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    Lung Collapse: A Review: Dr. Girish Kukade Radiology Department, AFH

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    Lung collapse, also known as atelectasis, can be obstructive or non-obstructive in nature. Obstructive atelectasis is caused by obstruction between the alveoli and trachea leading to reabsorption of alveolar gas. Non-obstructive atelectasis can be due to relaxation of the pleura, compression of the lung, loss of surfactant, scarring, or replacement of lung tissue. Different patterns of lung collapse can be identified on radiographs based on the shifted fissures and opacities observed. Recognition of atelectasis is important as it may indicate underlying pathology.

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    Lung Collapse: A Review: Dr. Girish Kukade Radiology Department, AFH

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    kukadegirish
    174 views61 pages
    Lung collapse, also known as atelectasis, can be obstructive or non-obstructive in nature. Obstructive atelectasis is caused by obstruction between the alveoli and trachea leading to reabsorption of alveolar gas. Non-obstructive atelectasis can be due to relaxation of the pleura, compression of the lung, loss of surfactant, scarring, or replacement of lung tissue. Different patterns of lung collapse can be identified on radiographs based on the shifted fissures and opacities observed. Recognition of atelectasis is important as it may indicate underlying pathology.

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    Lung collapse, also known as atelectasis, can be obstructive or non-obstructive in nature. Obstructive atelectasis is caused by obstruction between the alveoli and trachea leading to reabsorption of alveolar gas. Non-obstructive atelectasis can be due to relaxation of the pleura, compression of the lung, loss of surfactant, scarring, or replacement of lung tissue. Different patterns of lung collapse can be identified on radiographs based on the shifted fissures and opacities observed. Recognition of atelectasis is important as it may indicate underlying pathology.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
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    174 views61 pages

    Lung Collapse: A Review: Dr. Girish Kukade Radiology Department, AFH

    Uploaded by

    kukadegirish
    Lung collapse, also known as atelectasis, can be obstructive or non-obstructive in nature. Obstructive atelectasis is caused by obstruction between the alveoli and trachea leading to reabsorption of alveolar gas. Non-obstructive atelectasis can be due to relaxation of the pleura, compression of the lung, loss of surfactant, scarring, or replacement of lung tissue. Different patterns of lung collapse can be identified on radiographs based on the shifted fissures and opacities observed. Recognition of atelectasis is important as it may indicate underlying pathology.

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    The key takeaways are that there are different types of lung collapse including obstructive, non-obstructive, relaxation, adhesive atelectasis. The causes and radiological findings of each type are discussed.

    The different types of lung collapse discussed are obstructive, non-obstructive, relaxation, adhesive atelectasis.

    The causes of obstructive atelectasis discussed are foreign body, mucus plug, blood clot, benign or malignant tumor, bronchial transection, fibrotic stenosis from granulomas or inflammation, polychondritis, post brachytherapy or radiotherapy stenosis and other obstructive lesions.

    Lung Collapse: A Review

    Dr. Girish Kukade Radiology Department, AFH

    Introduction
    Also known as: Atelectasis: derived from Greek words ateles & ektasis, which mean incomplete expansion Recognition is important as may have sinister underlying pathology Types: -Obstructive -Nonobstructive

    Obstructive atelectasis
    obstruction between alveoli & trachea reabsorption of alveolar gas Causes: -foreign body, mucus plug & blood clot -benign or malignant tumor -bronchial transection -fibrotic stenosis from granulomas/ inflammation -polychondritis -post brachytherapy or radiotherapy stenosis -other obstructive lesions

    Nonobstructive atelectasis
    Loss of contact between parietal and visceral pleurae Causes: - Relaxation or passive: due to effusion (ML & LL) & pneumothorax (UL), bulla - Compression: when SOL of thorax compresses lung & forces air out of alveoli. SOL of chest wall, pleural/ intraparenchymal masses or loculated pleural collections - Adhesive: surfactant deficiency e.g. HMD, ARDS, radiation, blunt trauma, smoke inhalation, uermia, cardiac bypass - Cicatrization: due to severe parenchymal scarring, usually by granulomatous disease (Tb, fungus) or necrotizing pneumonia, IPF, radiation - Replacement: alveoli of a lobe filled by tumor e.g. BAC or fluid - Rounded: folded-lung syndrome, due to fibrous bands and adhesions to visceral pleura, in asbestos workers, benign

    Relaxation Atelectasis
    The lung is held in apposition to the chest wall because of negative pressure in the pleura. When the negative pressure is lost, as in pneumothorax or pleural effusion, the lung relaxes to its atelectatic position. The atelectasis is a secondary event. The pleural problem is primary and dictates other radiological findings

    Adhesive Atelectasis
    Alveoli are kept open by integrity of surfactant. When there is loss of surfactant, alveoli collapse. ARDS is an example of diffuse alveolar atelectasis. Plate-like atelectasis is an example of focal loss of surfactant.

    Round Atelectasis
    Mass like density Pleural based Base of lungs Blunting of CP angle Pleural thickening Pulmonary vasculature curving into the density Esophageal surgical clips

    Round Atelectasis

    Nonobstructive atelectasis
    Causes: - Platelike: discoid or subsegmental, due to hypoventilation, PE, LRTI - Postoperative: after thoracic & upper abdominal procedures. Basilar & segmental, diaphragmatic dysfunction & reduced surfactant are consequences of GA and surgical manipulation - Resorptive: by Ca bronchus, bronchial metastasis (breast/thyroid adenocarcinoma, RCC, melanoma), tuberculosis/ fungal infection, FB/ mucus plug, malposed ETT, extrinsic compression of airway by neoplasm/ LNpathy, aortic aneurysm or cardiac enlargement

    CXR & CT
    CXR: Generally sufficient to diagnose lobar atelectasis & to identify the collapsed lobe Not diagnostic when a concomitant pleural fluid or large pulmonary masses are present CT: for diagnosis, to assess possible cause & in evaluating mediastinum, chest wall, hilum, pleura & adjacent lung

    Position of fissures as on PA view

    RUL
    shifts medially and superiorly causes elevated right hilum & minor fissure may also collapse laterally, producing a pleuralbased opacity that may look like a loculated pleural effusion minor fissure is usually convex at its superior aspect, but it may appear concave because of an underlying mass lesion (S sign of Golden) Tenting of the diaphragmatic pleura, called juxtaphrenic peak sign

    RUL collapse

    Antero-superior collapse: RUL

    RUL collapse progression

    RUL collapse

    Density in the right upper lung field Transverse fissure pulled up Right hilum pulled up Smaller right lung Smaller right hemithorax

    RUL collapse

    RML
    Obscures right heart border on PA triangular opacity overlying the heart on lateral view (as major fissure shifts upward & minor fissure shifts downward) with worsening collapse, opacity diminishes in size & may be barely perceptible Lordotic view shows triangular opacity

    RML collapse: obliterated right heart border on PA view & wedge shaped density on lateral views

    RML collapse

    RML Lateral Segment Atelectasis

    Sub-segmental Atelectasis

    Anterior sub-segment of RUL

    RLL
    RLL shifts posteriorly & inferiorly a triangular opacity that obscures the RLL pulmonary artery major fissure, normally not visible on PA, is evident superior mediastinal structure shifts to right, causing a superior triangle sign On lateral view, collapsed RLL obliterates posterior 1/3rd of right hemidiaphragm & causes loss of lucency over lower thoracic vertebrae

    RLL collapse: obscured right hemidiaphragm

    RLL collapse

    RML & RLL combined collapse


    Concomitant RML & RLL atelectasis may appear as an elevated right hemidiaphragm or a subpulmonic effusion. An attempt to identify the fissures usually leads to the accurate diagnosis

    Combined RML & RLL collapse

    LUL
    LUL shifts anteriorly & superiorly. Since it collapses forwards, it presents no sharp margins on the frontal film (unlike that due to horizontal fissure on the right) In 50%, a hyperexpanded LLL superior segment is positioned between atelectatic UL & aortic arch, seen as a crescent of aerated lung (luftsichel sign) On PA, a faint veil like opacity in left upper hemithorax, obliterating left heart border, more dense towards apex On lateral, major fissure is displaced anteriorly behind the sternum

    Veil like opacity & anterior shift of major fissure

    O'Keeffe, S. A et al. BMJ 2008;337:a1505

    Luftsichel sign, veil like opacity is denser at the apex

    LUL collapse: opacity contiguous with aortic knob, a smaller left hemithorax & mediastinal shift

    Key findings: -loss of volume of left hemithorax (elevation of the left hemidiaphragm & shift of mediastinum to left) -- Arrows: indicate the major fissure, ordinarily not visible, but now bordering LUL because it has shifted upward. - Increased density seen at the left hilum suggests mass

    LUL collapse: haziness in middle third

    LUL collapse: Haziness mainly in lower half, but left heart border obscured

    S sign of Golden

    Concomitant RUL & LUL collapse

    Lingula (part of LUL)


    Obscures left heart border on PA triangular opacity overlying the heart on lateral view (as major fissure shifts upward & minor fissure shifts downward) with worsening collapse, opacity diminishes in size & may be barely perceptible

    LLL
    On PA, increased retrocardiac opacity obliterates the LLL pulmonary artery & left hemidiaphragm Hilar structures shift downward & rotation of the heart produces flattening of the cardiac waist (flat-waist sign) Superior mediastinum may shift and obliterate the aortic arch (top-of-the-aortic-knob sign) On Lateral, opacity silhouettes posterior 1/3rd of left diaphragm & causes loss of lucency over lower thoracic vertebrae

    LLL collapse: volume loss, elevated & silhouetted left diaphragm and opacity behind the heart (i.e. sail sign)

    LLL collapse: loss of lucency over lower thoracic vertebrae, postero-inferior displacement

    CT: LLL collapse with effusion

    LLL collapse

    LUL collapse

    Loss of left diaphragmatic silhouette Blunting of costophrenic angle Left main bronchus pulled down

    Retrocardiac triangular density No free fluid

    Complete collapse of right lung


    Homogenous density right hemithorax Mediastinal shift to right Right hemithorax smaller Right heart & diaphragmatic silhouette not identifiable

    Right Lung collapse: open bronchus sign

    Complete collapse of left lung

    Complete collapse of left lung


    Homogenous density left hemithorax Mediastinal shift to left Left hemithorax smaller Diaphragm and heart silhouette are not identifiable

    Complete collapse of left lung

    One diaphragm missing Increased density over spine Herniation of right lung retrosternally

    Left Lung collapse

    One diaphragm missing Increased density over spine Herniation of right lung retrosternally Left pulmonary artery missing in lateral view

    Rounded atelectasis

    Rounded atelectasis

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