect of obstruction to breathing on the ventilatory reponse toCO2. J. Clin. Invest.35: 1286–1290 (1956).PubMedCrossRefGoogle Scholar
  37. 37.
    Rigg, J.R.A. &Jones, N.L. Clinical assessment of respiratory function. Br. J. Anaesth.50: 3–13 (1978).PubMedCrossRefGoogle Scholar
  38. 38.
    Pooler, H.E. Relief of postoperative pain and its influence on vital capacity. Br. Med. J.2: 1200–1203 (1949).PubMedGoogle Scholar
  39. 39.
    Wightman, J.A.K. A prospective survey of the incidence of postoperative pulmonary complications. Br. J. Surg.55: 85–91 (1968).PubMedCrossRefGoogle Scholar
  40. 40.
    Marshall, B.E. &Miller, R.A. Some factors influencing postoperative hypoxaemia. Anaesthesia.20: 408–428 (1965).PubMedCrossRefGoogle Scholar
  41. 41.
    Cahill, J.M. Respiratory problems in surgical patients. Am. J. Surg.116: 362–368 (1968).PubMedCrossRefGoogle Scholar
  42. 42.
    Steward, D.J. &Sloan, I.A.J. Recent upper respiratory infection and pulmonary artery clamping in the aetiology of postoperative respiratory complications. Canad. Anaesth. Soc. J.16: 57–60 (1969).PubMedGoogle Scholar
  43. 43.
    Chalon, J., Tayyab, M.A. &Ramanathan, S. Cytology of respiratory epithelium as a predictor of respiratory complications after operation. Chest67: 32–35 (1975).PubMedCrossRefGoogle Scholar
  44. 44.
    Sullivan, C.E. Disorders of breathing in sleep. Mod. Med. Aust., March 1980: 7–17.Google Scholar
  45. 45.
    Oldenburg, F.A.Jnr., Dolovich, M.B., Montgomery, J.H. &Newhouse, M.T. Effects of postural drainage, exercise and cough on mucus clearance in chronic bronchitis. Am. Rev. Resp. Dis.120: 739–745 (1979).PubMedGoogle Scholar
  46. 46.
    Thoren, L. Postoperative pulmonary complications. Observations on their prevention by means of physiotherapy. Acta. Chir. Scand.107: 193–205 (1954).PubMedGoogle Scholar
  47. 47.
    Palmer, K.N.V. &Sellick, B.A. The prevention of postoperative pulmonary atelectasis. Lancet1: 164–168 (1953).PubMedCrossRefGoogle Scholar
  48. 48.
    Stein, M. &Cassara, E.L. Preoperative pulmonary evaluation and therapy for surgery patients. J. Am. Med. Assoc.211: 787–790 (1970).CrossRefGoogle Scholar
  49. 49.
    Powles, A.C.P. &Campbell, E.J.M. An improved rebreathing method for measuring mixed carbon dioxide tension and its clinical application. Can. Med. Assoc. J.118: 501–504 (1978).PubMedGoogle Scholar
  50. 50.
    Davis, C.C., Jones, N.L. &Sealey, B.S. Measurements of cardiac output in seriously ill patients using a CO2 rebreathing method. Chest73: 167–172 (1978).PubMedCrossRefGoogle Scholar
  51. 51.
    Franciosa, J.A. Evaluation of the CO2rebreathing cardiac output method in seriously ill patients. Circulation55: 449–455 (1977).PubMedGoogle Scholar
  52. 52.
    Powles, A.C.P., Hershler, R. &Rigg, J.R.A. A pocket calulator programme for bedside estimation of cardiopulmonary functions. Comp. Biol. Med.10: 143–151 (1980).CrossRefGoogle Scholar
  53. 53.
    Jones, N.L., Campbell, E.J.M., Edwards, R.H.T. &Robertson D.G. Clinical exercise testing. W.B. Saunders, Philadelphia (1975).Google Scholar
  54. 54.
    Nunn, J.F. Anaesthesia for Patients with Respiratory Disease.In: General Anaesthesia, 3rd Ed. T.C. Gray & J.F. Nunn. Butterworths, London (1971).Google Scholar
  55. 55.
    Holaday, D.A. &Rattenborg, C.C. Selection of a method of anaesthesia for patients with pulmonary dysfunction.In: Lung Disease, Clinical Anaesthesia series, Vol. l. ed. by D.A. Holaday, Oxford: Blackwell (1967).Google Scholar
  56. 56.
    Utting, J.E., Gray, T.C. &Rees, G.J. Anaesthesia for the respiratory cripple. Acta. Anaesth. Scand.9: 29–38 (1965).PubMedGoogle Scholar
  57. 57.
    Thornton, J.A. The problem of general anaesthesia in patients with chronic respiratory disease. Thorax.24:380 (1969).PubMedCrossRefGoogle Scholar
  58. 58.
    Nunn, J.F. &Payne, J.P. Hypoxaemia after general anaesthesia. Lancet2: 631–632 (1962).PubMedCrossRefGoogle Scholar
  59. 59.
    Nunn, J.F. Factors influencing the arterial oxygen tension during halothane anaesthesia with spontaneous respiration. Br. J. Anaesth.36: 327–41 (1964).PubMedCrossRefGoogle Scholar
  60. 60.
    Nunn, J.F. Influence of age and other factors on hypoxia in the postoperative period. Lancet2: 466–468 (1965).PubMedCrossRefGoogle Scholar
  61. 61.
    Nunn, J.F., Bergman, N.A. &Coleman, A.J. Factors influencing the arterial oxygen tension during anaesthesia with artificial ventilation. Br. J. Anaesth.37:898–914 (1965).PubMedCrossRefGoogle Scholar
  62. 62.
    Diament, M.L. &Palmer, K.N.V. Venous/arterial pulmonary shunting as the principal cause of postoperative hypoxaemia. Lancet1: 15–17 (1967).PubMedCrossRefGoogle Scholar
  63. 63.
    Thompson, D.S. &Eason, C.N. Hypoxaemia immediately after operation. Am. J. Surg.120: 649–651 (1970).PubMedCrossRefGoogle Scholar
  64. 64.
    Saunders, N.A., Powles, A.C.P. &Rebuck, A.S. Ear oximetry: accuracy and practicability in the assessment of arterial oxygenation. Am. Rev. Resp. Dis.113: 745–749 (1976).PubMedGoogle Scholar
  65. 65.
    Campbell, E.J.M. The management of acute respiratory failure in chronic bronchitis and emphysema. Am. Rev. Resp. Dis.96:626–639 (1967).PubMedGoogle Scholar
  66. 66.
    Leigh, J. Oxyten therapy at ambient pressure. In: Scientific Foundations of Anaesthesia, Heinemann, London, pp. 200–205 (1975).Google Scholar
  67. 67.
    Bendixen, H.H. &Laver, M.B. Hypoxia in anaesthesia. Clin. Pharmacol. Ther.6: 510–539 (1965).PubMedGoogle Scholar
  68. 68.
    Kleman,G.R., Nunn, J.F., Prys-Roberts, C. &Greenbaum, R. The influence of cardiac output on arterial oxygenation. Br. J. Anaesth.39: 450–458 (1967).CrossRefGoogle Scholar
  69. 69.
    Philbin, D.M., Sullivan, S.F., Bowman, F.O., Malm, J.R. &Papper, E.M. Postoperative hypoxaemia; contribution of the cardiac output. Anesthesiology,32: 136–142 (1970).PubMedCrossRefGoogle Scholar
  70. 70.
    Rackow, H., Salanitre, E. &Frumin, M.J. Dilution of alveolar gases during nitrous oxide excretion in man. J. Appl. Physiol.16: 723–728 (1961).PubMedGoogle Scholar
  71. 71.
    Fink, B.R. Diffusion anoxia. Anesthesiology16: 511–519 (1955).PubMedCrossRefGoogle Scholar
  72. 72.
    Sheffer, J., Steffenson, J.L. &Birch, A.A. Nitrous oxide induced diffusion hypoxia in patients breathing spontaneously. Anesthesiology37: 436–439 (1972).PubMedCrossRefGoogle Scholar
  73. 73.
    Frumin, M.J. &Edelist, G. Diffusion anoxia: a critical appraisal. Anesthesiology31: 243–249 (1969).PubMedCrossRefGoogle Scholar
  74. 74.
    Mather, L.E., Lindop, M.J., Tucker, G.T. &Pflug, A.E. Pethidine revisited: plasma concentration and effects after IM injections. Br. J. Anaesth.47: 1269–1275 (1975).PubMedCrossRefGoogle Scholar
  75. 75.
    Rigg, J.R.A., Browne, R.A., Davis, C., Khandelwal, J.K. &Goldsmith, C.H. Variation in the disposition of morphine after IM administration in surgical patients. Br. J. 1 naesth.50: 1125–1130 (1978).CrossRefGoogle Scholar
  76. 76.
    Berkowitz, B.A., Ngai, S.H., Yang, J.C., Hampstead, J. &Spector, S. The disposition of morphine in surgical patients. Clin. Pharmacol. Ther.17: 629–635 (1975).PubMedGoogle Scholar
  77. 77.
    Stapleton, J.V., Austin, K.L., Mather, L.E. A pharmacokinetic approach to postoperative pain: continuous infusion of pethidine. Anaesth. Intens. Care7: 25–32 (1979).Google Scholar
  78. 78.
    Rigg, J.R.A., Vedig, A.E. &Ilsley, A.H. Relationship of steady state plasma pethidine concentrations to ventilatory effects of pethidine. Brit. J. Anaesth, accepted for publication, 1981.Google Scholar
  79. 79.
    Pontoppidan, H., GEFFIN, B. &LOWENSTEIN, E. Acute respiratory failure in the adult. Little Brown, Boston (1973).Google Scholar

Copyright information

© Canadian Anesthesiologists 1981

Authors and Affiliations

  • John R. A. Rigg
    • 1
  1. 1.Department of AnaesthesiaMcMaster UniversityUSA

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