Atelectasis

Dr.dr H Djoko Trihadi

Medical Department
UNISSULA Medical Faculty

Atelectasis
Greek = incomplete stretching
Definition: diminished gas
within the lung associated with
reduced lung volume and
radiologic signs

Signs of Atelectasis
Direct
Indirect

Direct Signs
Displacement of fissures
Increased opacification of the
airless lobe.
Crowding of pulmonary vessels

Indirect Signs
Displacement of hilar structures
(Katans triangle sign)
Cardiomediastinal shift toward the side
of collapse
Narrowing of ipsilateral intercostal
spaces
Elevation of the ipsilateral
diaphragmatic leaflet (Juxtaphrenic
peak sign)

Indirect Signs
Compensatory hyperexpansion and
hyperlucency of the remaining
aerated parts of the lung
Obscuring of structures adjacent to
the collapsed lung, such as the
diaphragm, heart, or pulmonary
vessels.

Types of Atelectasis
Obstructive
Nonobstructive

Types of Atelectasis
Obstructive
Blockage of an airway.
Air retained distal to the occlusion
is then resorbed from
nonventilated alveoli. Over time,
the affected regions become
totally airless.

Obstructive Atelectasis
Causes:

1). Bronchogenic carcinoma (always a

consideration in patients with histories of
persistent atelectasis, recurrent atelectasis,
or recurrent pneumonia with failure of complete
clearing after treatment)
2). Bronchial carcinoid (above considerations
also apply here)
3). Metastases to the bronchi: most commonly
renal cell carcinoma, breast carcinoma,
melanoma, adenocarcinoma of the colon,
sarcomas

Obstructive Atelectasis
Causes:

4). Lymphoma (usually late stage and

accompanied by hilar and mediastinal
lymphadenopathy) or other causes of bulky
adenopathy
5). Tuberculosis
6). Left atrial enlargement from mitral stenosis
(left lower-lobe atelectasis)
7). Foreign body obstruction
8). Mainstem bronchus intubation

Types of Atelectasis
Nonobstructive
Causes:
Loss of contact between the parietal
and visceral pleura,
Parenchymal compression,
Loss of surfactant,
Replacement of lung tissue by
scarring or infiltrative disease.

Types of Atelectasis
Mechanisms of Atelactasis

Relaxation
Compressive
Adhesive
Cicatrization
Replacement
Rounded

Types of Atelectasis
Relaxation
Contact between the parietal and
visceral pleurae is eliminated.
1). Pleural effusion
2). Pneumothorax
3). Hydrothorax, hemothorax
4). Diaphragmatic hernia
5). Pleural masses (including
metastases and mesothelioma)

Types of Atelectasis
Compressive
Chest wall, pleural, intraparenchymal
masses, or loculated collections of
pleural fluid lead to a diminution in lung
volume below the usual resting volume.
It has much in common with relaxation
atelectasis, but is distinguished by local,
rather than generalized, collapse.

Types of Atelectasis
Compressive
Causes:
peripheral tumor compressing
adjacent normal lung,
extensive air trapping (as seen in
bullous emphysema, lobar
emphysema, interstitial emphysema,
or bronchial foreign body obstruction)

Types of Atelectasis
Adhesive

Induced by surfactant dysfunction.

Decreased production or
inactivation of surfactant leads to
alveolar instability and collapse.
Respiratory distress syndrome of
premature infants, ARDS, acute
radiation pneumonitis, PE and lung
contusion.

Types of Atelactasis
Adhesive
In the appropriate clinical setting,
PULMONARY EMBOLISM MUST
ALWAYS BE CONSIDERED in the
patient with SUBSEGMENTAL
atelectasis AND PLEURAL
EFFUSION. Induced by surfactant
dysfunction.

Types of Atelectasis
Cicatrization

Diminution of volume as a sequel of

severe parenchymal scarring.
Etiologies include:

granulomatous disease,
late sequelae of TB,
necrotizing pneumonia,
radiation
pneumoconioses
Collagen vascular diseases (e.g.,
scleroderma, rheumatoid lung)

Types of Atelectasis
Replacement
Occurs when the alveoli of an
entire lobe are filled by tumor,
such as bronchioloalveolar cell
carcinoma, with ensuing loss of
volume.

Types of Atelectasis
Rounded
Also called folded lung or
Blesofsky syndrome
A distinct form of atelectasis
associated with pleural disease,
particularly following asbestos
exposure

MRI
Can distinguish between
obstructive and nonobstructive
atelectasis.
Obstructive atelectasis displays
high signal intensity on T2weighted images due to protonrich mucus accumulation.

MRI
Nonobstructive atelectasis
shows low signal intensity on
T1 and T2 images
The use of MRI in diagnosing
atelectasis is still experimental,
and more experience needs to
be accrued

RUL (Right Upper Lobe)

Collapse
Elevation of the right hilum and
the minor fissure
Convex upward
Collapse lobe tends to shift
cephalad and medially

Right Upper Lobe

Atelectasis
This configuration of the minor
fissure is called the S-sign of Golden
and indicates a probable neoplastic
etiology for the obstructive
atelectasis.
A juxtaphrenic peak indicates loss of
volume in the upper lobe and can be
a helpful sign of upper lobe
atelectasis.

RUL Atelectasis
Medial collapse of the right upper
lobe can occasionally mimic a right
paratracheal mass
Lateral collapse lead to a peripheral
mass-like opacity that mimics a
loculated pleural effusion.
Right middle and lower lobes
hyperexpand superiorly and medially
rather than laterally.

RML(Right Medium
Lobe) Atelectasis
Greater tendency to collapse
because of:
1) decreased collateral
ventilation
2) a long thin curved bronchus
3) Possible compression by a
collar of enlarged lymph nodes
at bronchus origin

RML(Right Medium
Lobe) Atelectasis
Chronic RML Atelactasis
RML syndrome
Frequently nonobstructive
Accompanied by scarring and
bronchiectasis
Often found in elderly women

RML(Right Middle Lobe)

Total collapse has little impact
on appearance of surrounding
structures
Absent contour of right heart
border
A small triangular opacity
pointing laterally

RML(Right Middle Lobe)

Atelectasis
On CT scan, the atelectatic right
middle lobe presents as a
triangular opacity with its apex
pointing laterally and with its
medial contour apposed against
the right heart border.
This has been called the "tilted
ice cream cone" appearance

RLL (Right Lower Lobe)

Atelectasis
Tethered to the mediastinum by the
hilar structures and the inferior
pulmonary ligament.
Visibility of major fissure early sign
of RLL collapse on frontal X-ray
Forms a triangular opacity that
obscures the lower lobe pulmonary
artery.

RLL(Right Lower Lobe)

Atelectasis
Eventually, the collapsed lobe
forms a right paraspinal mass
that projects behind the right
atrium.
Superior mediastinal structures
shift to the right and form a
superior paratracheal triangular
opacity.

RLL (Right Lower Lobe)

Atelectasis
In lateral view, posterior third of
right hemidiaphragm is
obscured.
In frontal view, dome of right
hemidiaphragm is often not
obscured

RLL(Right Lower Lobe)

Atelectasis
On CT scan, RLL atelactasis
can mimic a paraspinal mass.
If present, air bronchograms
may reveal the true nature of
such a space occupying lesion.

RML(Right Mid Lobe)

and RLL Collapse
Combined RML and RLL collapse
can mimic an elevated right
hemidiaphragm or a
subpulmonic effusion.
Obscuring of the right hilum and
the straight contour of the
minor fissure interface help
establish the correct diagnosis.

LUL(Left Upper Lobe)

Atelectasis
The left upper lobe is larger than the right
upper lobe.
Because it lacks a minor fissure in most
cases, the pattern of collapse is different
from that seen with right upper lobe
collapse .
A completely atelectatic left upper lobe
tends to retract more anteriorly than
superiorly.
On the frontal view, it produces a faint, hazy
opacity in the left upper hemithorax, which
can be mistaken for pleural thickening

LUL (Left Upper Lobe)

Atelectasis
The left cardiac contour is
frequently obscured by the lingula
The main pulmonary trunk and the
upper contour of the left central
pulmonary artery are obliterated,
The left hilar structures are
retracted cephalad
The left lower lobe basilar segmental
arteries are elevated and clearly
visible in retrocardiac location.

LUL Atelectasis
The hyperexpanded left lower
lobe occupies most of the left
hemithorax, with the superior
segment occupying the apex,
thus mimicking an aerated
upper lobe.

LUL Atelactasis
Luftsichel, is an indirect sign of
left upper lobe atelectasis
Crescent of aerated lung
This represent an incomplete
major fissure pulled forward by the
atelectatic upper lobe, interposed
between the atelectasis and the
aortic arch

Note the increased opacification of the left upper

lung field with elevation of the left
hemidiaphragm. In addition, there is lucency
adjacent to the aorta. This is the Luftsichel sign,
representing an overexpanded right lower lobe.

LUL Atelectasis
On the lateral view, the major fissure
is markedly displaced anteriorly
The atelectatic left upper lobe forms
a narrow crescent adjacent to the
anterior chest wall.
The hyperexpanded anterior
segment of the right upper lobe can
herniate across the midline into the
retrosternal clear space, sharply
outlining the anterior contour of the
ascending aorta.

LUL Collapse
CT-scan reveals the anterior
orientation of the collapsed
lobe and displays the aerated
lung tissue of the right upper
lobe interposed between the
aortic arch and the collapsed
left upper lobe.

LLL(Left Lower Lobe)

Atelectasis
Collapse of the left lower lobe is frequently
seen after cardiac surgery.
Cold cardioplegia with damage to the left
phrenic nerve
Compression of the lobe by an enlarged
heart
Postoperative contusion
Mucus accumulation due to a slightly more
vertical orientation of the left mainstem
bronchus.

LLL(Left Lower Lobe)

Atelectasis
The left major fissure can
parallel the left cardiac border,
and the completely atelectatic
lobe can mimic a left paraspinal
mass.
Mediastinal shift can lead to
partial obliteration of the aortic
arch (the top of the knob sign)

RML(Right Mid Lobe)

and RLL(Right Lower
Lobe)
Atelectasis
The most
common combined
atelectasis.
Explaination: a simple
obstructing lesion, located
within the bronchus
intermedius, can affect the
aeration of both lobes
simultaneously.

RML and RLL Collapse

Common lesions:

mucous plugs,
lung cancer,
foreign bodies,
hamartomas
carcinoid tumors

RML and RLL Collapse

Rare lesions:

Endobronchial tuberculosis,
Histoplasmosis,
Broncholithiasis
Inflammatory pseudotumors.

Entire Lung Atelectasis

Total collapse of a lung leads to
complete opacification of an entire
hemithorax with ipsilateral
cardiomediastinal shift.
The latter finding distinguishes
atelectasis from a massive pleural
effusion, a setting in which the
mediastinum shifts to the
contralateral side.

Entire Lung Atelectasis

In the lateral projection, the
cardiac silhouette, one
hemidiaphragm, and one hilum
are obscured.
CT scan demonstrates to best
advantage the shift of
cardiomediastinal structures.