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