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JOURNAL PRESENTATION
ATELECTASIS
KAI HÅKON CARLSEN, MD, PhD, SUZANNE CROWLEY, DM, and BJARNE
SMEVIK, MD

LECTURED BY : DR.IRMA HASAN HIKMAT,SPRAD (K).,M.KES

PRESENTED BY : NURUL FATHIYA

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OUTLINE

ETIOLOGY

PATHOGENIC
PREVENTION MECHANISM

ATELECTASIS

CLINICAL
TREATMENT &
MANAGEMENT MANIFESTA
TION

DIAGNOSIS
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ATELECTASIS

 Stems from two Greek words: ateles, meaning “imperfect,” and

ektasiz, meaning “expansion.”

IMPERFECT EXPANSION
of a lung or lung tissue
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ETIOLOGY

• Obstruction of the lumen bronchial (>>)

• Increased surface tension of the fluid lining
PULMONARY the respiratory tract and alveoli

• Compression of airways and lung tissue

from outside the lung
EXTRA • Weakness of respiratory muscles in
PULMONARY neuromuscular disease.
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Classification

Based on mechanism :
 Obstructive (Resorptive) atelectasis
 Non obstructive atelectasis  Passive
 Compressive
 Cicatric
Based on morphology:  Adhesive
 Lobaris  Rounded
 Segmental
 Subsegmental (plate-like/linear/discoid)
 Whole lung
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PATHOGENIC MECHANISM

INTRAPULMONARY
Airways inflammation with
increased bronchial mucus
and formation of mucus plug
due to: Bronchial Wall Surfactant
-Bronchial asthma Involvement: Dysfunction:
-Respiratory tract infection
-Bronchiolitis, Pneumonia
•>Airway stenosis: -Respiratory
-After aspiration or inhalation
-Bronchopulmonary dysplasia
injury distress syndrome
-Cystic fibrosis (increased viscosity of
the mucus) -After intubation of the newborn
-Primary and secondary ciliary
-Complete cartilaginous rings
dyskinesia (impaired mucociliary
clearance) >Bronchiectasis
-Adult respiratory
-Immunodeficiency >Tracheobronchomalacia distress syndrome
-Tracheoesophageal fistula or
esophageal atresia >Bronchial tumor
-Foreign body in the lower respiratory
tract(Nuts, plastics, other foreign
bodies, misplaced tracheal tube)
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EXTRAPULMONARY

Compression of Compression of
Primary atelectasis
the airways lung tissue
•Lobar •Pneumothorax •Congenital
emphysema •CHF with cardiac malformation
•Lymph node enlargement
enlargement •Hemothorax
•Vascular ring •Chylothorax
•Complex •Lung tumor
congenital heart
disease (e.g LAH
compressing left
main bronchus)
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PRIMARY ATELECTASIS
(CONGENITAL ATELECTASIS)

Congenital airway malformation

Lack of communication of the main

bronchial tree with the affected parts of
the lungs that have never been inflated

Prevent the normal aeration of parts of

the lungs at birth
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SECONDARY ATELECTASIS
DD/PRIMARY ATELECTASIS

If a congenital
malformation
May develop Atelectasis
occludes or
shortly after
narrows the ??
birth
bronchial
lumen
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?? CONGENITAL ATELECTASIS

Pores of Kohn are small

communications between adjacent
pulmonary alveoli and provide a
collateral pathway for aeration.

ensure a more
even ventilation/perfusion ratio in
the lung

playing
a role in preventing atelectasis.
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At more proximal levels no such collateral

communications exist, and occlusion of the
bronchial lumen initially leads to :

air trapping in lung

tissue The trapped air is
peripheral to the gradually Atelectasis
occluded absorbed
bronchus
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The solubility of the trapped

gases

 Determines their absorption rate

atmospheric air will

take place
within hours

oxygen is
absorbed within
minutes

may partly explain

the increased risk HIPOVENTI
of atelectasis LATION
during anesthesia
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inflammation of the
mucous membranes
Total obstruction mucosal swelling+
increased respiratory
Foreign bodies in the secretions total lumen
obstruction
lower respiratory
tract
Partial
obstruction

ATELECTASIS
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Bronchial
inflamation

Bacterial Main cause of Respiratory viral

infection bronchial lumen insitial infection
obstruction (asthma
bronchial & acute
bronchiolitis)

-Middle lobe of
lung
-The lingula

Middle lobe syndrome

atelectasis
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Other
Asthma bronchiolitis respiratory
infection

Inflamation

increased bronchial secretions

may alter
• mucosal edema the airway
surface
bronchial smooth muscle contraction liquid
(surfactan)
• destruction of bronchial epithelium
• reduced ciliary function

• BPD
retention of mucus within • RDS
the bronchial lumen • Aspiration
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Diseases increase the

susceptibility of the respiratory
tract to infection
Increased risk of
airway infection

immunodeficiency
accumulation of
mucus
primary ciliary
dyskinesia (PCD)

Atelectasis
cystic fibrosis
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Vascular
ring
Tumor
Tracheobronch - Polip
omalacia - Papilloma
- Bronchocentric
carcinoma

Atelectasis
on
children

?? Bronchial wall processes

that narrow the bronchial
lumen
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Extrapulmonary process

congenital heart
defects
compress normal lung
tissue
ATELECTASIS pneumothorax

hemothorax
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Neuromuscular disease

reduced

Muscular movement of respiratory

muscles + causes impairs
hypotonia
difficulty in
clearing bronchial
ventilation
secretions

increasing the
individual’s
susceptibility to ATELECTASIS
respiratory
infections
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CLINICAL MANIFESTATION

single or multiple lobes are involved

the underlying cause

the age of the patient

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full-term
newborn
infants with
respiratory
distress

caused by

PCD
mucous
plugging
secondary
to poor
mucociliary
atelectasis + clearance
situs inversus
and the need
for prolonged
supplemental
oxygen
ATELECTASIS
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INFANT + BRONCHIOLITIS

 Mostly on preterm infant  Immaturity of collateral

ventilation (Kohn’s Pore) + canal of lambert
 Lobar atelectasis or whole lung exhaustion
sudden severe
deterioration
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 Generally clinical signs relate to the size of the atelectasis

 Impaired oxygen saturation
 Decreased expansion of the chest on the affected side
 Dullness to percussion
 Diminished or absent breath sounds.

 If the atelectasis is partial or airway obstruction is not complete

crackles may be heard during inspiration and expiration.
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DIAGNOSIS

 CHEST XRAY
 FRONTAL POSITION
 LATERAL POSITION  BETTER ON : MIDDLE LOBE SYND
& LOWER LOBES OF LUNG
 OBLIQUE POSITION  SEGMENTAL ATELECTASIS
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Sign on CXR

Direct signs

 Increased opacification in the area of atelectasis. Air bronchograms are normally

a feature of consolidation but may also be present in lobar collapse.

 Displacement of fissures. This occurs with large degree of collapse.

 Loss of aeration. If the collapsed lung is adjacent to the mediastinum or

diaphragm, then loss of definition of these structures indicates loss of aeration (the
silhouette sign)

 Vascular signs. In partial collapse, crowding of vessels may be seen.

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Indirect signs

 Elevation of a hemi-diaphragm. This sign is of limited value as

the normal position of the diaphragm is variable.

 Mediastinal displacement to the side of collapse. Some

contents of the mediastinum which are easily seen on plain
chest X-rays include the trachea, tracheal tube, central
venous catheters in the superior vena cava, and nasogastric
tubes in the oesophagus.

 Hilar displacement. The hilum may be elevated in the upper

lobe collapse, and depressed in the lower lobe collapse.
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CHEST X-RAY
Fig. 70.3 Two-month-old girl with cystic fibrosis. Chest radiograph
shows atelectasis of the right upper lobe and elevation of the
interlobar fissure.
 Right upper lobe atelectasis

Frontal projection : “golden S” sign

Lateral projection : “open umbrella sign”
Fig. 70.1 Three-year-old girl with repeated episodes of atelectasis of the
middle lobe. Chest radiograph. (A) Frontal projection shows slight blurring of
right heart contour. (B) Lateral projection shows triangular opacity with apex
toward the hilum.
 Right lower lobe
• Visible major fissure shifts downward as lower lobe
retracts
• On lateral view: posterior third of right diaphragm
indistinct
 Left upper lobe
• Opacity in upper left hilar region
• Shift of mediastinal structures to the left; elevation of left diaphragm
 Left lower lobe
• Opacity in retrocardiac space
• Indistinct vessels in the left lower lobe, visible air bronchogram in lower
lobe
• Left hilum displaced caudally
• Indistinct medial diaphragmatic contour
 Rounded atelectasis
On the lateral view there is a mass-like lesion that is pleural-based.
The first impresson is, that this is a pleural lesion.
 Plate-like (linear)atelectasis
They are characterized by linear shadows of increased density at the
lung bases.
They are usually horizontal, measure 1-3 mm in thickness and are only a few
cm long.
In most cases these findings have no clinical significance and are seen in
smokers and elderly.
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THORAX CT

 Computed tomography (CT) and multislice CT with

reconstruction may reveal atelectasis not visible on
chest x-ray
 But the use of general anesthesia, often required in
very young children, may induce atelectasis in up to
70% of cases.
 CT is of particular value with lesions:
- located close to the chest wall
- at the periphery of the lung
- close to the spine.
 Segmental atelectasis affecting a part of a lobe may
be more clearly seen with CT
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The typical findings of rounded atelectasis on CT are pleural thickening,
pleural-based mass and comet tail sign.

The theory is that a local pleuritis causes the pleura to thicken and contract.
The underlying lung shrinks and atelectasis develops in a round
configuration.
The distorted vessels appear to be pulled into the mass and resemble a
comet tail
Plate-like atelectasis is frequently seen in patients in the
ICU due to poor ventilation.
Platelike atelectasis is also frequently seen in pulmonary
embolism, but since it is non-specific, it is not a helpful sign in
making the diagnosis of pulmonary embolism.
Fig. 70.2 Eleven-year-old girl with asthma and idiopathic eosinophilic pneumonitis and
subtotal atelectasis of the left lung. She had coughed up a bronchial cast. (A)
Chest radiograph shows opacification and volume reduction of left hemithorax and
shift of trachea/mediastinum toward the affected side, as well as elevation of the
contour of the left diaphragm. It also shows reduced left intercostal spaces. (B)
Computed tomography shows volume reduction and reduced intercostal spaces on
the left side; the heart is shifted to the left, and there is atelectasis of the left lung and
some hyperinflation of the right lung
Fig. 70.4 Two-year-old boy born prematurely. He has bronchopulmonary dysplasia
and pulmonary hypertension. Computed tomography after sedation shows extensive
dependent atelectases in both lungs
Fig. 70.5 Four-year-old girl with subsegmental atelectasis in the right
lung. Bronchoscopy for suspicion of foreign body was negative.
Fig. 70.6 Sixteen-year-old boy with Kartagener syndrome. Bronchiectasis is most
pronounced in the atelectatic left-sided middle lobe
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MRI
 DIAGNOSIS
 FOLLOW UP
 Produces pictures of excellent quality in any plane,
it is a very good alternative to CT in children who
are able to cooperate during the study

 Ultrasonography and MRI can both be used without

considering the burden of ionizing radiation.
Fig. 70.7 Ten-year-old girl who underwent heart transplantation at 9 years of age.
Magnetic resonance imaging shows extensive atelectasis of both lower lobes
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ULTRASONOGRAPHY

 When the atelectasis is located near the thoracic

cage, and especially when it is combined with
pleural effusion (as is often the case after cardiac
surgery or pleural empyema), ultrasonography is a
quick and reliable bedside method.

 The collapsed lung is easily differentiated from

surrounding pleural effusion (Fig. 70.8).
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Fig. 70.8 Two-year-old girl treated with extracorporeal membranous

oxygenation because of pneumonia. Ultrasound shows atelectasis
of the left lung (a), which is clearly seen next to pleural effusion (p)
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Treatment and Management

 The cause of the atelectasis • type of treatment

 and the presence of any preexisting condition • the need for future
prophylactic
measures.

 Chest physiotherapy is often used as a first-line approach, but

proof of its efficacy is not firmly established
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In a prospective controlled study of 46
mechanically ventilated preschool
children with atelectasis

Intrapulmonary Conventional
percussive ventilation physiotherapy

comprising ventilation at 180–220

cycles per minute at pressures of 15– Clapping + vibration
30 cm H2O for 10–15 minutes 4 times
daily following instillation of 0.9%
saline
Shows no significant clinical
improvement
significant improvement in their
atelectasis
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FIBEROPTIC BRONCHOSCOPY

 DIAGNOSTIC
MIDDLE LOBE ATELECTASIS
 THERAPY

TO PREVENT BRONCHIECTASIS

Rigid bronchoscopy should be available to retrieve the

foreign body if necessary
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OPERATIVE INTERVENTION

 Lobectomy has been advocated in symptomatic children with

persistent right-middle-lobe and left-lower-lobe syndrome
that has not responded to intensive medical therapy, but
this is controversial and rarely indicated

 Silicone or wire mesh stents have been used to relieve airway

obstruction In children with tracheobronchial obstruction
secondary to adjacent vascular structures or an enlarged
heart, tumor, lymphadenopathy or severe airway malacia
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PULMONARY TB ON CHILDREN

subcarinal lymph nodes

airway compression

1 month of antituberculous
+ steroid treatment.

one-third of children requiring

surgical decompression
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Prevention of Atelectasis

 EARLY PHYSIOTHERAPY POST OPERATIVE PROCEDURE

 VENTILATION STRATEGY ON INTUBATED CHILDREN
 There is a clear need for prospective randomized controlled
studies :
- The effectiveness of physiotherapy techniques (including the use
of mucolytic agents and ventilation strategies)  In preventing
the development of atelectasis in children hospitalized with
bronchiolitis, inhalational injury, pulmonary infection, and
postcardiac and pulmonary surgery
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 Differential diagnosis
RUL Atelectasis vs RUL consolidation
 Differential diagnosis
whole lung atelectasis vs massive
pleural effusion
 Differential diagnosis
Round atelectasis vs lung
tumor