3

3
B ATELEKTASIS B

Dr. Abdul Rohman,

BACKGROUND
Greek : ateles - imperfect or incomplete,

ektasis - expansion
= incomplete expansion
= diminished vol. affecting all or part of lung
Several types
a characteristic radiographic pattern and
etiology

EPIDEMIOLOGY
Frequency
US postoperative atelectasis : extremely common
lobar atelectasis
: also common
Mortality/Morbidity
depends on the underliyng cause atelectasis
Age mean age of presentation rounded atelectasis : 60 ys
Race and Sex : No racial and sexual predilection exists

CLASIFICATION
Primary
lung fails to expand at birth
Secondary caused by obstructive and nonobstructive
Nonobstructive : relaxation, compressive, adhessive,
cicatrization, replacement, and rounded

PATHOPHYSOLOGY
Obstructive atelectasis : Obstruction absorbsion
retraction
Nonobstructive atelect : Loss of contact between
the visceral and parietal pleura
Platelike atelectasis : obstruction of small bronchus
Postoperative atelect : diaphragmatic dysfunction
and diminished surfactant activity

Atelectasis ( Collapse )
= Loss of volume of lung, lobe, or segment for any cause
The most important mechanism is obstruction of a major
bronchus by tumor, foreign body, or bronchial plug
Sign of labor collapse
- Decreased lung volume
- Displacement of pulmonary fissure
- Compensatory hyperinflation of remaining part of the
ipsilateral lung
- Elevation of hemidiaphram of ipsilateral side
- Mediastinal and hilar displacement. Trachea pulled to side
of collapse
- Radiopacity (white lung)

CLINICAL
A. History

Postoperative : thoracic or upper abdomen

Symptoms & signs rapidity, size, and infection :

pain on the affected side,

dyspnea, cyanosis, hypotension, tachycardia,
fever, and shock

- Rapid bronchial obstruction :

- Slowly asymptomatic

- Middle lobe syndr (asymptomatic irritation) :

severe,hacking, non- productive cough

B. Physical
involved area - dullness on percussion
- diminished or absent breath sound

Comparison of acute and chronic

obstruction
Acute
Chronic
Inhalation and
Tumors
impaction of
foreign bodies
Mucus plugging of
bronchi (e. g. after Lymphadenopathy
anesthesia)
After
Aneurysm

C. Causes
1. Bronchial obstruction : foreign bodies,
endobronchial tumor, etc
2. External pulm compression : pleural effusion,
pneumothorax
3. Abnormalities of surfactant : oxygen toxicity, ARDS
4. Resorptive atelectasis : bronchogenic Ca, mucous
plug
5. Relaxation atelectasis : pleural effusion, a large
emphysematous bulla
6. Adhesive atelectasis : ARDS, smoke
inhalation,prolonged shallow breathing
7. Cicatrization atelectasis : IPF, chronic TB, radiation
fibrosis, fungal infection
8. Replacement atelectasis : alveoli filled by tumor or
fluid
9. Rounded atelectasis : asbestos pleural plaques

DIFFERENTIAL
DIAGNOSIS
Asthma
Asbestosis
Blunt chest
trauma
Diaphragma
tic paralysis
Lung
abscess

Obesity
Pneumonia
Pneumothorax
Pulmonary
embolus
Pulmonary
fibrosis,
idiopathic

WORKUP
Lab studies
ABG : - hypoxemia atelectasis of a significant size
- PaCO : usually normal or low hyperventilation
( pH = pK log {[HCO]/[CO]} )

Procedures
FOB : - evaluate the cause of bronchial obstruction
- clear mucus plug
- limitations visualized only the subsegmental

Histologic finding
FOB washing, brushing and biopsy specimens :
1. Obstructing mass : malignancy
2. Mucous plugging : aspergillus

 Imaging studies (Chest R & CT scan)

Direct signs : - displacement of fissure
- opacification of the collapsed lobe
Indirect signs :

displacement of the hilum

mediastinal shift toward the side of collapse
loss of volume on ipsilateral hemithorax
elevation of ipsilateral diaphragm
crowding of the ribs
compensatory hyperlucency of the remaining
lobe
silhouetting of the diaphragm or the heart
border

TREATMENT
1.Nonpharmacologic

improving cough & clearance

secretions
Chest physiotherapy : postural
drainage, chest wall percussion
Nebulised Dnase
Fiberoptic bronchoscopy mucous
plugging
PEEP Passive and adhessive atelectasis

2. Medication

SaO > 90 %
Bronchodilators sputum expectoration &
increasing ventilation
Antibiotics : infection (fever, night sweat, or leukocytosis)
Analgesia perioperative : breathe deeply, cough
Suplemental O

forcefully

Dnase cystic fibrosis in children + infection

N-acetylcystein ?

acute bronchoconstriction

3. Surgical care chronic atelectasis

COMPLICATIONS

Acute pneumonia
Bronchiectasis
Hypoxemia and respiratory failure
Postobstructive drowning of the
lung
Sepsis
Pleural effusion and empyema

THANK YOU FOR

YOUR
ATTENTION
ABOUT
ATELECTASIS

Patient with ATELECTASIS

Chest x-ray examination

History
A Physical examination

B CT
C

Identify:

Postoperative
atelectasis
Evaluaate degree, chronicity of atelectasis, and associated problems

D Acute
Platelike
atelectasis

Chronic

E Lobar

Lobar
atelectasis

Platelike
atelectasis

Evaluate sputum

F CT

G PFT

atelectasis

Evaluate for:
Asthma
Rib fracture
Pulmonary embolus
Neuromuscular disease

Negative cytologist Positive cytologist

Normal PFT

Restrictive
Rule out:
Obesity
Interstitial lung disease
Neuromuscular disease
Pulmonary embolus
Asthma

Rule out :
Infection

Therapy

Follow

Bronchoscopy

Lesion seen

Rule out :
Neoplasm

Therapy

No lesion seen

Therapy

Follow

Collapse
Atelectasis (collapse) is loss of volume of a
lung, lobe, or segment for any cause.
The most important mechanism is obstruction
of a major bronchus by tumor, foreign body, or
bronchial plug
PA and lateral radiographs are required.
Compare with old films where available.
The lateral borders of the mediastinum are
silhoutted against the air-filled lung that lies
underneath. This silhoutte is lost if there is
consolidation in the underlying lung.

Signs of labor collapse

Decreased lung volume
Displacement of pulmonary fissures
Compensatory hyperinflation of remaining part
of the ipsilateral lung
Elevation of hemidiaphragm on ipsilateral side
Mediastinal and hilar displacement. Trachea
pulled to side of collapse
Radiopacity (white lung)
Absence of air bronchogram

 In upper lobe collapse of the right lung, a PA

film is most valuable in making diagnose; the
collapsed lobe lied adjacent to mediastinum
In the left lung, a lateral film is most valuable
in making diagnoses; the lobe collapses
superiomedially and arteriorly
Lower lobe collapse causes rotation and
visualization of the oblique fissure on PA film
A lateral film is most valuable in diagnosing
middle lobe collapse. Thin, wedge-shaped
opacity between horizontal and oblique
fissures is seen.

Consolidation
Is seen as an area of white lung and
represents fluid or cellular matter
where there would normally be air
There
are
many
causes
consolidation including :
- Pneumonia
- Pulmonary edema

of

In contrast to collapse:
The shadowing is typically heterogeneous (i.e.
not uniform)
The border is ill-defined
Fissures retain their normal position
There are two pattern of distribution:
Segmental or lobar distribution
Bats-wing distribution
Peripheral lung fields may be spared (e.g., in
pulmonary edema). Air bronchograms may be
seen; these are air-filled bronchi delineated by
surrounding consolidated lung.

 Atelectasis (from the Greek ateles, meaning imperfect,

and ektasis, meaning expansion)
Primary lung fails to expand at birth
Secondary caused by obstruction or compression

Obstructive atelectasis
Obstruction is the most common cause of atelectasis;
this also known as resorptive atelectasis. (Fig. 1)
- Follows an acute and complete obstruction of a large
bronchus. Air in the collapsed area of the lung is
absorbed and secretions distal to the obstruction
accumulate; subsequently these bronchial secretions
become infected and suppurate. Distal to the
blockage, the bronchi mechanically distend.
- If the collapse has been present for some time,
irreversible pulmonary fibrosis occurs. Pulmonary
artery branches may have narrowed lumens.

 Compressive atelectasis
In compressive atelectasis, bronchial obstruction does not
occur; therefore, bronchial secretions are free to drain up the
bronchial tree. As such, the collapsed lung does not become
seriously infected.
Compressive atelectasis results from external compression of
the lung.
Causes of compression include pleural effusion, hemothorax,
empymema, pneumothorax, space-occupying intrathoracic
lession, and abdominal distension.
Hemodynamic and vascular changes occur. High inflation
pressures on inspiration are required to overcome retractive
forces. Re-expansion of the lung usually occurs after
compression is resolved.

Patchy atelectasis
Depending on the cause, atelectasis may occur in a
patchy or diffuse distribution

- Follows an acute and complete obstruction of a large

bronchus. Air in the collapsed area of the lung is
absorbed and secretions distal to the obstruction
accumulate; subsequently these bronchial secretions
become infected and suppurate. Distal to the
blockage, the bronchi mechanically distend.
Obstructive atelectasis
- If the collapse has been present for some time,
irreversible pulmonary fibrosis occurs. Pulmonary
artery branches may have narrowed lumens.
Compressive atelectasis
Obstruction is the most common cause of atelectasis;
this also known as resorptive atelectasis. (Fig. 1)
In compressive atelectasis, bronchial obstruction does
not occur; therefore, bronchial secretions are free to
drain up the bronchial tree. As such, the collapsed
lung does not become seriously infected.
Compressive
atelectasis
results
from
external

Radiologic distribution of alveolar

processes
Bat-wing pattern
Segmental
pattern

Acute

Chronic

pneumonia

pulmonary
edema

atypical
pneumonia

pulmonary
infarct

pneumonia

lymphoma

pulmonary
collapse

pulmonary
hemorrhage

sarcoidosis

alveolar cell
carcinoma

pulmonary
alveolar
proteinosis