Atelectasis associated with mucus plugs is common in hospitalized patients. Bronchoscopy is the technique of choice for resolving this disorder, particularly when the patient's respiratory system is compromised.1 We present the case of a patient with obstructive atelectasis of the right upper lobe and respiratory acidosis, resolved with the application of non-invasive ventilation (NIV).

An 82-year-old woman with a history of diabetes mellitus type 2 and oromandibular and cervical dystonia with blepharospasm (Miege's syndrome). In 2010, she had a pure sensory right hemispheric lacunar transient ischemic attack. She presented in the hospital complaining of abdominal pain of 2 days’ duration. Evaluation in the emergency department led to a diagnosis of inflammation in the terminal ileum and admission to the general surgery unit for conservative management. Four days after admission, the patient's general status deteriorated, with dyspnea on minimal effort, worsening to dyspnea at rest accompanied by significant work-of-breathing and progressively diminishing level of consciousness. Temperature was 38°C. Of note on physical examination was tachypnea with 28 breaths/minute and intense subcostal retraction, tachycardia 110beats/min, arterial hemoglobin oxygen saturation (SpO2) 83% despite administration of O2 via a non-rebreathing mask. Pulmonary auscultation revealed generalized loss of breath sounds and abundant rhonchi. There were no other findings of interest in other organs. Laboratory testing showed leukocytosis (12.5×109) with left shift (75% neutrophils). Chest X-ray revealed atelectasis of the right upper lobe (RUL) with ipsilateral mediastinal shift (Fig. 1). X-ray on admission was normal. The respiratory unit was requested to perform bronchoscopy for resolution of the RUL atelectasis. The patient's situation was critical and the possibility of using Cough Assist®, a mechanical cough assistant, as alternative treatment was discussed. Blood gases determined while the patient was receiving reservoir O2 delivery showed pH: 7.06; PaCO2: 78mmHg; PaO2: 94mmHg; HCO3: 22.1mmol/l; SaO2: 86%. Ultimately, it was decided to start NIV. Bi-level pressure ventilation via a face mask with a Monnal T50® ventilator was initiated with the following settings: IPAP: 25; EPAP: 10; FR: 12; Ti: 1.3, with addition of O2 at 8l/min. Intravenous antibiotics were administered. After 1h of treatment, blood gases were pH: 7.22; PaCO2: 53mmHg; PaO2: 58mmHg; HCO3: 21.7mmol/l; SaO2: 83.3%. Respiratory rate and level of consciousness improved. After 24h, the patient's level of consciousness was normal, work-of-breathing had resolved and blood gases were pH: 7.36; PaCO2: 45mmHg; PaO2: 73mmHg; HCO3: 24.3mmol/l; SaO2: 94%. X-ray obtained at 12hours showed complete resolution of atelectasis in the RUL and condensation in the right lower lobe (RLL)(Fig. 2). After 24h of stable clinical signs and symptoms and blood gases, NIV was withdrawn. Antibiotic treatment continued for 14 days and progress was favorable.

Fig. 1.

Right upper lobe atelectasis with mediastinal shift toward the affected side.

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Fig. 2.

Absence of right upper lobe atelectasis after non-invasive ventilation. Infiltration can be seen in the right lower lobe.

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Atelectasis may be prevented with respiratory physiotherapy, mechanical insufflation–exsufflation devices, or the application of positive airway pressure. Respiratory physiotherapy in hospitalized patients has been largely ignored. Limited use of this technique leads to increased respiratory complications, including atelectasis. This in turn leads to the abuse of invasive treatment procedures, such as bronchoscopy.2 Mechanical insufflation–exsufflation devices such as Cough Assist® have been shown to be useful in the prevention and cure of atelectasis in neuromuscular patients with secretory disorders, although they are mainly used in the home setting in association with physiotherapy.3 Positive airway pressure, alone or in conjunction with other physiotherapy techniques, has also been shown to be effective in the prevention of post-operative atelectasis.4,5

Once atelectasis occurs, however, the intervention of choice is bronchoscopy for aspiration of mucous from the airway. In our patient, NIV was indicated due to hypercapnic respiratory failure; breathing, as expected, improved, accompanied by rapid, complete resolution of atelectasis. No references to NIV in the treatment of critical patients with contraindications for bronchoscopy were found in the literature. Our experience suggests that NIV may be useful in the treatment of atelectasis in some critical patients. Bronchoscopy is a more aggressive intervention that is also more costly in terms of resources and personnel, and the possibility of replacing it with NIV should be investigated in further studies.