A Novel Maneuver to Treat Refractory Atelectasis in Mechanically Ventilated Children

Abstract

We developed a novel airway clearance and lung recruitment maneuver for children with refractory unilateral atelectasis undergoing invasive mechanical ventilation. In this retrospective, single-center, proof of concept study, we describe the steps involved in this novel maneuver and evaluate its effectiveness in 15 patients through objective quantitation of changes in respiratory system compliance and in the degree of atelectasis assessed by a validated Modified Radiology Atelectasis Score. Compared with the premaneuver baseline, the median atelectasis score improved significantly following the maneuver (9 [7.5-10] vs. 1 [0-3.3], respectively, p < 0.01). Likewise, dynamic compliance was significantly higher following the maneuver (0.3 [0.32-0.44] vs. 0.61 [0.53-0.69] mL/kg/cm H ₂ O, respectively, p < 0.01). No patients required a bronchoscopy. This simple and effective maneuver resulted in a significant improvement in the degree of atelectasis and dynamic compliance in this cohort of mechanically ventilated children with refractory unilateral atelectasis.

Keywords: atelectasis; mechanical ventilation; pediatric critical care.

Fig. 1

Cartoon illustrating the various phases of the maneuver: ( A ) assessment phase ( circles on the chest wall indicate auscultation points ); ( B ) restricted inspiration phase; ( C ) assisted exhalation phase; ( D ) bilateral-assisted exhalation and derecruitment phase; ( E ) suction phase; ( F ) re-recruitment phase.

Fig. 2

Diagram illustrating the progression of the maneuver through its distinct phases: ( A ) assessment phase; ( B ) restricted inspiration phase; ( C ) assisted exhalation phase; ( D ) bilateral-assisted exhalation and derecruitment phase; ( E ) suction phase; ( F ) re-recruitment phase. Note that the operator cycles between phases B and C until evidence of secretion mobilization is noted, before advancing to phase D.

Fig. 3

Modified radiology atelectasis score (MRAS) before and after application of the maneuver. Bars are medians, and whiskers are upper and lower quartiles.

Fig. 4

Dynamic compliance (Cdyn) corrected for body weight before and after application of the maneuver. Bars are medians, and whiskers are upper and lower quartiles.

Fig. 5

Representative chest radiographs taken before (pre) and immediately after (post) application of the maneuver.