Atelektasis

Galih Arief
1102011110

Atelektasis
Kolapsnya atau hilangnya volume paru
Dapat terjadi pada seluruh lapang paru, lobus,
segmen, dan subsegmental
Terdapat 5 mekanisme atelektasis :
1) (Post) obstructive
2-5) Non-obstructive typically due to loss of contact
between parietal and visceral pleura.

Pada
presentasi
ini
akan
dijelaskan
5
mekanisme terjadinya atelektasis dan gambaran
radiologisnya ( X-ray Finding )

XR Findings in Atelectasis
Direct:
Displacement of fissures
Increased opacification of airless lobe
Crowded air bronchograms (non-obstructive only) or
vessels

Indirect:

Displacement of hilar structures

Ipsilateral cardiomediastinal shift
Narrowing of ipsilateral intercostal spaces
Obscured structures adjacent to atelectasis
Elevation of ipsilateral diaphragmatic leaflet
Hyperexpansion/hyperlucency of remaining aerated lung

Typical
findings
of
atelectasis
in
this
patient include:
1) Hazy opacity in left
upper
lung
(direct
sign)
2) Left tracheal shift
(indirect sign)
3) Loss of left cardiac
silhouette
(indirect
sign)

Lobar Collapse

Right Lobar Anatomy

Approximate position of right upper, middle and lower

lobes on chest x-ray.

Right Lobar Anatomy

Lateral View

Left Lobar Anatomy

Approximate position of left upper and lower lobes

on chest x-ray.

Left Lobar Anatomy

Lateral View

Right Upper Lobe Atelectasis

Findings include:
Elevation of right hilum and minor fissure
Collapsed lobe shifts cephalad and medially
If due to a central mass, the minor fissure
retracts cranially with a lateral upward
convexity and a medial caudal convexity (Ssign of Golden). This suggests neoplastic
etiology.

Right upper lobe

atelectasis:
The
atelectatic
RUL
forms a triangular
opacity
(arrow).
The elevated minor
fissure is retracted
cranially (see image
below) and forms a
reverse S shape (Ssign of Golden) as it
curves around the
hilar mass (M).

Right Middle Lobe Atelectasis

Right middle lobe is only 10% of total lung
volume.
Greater tendency to collapse than other
lobes.
Radiographic findings can be subtle:
Small triangular opacity pointing laterally
Obscured right heart border
Lateral view: obliquely oriented triangular opacity
with apex pointed toward hilum.

Right middle lobe

atelectasis: There
is
a
small
triangular opacity
pointing laterally,
right
cardiac
border is partially
obscured,
and
slightly
lower
lung volume in
right compared to
left.

Lateral view:
The arrows point to
the major and minor
fissures which are
parallel
to
each
other.
The
atelectatic
middle
lobe is the opacity
between
the
fissures. Notice that
it projects over the
cardiac silhouette.

Right Lower Lobe Atelectasis

When
atelectatic,
right
posteromedially and inferiorly.

lower

lobe

retracts

Major fissure is shifted downward and becomes visible

As RLL collapses, it forms a triangular opacity which
obscures the left lobe pulmonary artery, and eventually
forms a right paraspinal mass that projects behind the
right atrium.
On lateral view, posterior 1/3 of right diaphragm is
obscured by collapsed RLL. Diaphragm may not be
obscured on frontal view because hyperexpanded middle
lobe abuts it.

RLL Atelectasis:
Triangular
opacity
in
right
lower
hemithorax.
The
lateral border is the
major fissure (not
normally seen on
frontal view). Right
hilum is displaced
caudally
and
partially obscured.
The hyperexpanded
RML outlines the
cardiac border and
right
hemidiaphragm.

Left Upper Lobe Atelectasis

Faint, hazy opacity in left upper hemithorax
50% of patients have complete major fissure
Main pulmonary trunk and upper contour of left pulmonary
artery are obliterated
Left hilar structures and left lower lobe are retracted caudally
(look for superior segment vessels from the lower lobe
occupying the apex, mimicking an aerated upper lobe)
50% have an incomplete major fissure

Tongue of aerated lower lobe is pulled forward by atelectatic lobe,

between the atelectasis and the aortic arch, forming a crescentshaped lucency (Luftsichel sign)

Diaphragm typically elevated

Left
upper
lobe
atelectasis:
Opacity
contiguous to the aortic
arch. The mediastinum
is shifted toward the left
hemithorax,
which
is
small in comparison to
the
right.
The
main
pulmonary trunk and the
left pulmonary artery
are obliterated.

Left
upper
lobe
atelectasis in patient
with
incomplete
major fissure: There
is
an
ill-defined
opacity in the left
half of the left upper
thorax. The trachea
is deviated left and
the left hilum is
retracted superiorly.
Vascular branches to
the left lower lobe
superior
segment
form an array of
linear and tubular
opacities. The arrow
shows
a
vertical
lucency
separating
the aortic arch from
the vertical margin
of the collapsed lobe
(Luftsichel).

Left Lower Lobe Atelectasis

Common after cardiac surgery
Radiographic findings include:
Increased retrocardiac opacity
Obscuring of the left lower lobe vessels and left
hemidiaphragm
Caudal displacement of left hilum
Levorotation of cardiac silhouette with flattening of
cardiac waist
Mediastinal shift can cause partial obliteration of
aortic arch

LLL Atelectasis:
Notice the wedge
shaped
opacity
behind the cardiac
silhouette.
The
border is formed by
the major fissure
(arrow). The left
hilum is partially
obscured
and
displaced caudally.
The left upper lobe
is
hyperexpanded
accounting for the
increased lucency in
the left hemithorax.

Complete Atelectasis of Entire Lung

Total collapse of a lung
Complete opacification of an entire hemithorax
Ipsilateral cardiomediastinal shift (in massive
pleural effusion, would shift to contralateral side).
Cardiac silhouette, one hemidiaphragm, and one
hilum are obscured in lateral projection.

Complete left lung

atelectasis: There is
mediastinal
displacement,
opacification,
and
loss of volume in the
left hemithorax. The
cardiac
silhouette
(which is shifted left)
is obscured, as are
the left hilum and left
hemidiaphragm.

Mechanisms of
Atelectasis

Obstructive (Resorptive) Atelectasis

Most common type
Results from blockage of airway
mucous plugging, foreign body, neoplasm, or
inflammatory debris

Air distal to obstruction is resorbed from

nonventilated alveoli
Findings include loss of lung volume without
presence of air bronchograms

Post-obstructive
atelectasis
of
RLL: The major
fissure is visible
as it has rotated
into view. There
are
no
air
bronchograms
seen within the
atelectatic region
of
lung.
The
patient
is
intubated.
The
obstruction
is
likely
due
to
mucous plugging.

Non-obstructive
Atelectasis
1) Passive
2) Compressive
3) Cicatrization
4) Adhesive
In these forms of atelectasis secretions are able
drain up the bronchial tree. Because there is
no
obstruction,
bronchoscopy
is
not
therapeutic.

Passive (Relaxation) Atelectasis

2nd most common form of atelectasis
Contact between parietal and visceral
pleura is lost due to pleural effusion or
pneumothorax.
Leads to generalized collapse.

Passive atelectasis:
Notice the crowded
air
bronchograms
(arrows)
in
the
setting of a left
pleural effusion. Air
bronchograms
are
not present in postobstructive
atelectasis.

Compressive Atelectasis
Due to external compression of lung
May be caused by loculated collection of
pleural fluid or by masses in chest wall,
pleura, or parenchyma.
Similar to relaxation atelectasis but collapse
is local rather than generalized.

Compressive
atelectasis: Chest
x-ray showing a
giant
bulla
occupying more
than two thirds
of
the
right
hemithorax and
compressing the
underlying
lung
upward
and
toward
the
mediastinum.
Crowded
air
bronchograms
can
be
seen
(arrows).

Adhesive Atelectasis
Caused by adherence of the alveolar wall
surfaces in the setting of surfactant
deficiency (e.g., hyaline membrane disease)
Surfactant has phospholipid dipalmitoyl
phosphatidylcholine, which prevents lung
collapse by reducing the surface tension of
the alveoli
Lack of surfactant or inactive surfactant
cause alveolar instability and collapse

Adhesive atelectasis
in
infant
with
hyaline membrane
disease:
CXR
reveals
bilateral
ground-glass
appearance of the
lungs (atelectasis)
and
air
bronchograms
standing
(red
arrow) out against
the
collapsed
parenchyma.

Cicatrization Atelectasis
Secondary to fibrosis (scarring) of lung
parenchyma with subseqent lack of
expansion
Etiologies include granulomatous disease
(often occurs in sarcoid, fungal, and chronic
TB), necrotizing pneumonia, and radiation.

Cicatrization
atelectasis:
Lung
destruction
in patient
with chronic
pulmonary
tuberculosis.

References:
1) Sharma, Sat. Atelectasis. e-medicine, 2004.
http://www.emedicine.com/med/topic180.htm#section~pictures
2) Brad H. Thompson, M.D., William J. Lee, B.S., Jeffrey R. Galvin, M.D. and Jeffrey S. Wilson, M.D Lobar
Anatomy ElectricLungAnatomy
www.vh.org/adult/provider/radiology/LungAnatomy/LobarAnat/LobarAnat.html
3) Daffner, RH. Clinical Radiology The Essentials. Williams and Wilkins, 1993, pp 80-85.
4) Engoren, Milo. Lack of Association Between Atelectasis and Fever. Chest. Volume 107(1) January
1995pp 81-84
5) Roberts J, Barnes W, Pennock M, Browne GD. Diagnostic Accuracy of Fever as a Measure of
Postoperative Pulmonary Complications. Heart Lung. 1988 Mar;17(2):166-70
6) Stark, Paul. Atelectasis: Types and Pathogenesis. UpToDate, 2004.
7) Stark, Paul. Radiologic Patterns of Lobar Atelectasis. UpToDate, 2004.
8) Weed HG, Baddour LM. Postoperative Fever. UpToDate, 2004.
9) Federico Venuta and Tiziano de Giacomo. Giant Bullous Emphysema. CTSNET Experts' Techniques,
General Thoracic Experts' Techniques . http://www.ctsnet.org/doc/6761