Atelectasis/Lung Collapse Part-1 by Dr Bashir Ahmed Dar Associate Professor Medicine Sopore Kashmir
drbashir
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Nov 02, 2014
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About This Presentation
The term atelectasis is derived from the Greek words ateles and ektasis, which mean incomplete expansion.The incomplete expansion of lung may involve part of lung or entire lung.Most symptoms and signs are determined by the rapidity with which the collapse of lung occurs,the size of the lung area af...
Slide Content
Dr Bashir Ahmed Dar
Associate Professor Medicine
Chinkipora Sopore Kashmir /
Email: [email protected]
Associate Professor Medicine
Chinkipora Sopore Kashmir /
Email: [email protected]
as
UMA bersama 7
or-doktor pakar dar
bagal bidang x]
-
RIKSAAN GIGI RE.
RIKSAAN UJIAN
À UNTUK 100 ORANG PERTAMA SAHAJA)
UMA bersama 7
or-doktor pakar dar
bagal bidang x]
-
RIKSAAN GIGI RE.
RIKSAAN UJIAN
À UNTUK 100 ORANG PERTAMA SAHAJA)
Note
This slide presentation is divided into three parts.
Part-1
Part-2
Part-3
Part two describes collapse of different lobes of
lung and how to recognise them and is full of x-rays
& Part three deals with treatment. All these slides
you can find on slideshare and on some other sites
This slide presentation is divided into three parts.
Part-1
Part-2
Part-3
Part two describes collapse of different lobes of
lung and how to recognise them and is full of x-rays
& Part three deals with treatment. All these slides
you can find on slideshare and on some other sites
Definition
Loss of lung volume. Atelectasis from Greek word means
incomplete expansion. It may affect part or all of the lung
Collapsed
lung
Loss of lung volume. Atelectasis from Greek word means
incomplete expansion. It may affect part or all of the lung
Collapsed
lung
Atelectasis/Lung Collapse
* It is a condition where the alveoli are deflated,
and devoid of air resulting in loss of volume
of lung.
* The air is actually not replaced as distinct from
pulmonary consolidation but just devoid of air
A
* It is a condition where the alveoli are deflated,
and devoid of air resulting in loss of volume
of lung.
* The air is actually not replaced as distinct from
pulmonary consolidation but just devoid of air
A
Atelectasis/Lung Collapse
+ Atelectasis may be an acute or chronic condition.
* In acute atelectasis, the lung has recently
collapsed and is primarily notable only for air
lessness
+ Atelectasis may be an acute or chronic condition.
* In acute atelectasis, the lung has recently
collapsed and is primarily notable only for air
lessness
Atelectasis/Lung Collapse
« In chronic atelectasis, the affected area is often
characterized by a complex mixture of
airlessness, infection, widening of the bronchi
(bronchiectasis), destruction, and scarring
(fibrosis) of lung tissue
« In chronic atelectasis, the affected area is often
characterized by a complex mixture of
airlessness, infection, widening of the bronchi
(bronchiectasis), destruction, and scarring
(fibrosis) of lung tissue
Atelectasis/Lung Collapse
¢ The natural tendency for alveoli to collapse is
countered by the following:
Surfactant (which maintains surface tension)
Continuous breathing (which keeps the alveoli
open)
Intermittent deep breathing (which releases
surfactant into the alveoli)
Periodic coughing (which clears the airways of
secretions) A
¢ The natural tendency for alveoli to collapse is
countered by the following:
Surfactant (which maintains surface tension)
Continuous breathing (which keeps the alveoli
open)
Intermittent deep breathing (which releases
surfactant into the alveoli)
Periodic coughing (which clears the airways of
secretions) A
Types of atelectasis
Obstructive ompressive| | Cicatricial Adhesive
collapse collapse collapse collapse
Obstructive ompressive| | Cicatricial Adhesive
collapse collapse collapse collapse
Obstructive
Resorption of alveolar air
by circulating blood.
Bronchial
obstruction
Compressive
+ve pleural pressure
Pleural effusion.
Pneumothorax.
Cicatricial
Pulmonary fibrosis
TB
Post-irradiation
Adhesive
Loss of pulmonary
surfactant
RDS
Resorption of alveolar air
by circulating blood.
Bronchial
obstruction
Compressive
+ve pleural pressure
Pleural effusion.
Pneumothorax.
Cicatricial
Pulmonary fibrosis
TB
Post-irradiation
Adhesive
Loss of pulmonary
surfactant
RDS
Obstructive or Resorptive atelectasis
+ Airways may have intrinsic obstruction within
its lumen or may be compressed from outside
(extrinsic airway obstruction).
+ Airways may have intrinsic obstruction within
its lumen or may be compressed from outside
(extrinsic airway obstruction).
Obstructive or Resorptive atelectasis
+ Occurs as a result of complete intrinsic or
extrinsic obstruction of an airway.
* No new air can enter the portion of the lung
distal to the obstruction and any air that is
already there is eventually absorbed into the
pulmonary capillary system, leaving a
collapsed section of the affected lung.
+ Occurs as a result of complete intrinsic or
extrinsic obstruction of an airway.
* No new air can enter the portion of the lung
distal to the obstruction and any air that is
already there is eventually absorbed into the
pulmonary capillary system, leaving a
collapsed section of the affected lung.
Intrinsic airway obstruction
+ Intrinsic airway obstruction is the most common
cause of atelectasis in children, and asthma is
the most common underlying disorder that
predisposes patients to atelectasis.
+ Intrinsic airway obstruction is the most common
cause of atelectasis in children, and asthma is
the most common underlying disorder that
predisposes patients to atelectasis.
intrinsic airway obstruction
+ Other causes include bronchiolitis, aspiration
due to a swallowing disorder, endobronchial
tuberculosis, aspiration from gastro esophageal
reflux, airway foreign bodies, cystic fibrosis, and
increased or abnormal airway secretions for
other reasons, thick mucus plug
+ Other causes include bronchiolitis, aspiration
due to a swallowing disorder, endobronchial
tuberculosis, aspiration from gastro esophageal
reflux, airway foreign bodies, cystic fibrosis, and
increased or abnormal airway secretions for
other reasons, thick mucus plug
intrinsic airway obstruction
¢ Children younger than 10 years are less likely to
have developed the inter airway canals of
Lambert or the inter alveolar pores of Kohn.
* And these are collateral communications
between one alveoli to other or between airways
¢ Children younger than 10 years are less likely to
have developed the inter airway canals of
Lambert or the inter alveolar pores of Kohn.
* And these are collateral communications
between one alveoli to other or between airways
intrinsic airway obstruction
Thus, young children whose airways become
obstructed, they are more likely to develop
atelectasis than older children who have
developed these communications.
Thus, young children whose airways become
obstructed, they are more likely to develop
atelectasis than older children who have
developed these communications.
Extrinsic airway obstruction
« Extrinsic compression on the airways is most
likely to come from enlarged lymph nodes (such
as those due to tuberculosis infection),
lymphoma and other tumors in the lungs or
chest pressing over the airways i mean bronchi
larger or smaller and leading to obstruction
« Extrinsic compression on the airways is most
likely to come from enlarged lymph nodes (such
as those due to tuberculosis infection),
lymphoma and other tumors in the lungs or
chest pressing over the airways i mean bronchi
larger or smaller and leading to obstruction
Extrinsic airway obstruction
+ Extrinsic or intrinsic obstruction of a lobar
bronchus is likely to produce lobar atelectasis;
obstruction of a segmental bronchus is likely to
produce segmental atelectasis.
+ Extrinsic or intrinsic obstruction of a lobar
bronchus is likely to produce lobar atelectasis;
obstruction of a segmental bronchus is likely to
produce segmental atelectasis.
Extrinsic airway obstruction
Middle lobe is also affected commonly because
the right middle lobe orifice is the narrowest of
the lobar orifices and because it is surrounded by
lymphoid tissue, it is the most common lobe to
become atelectatic. This is referred to as right
middle lobe syndrome.
3
Middle lobe is also affected commonly because
the right middle lobe orifice is the narrowest of
the lobar orifices and because it is surrounded by
lymphoid tissue, it is the most common lobe to
become atelectatic. This is referred to as right
middle lobe syndrome.
3
Extrinsic airway obstruction
¢ Even an enlarged heart that compresses the left
main or left lower lobe bronchus, and left-to-
right intracardiac shunts that increase blood flow
through the pulmonary arteries.
* Loculated collection of pleural fluid for example
posterior Loculated collection of pleural fluid can
lead to compressed lower lobe atelectasis
¢ Even an enlarged heart that compresses the left
main or left lower lobe bronchus, and left-to-
right intracardiac shunts that increase blood flow
through the pulmonary arteries.
* Loculated collection of pleural fluid for example
posterior Loculated collection of pleural fluid can
lead to compressed lower lobe atelectasis
Absorption or Resorption or obstructive atelectasis due
to intrinsic or extrinsic causes
+ The atmosphere is composed of 78% nitrogen
and 21% oxygen. Since oxygen is exchanged at
the alveoli-capillary membrane, nitrogen is a
major component for the alveoli's state of
inflation. If a large volume of nitrogen in the
lungs is replaced with oxygen, the oxygen may
subsequently be absorbed into the blood,
reducing the volume of the alveoli, resulting in a
form of alveolar collapse known as absorption
atelectasis
to intrinsic or extrinsic causes
+ The atmosphere is composed of 78% nitrogen
and 21% oxygen. Since oxygen is exchanged at
the alveoli-capillary membrane, nitrogen is a
major component for the alveoli's state of
inflation. If a large volume of nitrogen in the
lungs is replaced with oxygen, the oxygen may
subsequently be absorbed into the blood,
reducing the volume of the alveoli, resulting in a
form of alveolar collapse known as absorption
atelectasis
Absorption or Resorption or obstructive
atelectasis due to intrinsic or extrinsic causes
So as | said nitrogen absorption is delayed and
slow thus this nitrogen is main gas to prevent
collapse and if nitrogen is replaced by high
concentration of oxygen then collapse is
accelerated
atelectasis due to intrinsic or extrinsic causes
So as | said nitrogen absorption is delayed and
slow thus this nitrogen is main gas to prevent
collapse and if nitrogen is replaced by high
concentration of oxygen then collapse is
accelerated
Absorption or Resorption or obstructive
atelectasis due to intrinsic or extrinsic causes
+ Nitrogen is therefore poorly soluble in plasma,
and thus remains in high concentration in
alveolar gas and keep the alveoli expanded
atelectasis due to intrinsic or extrinsic causes
+ Nitrogen is therefore poorly soluble in plasma,
and thus remains in high concentration in
alveolar gas and keep the alveoli expanded
Absorption or Resorption or obstructive
atelectasis due to intrinsic or extrinsic causes
If nitrogen is replaced by another gas, that is if it
is actively “washed out” of the lung by either
breathing high concentrations of oxygen, or
combining oxygen with more soluble nitrous
oxide in anesthesia, the process of absorption
atelectasis is accelerated.
atelectasis due to intrinsic or extrinsic causes
If nitrogen is replaced by another gas, that is if it
is actively “washed out” of the lung by either
breathing high concentrations of oxygen, or
combining oxygen with more soluble nitrous
oxide in anesthesia, the process of absorption
atelectasis is accelerated.
Other causes of diminished alveolar distention
include the following
Small or dysmorphic chest wall
Severe scoliosis
Neuromuscular diseases
Anesthesia or sedation
Pain from upper abdominal surgery
Abdominal distention
Chest wall or upper abdominal pain
Even it may be caused by deep normal exhalation
include the following
Small or dysmorphic chest wall
Severe scoliosis
Neuromuscular diseases
Anesthesia or sedation
Pain from upper abdominal surgery
Abdominal distention
Chest wall or upper abdominal pain
Even it may be caused by deep normal exhalation
Other causes of diminished alveolar distention
include the following
¢ Thoracic and abdominal surgeries are very
common causes because they involve general
anesthesia, opioid use (with possible secondary
respiratory depression), and often painful
respiration since cough is suppressed or mucus
not cleared leading to obstruction.
+ Amalpositioned endotracheal tube can also
cause atelectasis by occluding a mainstem
bronchus.
include the following
¢ Thoracic and abdominal surgeries are very
common causes because they involve general
anesthesia, opioid use (with possible secondary
respiratory depression), and often painful
respiration since cough is suppressed or mucus
not cleared leading to obstruction.
+ Amalpositioned endotracheal tube can also
cause atelectasis by occluding a mainstem
bronchus.
Other causes of diminished alveolar distention
include the following
+ Suppression of respiration or cough (eg, by
general anesthesia, oversedation, severe pleuritic
pain) and Supine positioning, particularly in
obese patients can all lead to atelectasis
+ It is important to realize that alveoli in
dependent regions, are particularly vulnerable to
collapse in such cases
include the following
+ Suppression of respiration or cough (eg, by
general anesthesia, oversedation, severe pleuritic
pain) and Supine positioning, particularly in
obese patients can all lead to atelectasis
+ It is important to realize that alveoli in
dependent regions, are particularly vulnerable to
collapse in such cases
Linear (plate, discoid, subsegmental)
atelectasis
« linear (plate, discoid, subsegmental) atelectasis -
a minimal degree of collapse as seen in patients
who are not taking deep breaths , such as
postoperative patients or patients with rib
fracture or pleuritic chest pain.
» The opacities are plate like bands seen on x ray
atelectasis
« linear (plate, discoid, subsegmental) atelectasis -
a minimal degree of collapse as seen in patients
who are not taking deep breaths , such as
postoperative patients or patients with rib
fracture or pleuritic chest pain.
» The opacities are plate like bands seen on x ray
Linear (plate, discoid, subsegmental)
atelectasis
« Plate like atelectasis probably due to
obstruction of a small bronchus also seen in
states of hypoventilation, pulmonary embolism,
or lower respiratory tract infection.
« Small bronchi get obstructed by various reasons
leading to collapse of small areas
atelectasis
« Plate like atelectasis probably due to
obstruction of a small bronchus also seen in
states of hypoventilation, pulmonary embolism,
or lower respiratory tract infection.
« Small bronchi get obstructed by various reasons
leading to collapse of small areas
Linear (plate, discoid, subsegmental)
atelectasis
These small areas of atelectasis may also happen
due to abnormalities in surfactant formation from
hypoxia, ischemia, and exposure to various toxins.
Plain film — CT may show relatively thin, linear
densities in the lung bases oriented parallel to the
diaphragm (known as Fleischner's lines)
Just to note here kerley B lines start from periphery
pleura to hilum run upto 2cm horizontal lines on
plain x ray is not the atelectasis ,don’t confuse with
thick linear bands of opacities of atelectasis
atelectasis
These small areas of atelectasis may also happen
due to abnormalities in surfactant formation from
hypoxia, ischemia, and exposure to various toxins.
Plain film — CT may show relatively thin, linear
densities in the lung bases oriented parallel to the
diaphragm (known as Fleischner's lines)
Just to note here kerley B lines start from periphery
pleura to hilum run upto 2cm horizontal lines on
plain x ray is not the atelectasis ,don’t confuse with
thick linear bands of opacities of atelectasis
Compression Collapse or Passive (relaxation)
atelectasis
» Atelectasis due to compressed lung tissue which
is also called as Passive or relaxation of lung
collapse or atelectasis occurs most commonly
when air, blood, pus, or chyle is present in the
pleural space
atelectasis
» Atelectasis due to compressed lung tissue which
is also called as Passive or relaxation of lung
collapse or atelectasis occurs most commonly
when air, blood, pus, or chyle is present in the
pleural space
Compression Collapse or Passive
(relaxation) atelectasis
Intrathoracic abdominal contents, chest wall
masses, cardiomegaly, and an abnormal chest
wall can also compress adjacent lung tissue.
Please note here obstructive in which bronchi
mainly obstructed and compressive in which
lung parenchyma as a whole or part
compressed
(relaxation) atelectasis
Intrathoracic abdominal contents, chest wall
masses, cardiomegaly, and an abnormal chest
wall can also compress adjacent lung tissue.
Please note here obstructive in which bronchi
mainly obstructed and compressive in which
lung parenchyma as a whole or part
compressed
Compression Collapse or Passive
(relaxation) atelectasis
If a portion of lung enlarges, such as with
congenital emphysema, or if focal overinflation
occurs for any other reason, it may compress the
adjacent lung, causing atelectasis.
(relaxation) atelectasis
If a portion of lung enlarges, such as with
congenital emphysema, or if focal overinflation
occurs for any other reason, it may compress the
adjacent lung, causing atelectasis.
Compression Collapse or Passive
(relaxation) atelectasis
¢ Usually occurs when contact between the
parietal and visceral pleura is disrupted.
« the two most common specific aetiologies of
passive atelectasis are pleural effusion and
pneumothorax.
(relaxation) atelectasis
¢ Usually occurs when contact between the
parietal and visceral pleura is disrupted.
« the two most common specific aetiologies of
passive atelectasis are pleural effusion and
pneumothorax.
Compression Collapse or Passive
(relaxation) atelectasis
The lung is held close to chest wall because of
the negative pressure in the pleural space. Once
the negative pressure is lost the lung tends to
recoil due to elastic properties and becomes
atelectatic.
(relaxation) atelectasis
The lung is held close to chest wall because of
the negative pressure in the pleural space. Once
the negative pressure is lost the lung tends to
recoil due to elastic properties and becomes
atelectatic.
Compression Collapse or Passive (relaxation)
atelectasis
¢ Negative pressure in the pleura actually permits
lung to expand if this negative pressure is lost it
will then cause positive pressure in pleura thus
will not allow it to expand rather will make it
compress and collapse
« There is common misconception that atelectasis
is due to compression.
atelectasis
¢ Negative pressure in the pleura actually permits
lung to expand if this negative pressure is lost it
will then cause positive pressure in pleura thus
will not allow it to expand rather will make it
compress and collapse
« There is common misconception that atelectasis
is due to compression.
Compression Collapse or Passive (relaxation)
atelectasis
* Generally, the uniform elasticity of a normal lung
leads to preservation of shape even when
volume is decreased that elasticity is made
difficult due to positive pressure outside in
pleura
atelectasis
* Generally, the uniform elasticity of a normal lung
leads to preservation of shape even when
volume is decreased that elasticity is made
difficult due to positive pressure outside in
pleura
Compression Collapse or Passive (relaxation)
atelectasis
The different lobes also respond differently, eg,
the middle and lower lobes collapse more than
the upper lobe in the presence of pleural
effusion, while the upper lobe is typically
affected more by pneumothorax.
atelectasis
The different lobes also respond differently, eg,
the middle and lower lobes collapse more than
the upper lobe in the presence of pleural
effusion, while the upper lobe is typically
affected more by pneumothorax.
Cicatricial Atelectasis
» Alveoli gets trapped in scar unable to expand and
becomes atelectatic in fibrotic disorders.
» Alveoli gets trapped in scar unable to expand and
becomes atelectatic in fibrotic disorders.
Cicatricial Atelectasis
+ Scarring or fibrosis reduces lung expansion.
common etiologies include granulomatous
diseases,TB, necrotizing pneumonia and
radiation fibrosis.
* In short fibrosis due to any cause like chronic
lung diseases
+ Scarring or fibrosis reduces lung expansion.
common etiologies include granulomatous
diseases,TB, necrotizing pneumonia and
radiation fibrosis.
* In short fibrosis due to any cause like chronic
lung diseases
Cicatrization atelectasis
+ Cicatrization atelectasis results in diminution of
volume of lung
¢ Replacement atelectasis occurs when the alveoli
of an entire lobe are filled by tumor (eg,
bronchioalveolar cell carcinoma), resulting in loss
of volume.
+ Cicatrization atelectasis results in diminution of
volume of lung
¢ Replacement atelectasis occurs when the alveoli
of an entire lobe are filled by tumor (eg,
bronchioalveolar cell carcinoma), resulting in loss
of volume.
Adhesive atelectasis
¢ Adhesive atelectasis results from surfactant
deficiency or qualitative or quantitative
surfactant abnormalities
¢ Surfactant normally reduces the surface tension
of the alveoli, thereby decreasing the tendency
of these structures to collapse.
¢ Adhesive atelectasis results from surfactant
deficiency or qualitative or quantitative
surfactant abnormalities
¢ Surfactant normally reduces the surface tension
of the alveoli, thereby decreasing the tendency
of these structures to collapse.
Adhesive atelectasis
Decreased production or inactivation of
surfactant leads to alveolar instability and
collapse. This is observed particularly in acute
respiratory distress syndrome (ARDS) and similar
disorders.
Decreased production or inactivation of
surfactant leads to alveolar instability and
collapse. This is observed particularly in acute
respiratory distress syndrome (ARDS) and similar
disorders.
Rounded atelectasis
« Rounded atelectasis historically called as
* Folded syndrome
« Helical atelectasis
Blesovsky syndrome
Pleural Pseudotumor
+ Pleuroma
« Rounded atelectasis historically called as
* Folded syndrome
« Helical atelectasis
Blesovsky syndrome
Pleural Pseudotumor
+ Pleuroma
Rounded atelectasis
In rounded atelectasis (folded lung syndrome),
an outer portion of the lung slowly collapses as a
result of scarring and shrinkage of the
membrane layers covering the lungs (pleura).
This produces a rounded appearance on x-ray
that doctors may mistake for a tumor.
In rounded atelectasis (folded lung syndrome),
an outer portion of the lung slowly collapses as a
result of scarring and shrinkage of the
membrane layers covering the lungs (pleura).
This produces a rounded appearance on x-ray
that doctors may mistake for a tumor.
Rounded atelectasis
Usually a complication of asbestos-induced
disease of the pleura, but it may also result from
other types of chronic scarring and thickening of
the pleura.
Usually a complication of asbestos-induced
disease of the pleura, but it may also result from
other types of chronic scarring and thickening of
the pleura.
Rounded atelectasis
Rounded atelectasis is another variant of
segmental or subsegmental atelectasis. Usually
located in posterior and lower lobes, lingula, or
right middle lobe.
On CT scan it presents as a subpleural mass, out
of which comes out bunch of vessels and bronchi
that curve like a comet tail as they enter the
atelectatic lung parenchyma (Radiograph and
histologically).
Rounded atelectasis is another variant of
segmental or subsegmental atelectasis. Usually
located in posterior and lower lobes, lingula, or
right middle lobe.
On CT scan it presents as a subpleural mass, out
of which comes out bunch of vessels and bronchi
that curve like a comet tail as they enter the
atelectatic lung parenchyma (Radiograph and
histologically).
Rounded atelectasis
The diagnosis is made from the characteristic
radiologic CT findings.
Rounded atelectasis generally occur in
association with a pleural plaque or a currently
present or resolving pleural effusion.
Below this pleural plaque or thickening or
diseased pleural the lung also goes into small
collapse
The diagnosis is made from the characteristic
radiologic CT findings.
Rounded atelectasis generally occur in
association with a pleural plaque or a currently
present or resolving pleural effusion.
Below this pleural plaque or thickening or
diseased pleural the lung also goes into small
collapse
Rounded atelectasis
Approximately 70 percent of cases are associated
with previous asbestos exposure that is
responsible for the pleural injury. This finding has
also been reported in association with pleural
tuberculosis.
Approximately 70 percent of cases are associated
with previous asbestos exposure that is
responsible for the pleural injury. This finding has
also been reported in association with pleural
tuberculosis.
Rounded atelectasis
Furthermore, pleural thickening is always present
and is frequently greatest near the mass. The
mass often has a curvilinear tail, frequently
referred to as the “comet tail sign.” as i said
Furthermore, pleural thickening is always present
and is frequently greatest near the mass. The
mass often has a curvilinear tail, frequently
referred to as the “comet tail sign.” as i said
RaIiIndad ata
Ro unaea atele
+ This sign is produced by the crowding together of
bronchi and blood vessels that extend from the
lower border of this rounded collapsed mass to
the hilum, creating a whorled appearance of the
bronchovascular bundle on CT scan
Ro unaea atele
+ This sign is produced by the crowding together of
bronchi and blood vessels that extend from the
lower border of this rounded collapsed mass to
the hilum, creating a whorled appearance of the
bronchovascular bundle on CT scan
Rounded atelectasis
Not all rounded atelectasis is actually round:
Atypical features include wedge-shaped,
lentiform, or (less often) irregular opacities or
attenuation. Volume loss of the affected lobe is
uniformly present, often with hyperlucency of
the adjacent lung. Serial examination usually
showsa stable appearance.
Not all rounded atelectasis is actually round:
Atypical features include wedge-shaped,
lentiform, or (less often) irregular opacities or
attenuation. Volume loss of the affected lobe is
uniformly present, often with hyperlucency of
the adjacent lung. Serial examination usually
showsa stable appearance.
Rounded atelectasis
As | said generally in association with a:pleural
plaque Or a currently present or resolving pleural
effusion.
+ Can
Persist for years
Clear spontaneously
Grow rarely
+ If remains stable then no problem and leave it
As | said generally in association with a:pleural
plaque Or a currently present or resolving pleural
effusion.
+ Can
Persist for years
Clear spontaneously
Grow rarely
+ If remains stable then no problem and leave it
Rounded atelectasis
Affected patients typically are asymptomatic, and
the mean age at presentation is 60 years.
Rounded atelectasis may mimic a Neoplastic
tumor. The comet tail sign or talon sign is its
distinguishing radiographic characteristic.
Affected patients typically are asymptomatic, and
the mean age at presentation is 60 years.
Rounded atelectasis may mimic a Neoplastic
tumor. The comet tail sign or talon sign is its
distinguishing radiographic characteristic.
Direct Signs of collapse on x ray
+ Displacement of the interlobar fissures towards
the area of atelectasis (most reliable sign).
« Crowding of the broncho-vascular markings at
the collapsed area of lung
¢ Increased lung opacity (non specific).
y
+ Displacement of the interlobar fissures towards
the area of atelectasis (most reliable sign).
« Crowding of the broncho-vascular markings at
the collapsed area of lung
¢ Increased lung opacity (non specific).
y
Movement of Fissures
You need a lateral view to
appreciate the movement
of oblique fissures.
Forward movement of
oblique fissure in LUL
atelectasis. Backward
movement in Lower lobe
atelectasis.
Movement of transverse
fissure can be recognized
in the PA film
You need a lateral view to
appreciate the movement
of oblique fissures.
Forward movement of
oblique fissure in LUL
atelectasis. Backward
movement in Lower lobe
atelectasis.
Movement of transverse
fissure can be recognized
in the PA film
Left Oblique or Major Fissure
Anterior Posteriol
Anterior Posteriol
Indirect signs of collapse on x ray
+ Hilar displacement./Normally left hilum is upto 2cm
higher than right hilum
« Shift of Mediastinum: The trachea and heart gets shifted
towards the atelectatic lung
+ Hilar displacement./Normally left hilum is upto 2cm
higher than right hilum
« Shift of Mediastinum: The trachea and heart gets shifted
towards the atelectatic lung
Indirect signs of collapse on x ray
Upward displacement of hemidiaphragm
ipsilateral to the side of Atelectasis and the
normal relationship between left and right side
gets altered. Normally right hemidiaphragm is
upto 2cm higher than left
« Approximation of / Ribs and intercostal spaces
« Compensatory hyperinflation.
(à
Upward displacement of hemidiaphragm
ipsilateral to the side of Atelectasis and the
normal relationship between left and right side
gets altered. Normally right hemidiaphragm is
upto 2cm higher than left
« Approximation of / Ribs and intercostal spaces
« Compensatory hyperinflation.
(à
Alterations in proportion of Left and Right
Lung
¢ The right lung is approximately 55% and left lung
45%. In atelectasis this apportionment will
change and can be a clue to recognition of
atelectasis.
Lung
¢ The right lung is approximately 55% and left lung
45%. In atelectasis this apportionment will
change and can be a clue to recognition of
atelectasis.
* Airbronchogram sign
— Produced as a
result of airspace
opacification of the
lung parenchyma
— This results in
visibility of the
normally invisible
black bronchi
against a
background of
white opacification
» Seenin
consolidation and
collapse with atleast
some patency of the
bronchus
— Produced as a
result of airspace
opacification of the
lung parenchyma
— This results in
visibility of the
normally invisible
black bronchi
against a
background of
white opacification
» Seenin
consolidation and
collapse with atleast
some patency of the
bronchus
Homogenous opacity left upper and mid zones
1, Air bronchogram
2. Loss of left heart border sithouette
3. Left dome diaphragm well seen
4, No evidence of push/pull
5. Normal CP angles
6. No volume loss
No signs of push/pull
1. Homogenous opacity left side thorax
2. Classic air bronchogram
3. Loss of left heart border silhouette
4, Left diaphragm dome well seen
Consolidation left lung upper lobe including lingular
segment
1, Air bronchogram
2. Loss of left heart border sithouette
3. Left dome diaphragm well seen
4, No evidence of push/pull
5. Normal CP angles
6. No volume loss
No signs of push/pull
1. Homogenous opacity left side thorax
2. Classic air bronchogram
3. Loss of left heart border silhouette
4, Left diaphragm dome well seen
Consolidation left lung upper lobe including lingular
segment
Causes of Air Bronchogram
Common Rare
Expiratory film Lymphoma
Consolidation Alveolar cell carcinoma
Pulmonary ocdema Sarcoidosis
Hyaline membrane disease Fibrosing alveolitis
Alveolar proteinosis Radiation fibrosis
ARDS
Common Rare
Expiratory film Lymphoma
Consolidation Alveolar cell carcinoma
Pulmonary ocdema Sarcoidosis
Hyaline membrane disease Fibrosing alveolitis
Alveolar proteinosis Radiation fibrosis
ARDS
Open bronchus sign
« When air bronchogram is visible in an atelectatic
lung, it implies that there is no airway
obstruction. It is more a trapped lung with patent
airways.
« When air bronchogram is visible in an atelectatic
lung, it implies that there is no airway
obstruction. It is more a trapped lung with patent
airways.
Special signs
* Luftsichel sign: compensatory hyperinflation of the superior
segment of the lower lobe in upper lobe collapse which herniates
between the collapsed lobe and the mediastinum.
* Juxtphrenic peak: a small triangular opacity near the dome of
the diaphragm due to stretching of the inferior accessory fissure
or inferior pulmonary ligament
* Broncholobar sign: A lobe collapses around the bronchus that
enters it, so that if both the collapsed lobe & the bronchus are
seen, they should be related to each other.
* Luftsichel sign: compensatory hyperinflation of the superior
segment of the lower lobe in upper lobe collapse which herniates
between the collapsed lobe and the mediastinum.
* Juxtphrenic peak: a small triangular opacity near the dome of
the diaphragm due to stretching of the inferior accessory fissure
or inferior pulmonary ligament
* Broncholobar sign: A lobe collapses around the bronchus that
enters it, so that if both the collapsed lobe & the bronchus are
seen, they should be related to each other.
Physical Findings of Collapse Lung
+ Inspection
* Patient having cough
« Drooping of Shoulder on the affected side may
be present
+ Delayed chest expansion on the affected side
Increased respiratory rate
Increased pulse
Possible cyanosis (À
/
+ Inspection
* Patient having cough
« Drooping of Shoulder on the affected side may
be present
+ Delayed chest expansion on the affected side
Increased respiratory rate
Increased pulse
Possible cyanosis (À
/
Physical Findings of Collapse Lung
« Palpation
¢ Chest expansion decreased on the affected side
« Tactile fremitus decreased or absent over the
involved area
» With a large collapse, the trachea may deviate or
shift toward the affected side
y
« Palpation
¢ Chest expansion decreased on the affected side
« Tactile fremitus decreased or absent over the
involved area
» With a large collapse, the trachea may deviate or
shift toward the affected side
y
Physical Findings of Collapse Lung
« Percussion
« Dull over affected area
¢ Auscultation
« Breath sounds decreased or absent over
involved area
+ No adventitious sounds if bronchus is obstructed
* Occasional fine crackles if bronchus is patent
« Percussion
« Dull over affected area
¢ Auscultation
« Breath sounds decreased or absent over
involved area
+ No adventitious sounds if bronchus is obstructed
* Occasional fine crackles if bronchus is patent
Patterns of Atelectasis
* Complete white-out of a
hemithorax on the chest
x-ray has a limited
number of causes. The
differential diagnosis can |
be shortened further with
one simple observation -
the position of the
trachea. Is it central,
pulled or pushed from the
side of opacification?
tittle
hemithorax on the chest
x-ray has a limited
number of causes. The
differential diagnosis can |
be shortened further with
one simple observation -
the position of the
trachea. Is it central,
pulled or pushed from the
side of opacification?
tittle
D/D of complete opacification of a
, hemithorax (complete white out)
Trachea central Trachea shifted
a
Trachea pulled
, hemithorax (complete white out)
Trachea central Trachea shifted
a
Trachea pulled
‘= Causes of opacification of a hemithorax
1. Massive pleural effusion
2. Massive collapse
3. Massive consolidation
4. Pneumonectomy
5. Fibrothorax
6. Massive tumor
7. Combination of above lesions
8. Lung agenesis
1. Massive pleural effusion
2. Massive collapse
3. Massive consolidation
4. Pneumonectomy
5. Fibrothorax
6. Massive tumor
7. Combination of above lesions
8. Lung agenesis
Complete white-out of a hemithorax Trachea
pulled toward the opacified side
Massive fibro thorax
Pneumonectomy
Total or Massive lung collapse
Pulmonary Agenesis
Pulmonary Hypoplasia
pulled toward the opacified side
Massive fibro thorax
Pneumonectomy
Total or Massive lung collapse
Pulmonary Agenesis
Pulmonary Hypoplasia
Complete white-out of a hemithorax Trachea
pushed toward the opposite of opacified side
* Massive consolidation
« Massive Pulmonary oedema/ARDS
« Massive Pleural mass: e.g. Mesothelioma
+ Massive chest wall mass: e.g. Askin/Ewing
sarcoma
pushed toward the opposite of opacified side
* Massive consolidation
« Massive Pulmonary oedema/ARDS
« Massive Pleural mass: e.g. Mesothelioma
+ Massive chest wall mass: e.g. Askin/Ewing
sarcoma
Complete white-out of a hemithorax Trachea
pushed toward the opposite of opacified side
+ Massive pleural effusion
+ Massive diaphragmatic hernia
+ Massive tumour
pushed toward the opposite of opacified side
+ Massive pleural effusion
+ Massive diaphragmatic hernia
+ Massive tumour
Complete white-out of a hemithorax Trachea
pulled toward the opacified side
¢ If complete white out of hemithorax on x ray is
due to pneumonectomy then patient will give
you history of surgery done on thorax-
thoracotomy and there will be a scar on his
thorax even there may be evidence of rib
resection on x ray etc
pulled toward the opacified side
¢ If complete white out of hemithorax on x ray is
due to pneumonectomy then patient will give
you history of surgery done on thorax-
thoracotomy and there will be a scar on his
thorax even there may be evidence of rib
resection on x ray etc
Two types of Pneumonectomy
+ Simple pneumonectomy: removal of just the
affected lung
« Extra pleural pneumonectomy (EPP): removal of
the affected lung, plus part of the diaphragm, the
parietal pleura (lining of the chest) and the
pericardium (lining of the heart) on that side
3
+ Simple pneumonectomy: removal of just the
affected lung
« Extra pleural pneumonectomy (EPP): removal of
the affected lung, plus part of the diaphragm, the
parietal pleura (lining of the chest) and the
pericardium (lining of the heart) on that side
3
Wedge resection Lobectomy Pneumonectomy
À An
f N (>
Ve à £ A
N a \
A À 1 %
Rs |A Len
PERERA |
er Y — |
Lobectomy Pneumonectomy
| hon Ms %
es WS D 22)
Wedge Resection
j
f
|
Segmentectomy
f N (>
Ve à £ A
N a \
A À 1 %
Rs |A Len
PERERA |
er Y — |
Lobectomy Pneumonectomy
| hon Ms %
es WS D 22)
Wedge Resection
j
f
|
Segmentectomy
Figure 19A: This PA radiograph of the chest was obtained in
a patient following a pneumonectomy for bronchogenic carci-
noma involving the left lung. There is opacification of the left
hemithorax with a shift of the mediastinum toward the left side
and elevation of the left hemidiaphragm, as indicated by an
elevated gastric air bubble.
a patient following a pneumonectomy for bronchogenic carci-
noma involving the left lung. There is opacification of the left
hemithorax with a shift of the mediastinum toward the left side
and elevation of the left hemidiaphragm, as indicated by an
elevated gastric air bubble.
Pneumonectomy
The trachea, hila and mediastinur are deviated
to the left. Are they PUSHED or PULLED?
This patient has had a pneumonectomy
{removal of the left lung) to treat a lung cancer
Note the left main bronchu otly | EIASTINGT
(anowhead) d SUN un ol
heart and great ve:
the fill the space vacated by the remo:
The tight lung has expanded to fill the s
The trachea, hila and mediastinur are deviated
to the left. Are they PUSHED or PULLED?
This patient has had a pneumonectomy
{removal of the left lung) to treat a lung cancer
Note the left main bronchu otly | EIASTINGT
(anowhead) d SUN un ol
heart and great ve:
the fill the space vacated by the remo:
The tight lung has expanded to fill the s
Photo 1
Chest X-ray of a 45-year-
old female patient who
underwent aright
pneumonectomy for stage
2b adenocarcinoma and
who presented with
postpneumonectomy
syndrome 6 months after
au the operation. Massive
View larger verzion: mediastinal shift toward the
» In this page » In a new window pneumonectomy space as
Le IR well as stretching of the left
main bronchus across the
Chest X-ray of a 45-year-
old female patient who
underwent aright
pneumonectomy for stage
2b adenocarcinoma and
who presented with
postpneumonectomy
syndrome 6 months after
au the operation. Massive
View larger verzion: mediastinal shift toward the
» In this page » In a new window pneumonectomy space as
Le IR well as stretching of the left
main bronchus across the
(a Differential diagnosis of common causes of unilateral lung opacity
Parameter Pleural effusio ¡ Consolidation | Post-pneumonectomy
1. Tracheal shift Opposite side Sameside No shit Same side
2. Mediastinal shift Opposie side Same side No shift Same side
3. Thoracicvolume Inereased Reduced Normal Reduced
4, Signs of push Seen No No No
5, Signs of pul No Seen No Seen
6, Airbronchogram No +Minimal Marked No
7. Costophrenic recess Full, effaced, blunted Normal Normal Normal
8. Evidence of surgery Nil Nil NIL Yes, ib resection
Parameter Pleural effusio ¡ Consolidation | Post-pneumonectomy
1. Tracheal shift Opposite side Sameside No shit Same side
2. Mediastinal shift Opposie side Same side No shift Same side
3. Thoracicvolume Inereased Reduced Normal Reduced
4, Signs of push Seen No No No
5, Signs of pul No Seen No Seen
6, Airbronchogram No +Minimal Marked No
7. Costophrenic recess Full, effaced, blunted Normal Normal Normal
8. Evidence of surgery Nil Nil NIL Yes, ib resection
Signs of ‘push’ (to opposite side of the lesion) and signs of ‘pull’ (toward same side
of the lesion)
Structure
Massive pleural effusion Lobar collapse
Displaced to opposite side Displaced to same side
Displaced to opposite side Displaced to same side
Displaced to opposite side Displaced to same side
Widened Narrowed
Not seen Crowded
Ipsilateral side depressed Ipsilateral dome pulled up
Not seen Pulled
of the lesion)
Structure
Massive pleural effusion Lobar collapse
Displaced to opposite side Displaced to same side
Displaced to opposite side Displaced to same side
Displaced to opposite side Displaced to same side
Widened Narrowed
Not seen Crowded
Ipsilateral side depressed Ipsilateral dome pulled up
Not seen Pulled
Massive Pleural Effusion
2
a
ña Signs of push-opposite side
Chest X-ray PA view erect
Opacity rot hemithorax 1. Opacity right hemithorax
Right diaphragm dome obscured 2. Tracheal shift to left side
Right cardiac border obscured 3. Mediastinal shift to teft-black arrow
No air bronchogram/bronchovascular markings : En ponia Sm si arrow
Signs of push-mediacstinal shift to left tracheal shift to left ight cardiac border obscure
widened, Le. spaces Right massive pleural effusion in tension
Increased thoracic volume right side
Fig. 3.1: Chest X-ray showing massive pleural effusion
2
a
ña Signs of push-opposite side
Chest X-ray PA view erect
Opacity rot hemithorax 1. Opacity right hemithorax
Right diaphragm dome obscured 2. Tracheal shift to left side
Right cardiac border obscured 3. Mediastinal shift to teft-black arrow
No air bronchogram/bronchovascular markings : En ponia Sm si arrow
Signs of push-mediacstinal shift to left tracheal shift to left ight cardiac border obscure
widened, Le. spaces Right massive pleural effusion in tension
Increased thoracic volume right side
Fig. 3.1: Chest X-ray showing massive pleural effusion
e Difereniting colapse fom consoldation
Consolidation
1. Shape ra Confined to belbronehapulmanar segment
2. Arbronchogam Maybe presen Always presen
3, Lungvolume loss Present Absent
4, Signs ofpul Presa, same sde Absent
5, Apex a hum les Apex nt centred at hlum
Consolidation
1. Shape ra Confined to belbronehapulmanar segment
2. Arbronchogam Maybe presen Always presen
3, Lungvolume loss Present Absent
4, Signs ofpul Presa, same sde Absent
5, Apex a hum les Apex nt centred at hlum
Massive Lung Collapse
Chest X-ray PA view erect
Homogenous opacity right side thorax
No bronchovascular marking in right
No air bronchogram
Tracheal shift to right
Cardiac (mediastinal) shit to right
Crowding of ribs right
Right diaphragm dome and
Right cardiac border obscured
Signs of pull~same side
Right lung collapse
1. Tracheal shift to right side—arrow
2. Cardiac shift to right side—arrow
3. Loss of right dome diaphragm outline—arrow
4. Loss of right heart border outline
Massive total collapse right side
Chest X-ray PA view erect
Homogenous opacity right side thorax
No bronchovascular marking in right
No air bronchogram
Tracheal shift to right
Cardiac (mediastinal) shit to right
Crowding of ribs right
Right diaphragm dome and
Right cardiac border obscured
Signs of pull~same side
Right lung collapse
1. Tracheal shift to right side—arrow
2. Cardiac shift to right side—arrow
3. Loss of right dome diaphragm outline—arrow
4. Loss of right heart border outline
Massive total collapse right side
Chest X-ray PA view erect
Homogenous opacity left side thorax
No volume loss
1, Air bronchogram
2. Loss of left heart border silhouette
3. Left dome diaphragm well seen
4, No evidence of push/pull
5. Normal CP angles
No signs of push/pull
1, Homogenous opacity left side thorax
2. Classic airbronchogram
3. Loss of left heart border silhouette
4, Left diaphragm dome well seen
Consolidation left lung upper lobe including lingular
segment
Homogenous opacity left side thorax
No volume loss
1, Air bronchogram
2. Loss of left heart border silhouette
3. Left dome diaphragm well seen
4, No evidence of push/pull
5. Normal CP angles
No signs of push/pull
1, Homogenous opacity left side thorax
2. Classic airbronchogram
3. Loss of left heart border silhouette
4, Left diaphragm dome well seen
Consolidation left lung upper lobe including lingular
segment
Left side post-pneumonectomy
Evidence of rib resection left side
Opacity left side thorax
Reduced left side thoracic volume
Marked signs of pul
tracheal shift to left
mediastinal shift to left
crowding of lef side ribs
left heart border obscured
left diaphragm dome obscured
Signs of pull
1. Tracheal shift to left side
2. Mediastinal shift to left
3. Left heart border obscured
4. Left diaphragm dome obscured
5. Opacity left hemithorax
6. Air trapped postoperative complication
7. Rib resection-evidence of surgery
S/P post-pneumonectomy left lung
Evidence of rib resection left side
Opacity left side thorax
Reduced left side thoracic volume
Marked signs of pul
tracheal shift to left
mediastinal shift to left
crowding of lef side ribs
left heart border obscured
left diaphragm dome obscured
Signs of pull
1. Tracheal shift to left side
2. Mediastinal shift to left
3. Left heart border obscured
4. Left diaphragm dome obscured
5. Opacity left hemithorax
6. Air trapped postoperative complication
7. Rib resection-evidence of surgery
S/P post-pneumonectomy left lung
—
ES
we
a
au
iS |
B en
Gy
ES
we
a
au
iS |
B en
Gy
Pleural effusion
= > À
| |
= > À
| |
ton
Pn
\eumone
1ec
al
©
3
<<
Pn
\eumone
1ec
al
©
3
<<
Bronchial cutoff sign
Crowding of ribs
,interspaces getting
narrowed
Trachea deviated to Rt
Mediastinum shifted
heart shifted to Rt
Compensatory
hyperinflation of the
contralateral lung
Crowding of ribs
,interspaces getting
narrowed
Trachea deviated to Rt
Mediastinum shifted
heart shifted to Rt
Compensatory
hyperinflation of the
contralateral lung
« Atelectasis also show in other forms sharply-
defined opacity obscuring vessels without air-
bronchogram
« Volume loss results in displacement of
diaphragm, fissures, hili or mediastinum as we
will see in following x rays
defined opacity obscuring vessels without air-
bronchogram
« Volume loss results in displacement of
diaphragm, fissures, hili or mediastinum as we
will see in following x rays
Lung Collapse & Consolidation & Pleural
effusion
1. Collapse and consolation can occur
independently or together
2. Collapse can be partial or complete
3. It is often not clear to what extent the
appearance is due to collapse or consolidation or
both. The degrees of each are often unclear.
effusion
1. Collapse and consolation can occur
independently or together
2. Collapse can be partial or complete
3. It is often not clear to what extent the
appearance is due to collapse or consolidation or
both. The degrees of each are often unclear.
Lung Collapse & Consolidation
4. If a lobe is only partially collapsed and there is
no accompanying consolidation, there may be no
increase in opacity
5. In cases of pure collapse, only when the collapse
is virtually complete will there be a significant
increase in density or opacity of the affected lung
4. If a lobe is only partially collapsed and there is
no accompanying consolidation, there may be no
increase in opacity
5. In cases of pure collapse, only when the collapse
is virtually complete will there be a significant
increase in density or opacity of the affected lung
On x ray
* Complete opacification of
the ipsilateral hemithorax.
+ Mediastinal shift to the
opposite side.
+ OnCT Scan Chest
* The collapsed lung opacifies
and appear denser than
fluid in pleural space.
* The collapsed lung appears
tethered to the hilum.
« This is relaxation or
compression collapse
* Complete opacification of
the ipsilateral hemithorax.
+ Mediastinal shift to the
opposite side.
+ OnCT Scan Chest
* The collapsed lung opacifies
and appear denser than
fluid in pleural space.
* The collapsed lung appears
tethered to the hilum.
« This is relaxation or
compression collapse
ssive
+ Onx ray
* Signs of pneumothorax.
+ The lung is tethered to
the hilum.
* There is no increase in
lung density until collapse
is complete and lung
become airless
* This is also relaxation or
compression collapse
+ Onx ray
* Signs of pneumothorax.
+ The lung is tethered to
the hilum.
* There is no increase in
lung density until collapse
is complete and lung
become airless
* This is also relaxation or
compression collapse
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