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Atelectasis

Atelectases

Atelectasis is the reduction or absence of air in part or all of a lung. It may be an acute or chronic condition.


Presentation

Atelectasis may or may not show signs and symptoms depending upon the extent of lung tissue which has collapsed. If a major segment of lung tissue is involved the patient will present the following symptoms:

In severe cases of atelectasis, acute respiratory failure may occur [6].

Cough
  • The RTX respirator is a biphasic external cuirass-style ventilator that supports both inspiration and expiration at various cycle rates and pressures, as well as allowing application of the vibration and cough modes.[ncbi.nlm.nih.gov]
  • Coughing, percussion on affected side will loosen mucus accumulation. Deep breathing exercises are done with spirometry.[symptoma.com]
  • There were no preceding signs except for a mild cough and one febrile episode. Bronchoscopy revealed PNBA, and Aspergillus nidulans was cultured from the bronchial wash.[ncbi.nlm.nih.gov]
  • We report the case of an 11-year-old boy investigated for persistent cough and dyspnea with complete left lung atelectasis mimicking pneumonia. CT and MRI showed an endobronchial mass of the left main bronchus.[ncbi.nlm.nih.gov]
  • Twenty four-hour 5L/min oxygen was begun, while mechanical cough assist aids were applied for seven days. In the following three days, treatment with nebulized Dornase alpha (rhDNase) b.i.d. was tested, without any significant improvement.[ncbi.nlm.nih.gov]
Pleural Effusion
  • Changes in lung density due to atelectasis, pleural effusion and pneumonia/pneumonitis are observed in lung cancer patients.[ncbi.nlm.nih.gov]
  • Chest X-rays revealed the persistence of a partial collapse of the left inferior lobe associated with a pleural effusion. A chest ultrasound confirmed the presence of a lung consolidation and of a modest pleural effusion.[ncbi.nlm.nih.gov]
  • We present a case of whole-lung torsion after massive pleural effusion and atelectasis.[ncbi.nlm.nih.gov]
  • Effusion (see Pleural Effusion-Transudate , [[Pleural Effusion-Transudate]] and Pleural Effusion-Exudate , [[Pleural Effusion-Exudate]]): loss of contact between the visceral and parietal surfaces with deformation of shape of lung, resulting in atelectasis[mdnxs.com]
  • The second theory is more favoured while the multi-factorial aetiology suggests both mechanisms probably operate in different patients: Hanke and Kretzschmar underlying pleural effusion causes local atelectasis in the adjacent lung a cleft or infolding[radiopaedia.org]
Dyspnea
  • We report the case of an 11-year-old boy investigated for persistent cough and dyspnea with complete left lung atelectasis mimicking pneumonia. CT and MRI showed an endobronchial mass of the left main bronchus.[ncbi.nlm.nih.gov]
  • Pulmonary atelectasis (PA) is a common clinical complication among newborns, and it is one of the most common causes of neonatal dyspnea, a condition with no specific effective treatment.[ncbi.nlm.nih.gov]
  • In the chronic form, the patient may experience no symptoms other than gradually developing dyspnea and weakness. X-ray examination may show a shadow in the area of collapse.[healthcentral.com]
  • Atelectasis is an important prognostic factor that can cause pleuritic chest pain, coughing or dyspnea, and even may be a cause of death.[ncbi.nlm.nih.gov]
  • Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Atelectasis is usually asymptomatic, but hypoxemia and pleuritic chest pain may be present in certain cases. Diagnosis is by chest x-ray.[msdmanuals.com]
Tachypnea
  • Small number of affected alveoli or slowly manifesting atelectasis asymptomatic or minimal symptoms Large number of affected alveoli or rapid onset acute dyspnea , chest pain , tachypnea , tachycardia , and cyanosis Dull percussion note , diminished breath[amboss.com]
  • .  Marked respiratory distress  Dyspnea, tachycardia,  Tachypnea, pleural pain, and central cyanosis  Difficulty breathing in the supine position  Anxious 12.[slideshare.net]
Painful Cough
  • Atelectasis is an important prognostic factor that can cause pleuritic chest pain, coughing or dyspnea, and even may be a cause of death.[ncbi.nlm.nih.gov]
  • The symptoms of atelectasis include: Difficulty breathing Rapid breathing Chest pain Coughing. Diagnosis and Treatment Atelectasis is routinely diagnosed using a chest X-ray to visualize the lungs and surrounding areas.[innerbody.com]
Fever
  • It is a common misconception that atelectasis causes fever.[en.wikipedia.org]
  • A 12-year-old boy presented to our clinic with recurrent lower respiratory tract symptoms that are wheezing, cough, bronchopneumonia, and fever and with a diagnosis of bacterial endocarditis.[ncbi.nlm.nih.gov]
  • Introduction Refers to the collapse of the lung in an area distal t o an area of obstruction Most common cause of fever in first 24 postoperative hours caused by dry secretions from anasthesia fever is the result of a nidus of infection Evaluation Elevated[medbullets.com]
  • Of the 68 patients with atelectasis, nine patients developed fever, and six patients displayed pneumonic infiltration. The others had no symptoms related to atelectasis.[ncbi.nlm.nih.gov]
  • Fever: For unknown reasons atelectasis often results in development of early post-surgical fevers, usually 1-2 days post-operatively. Pneumonia: If left uncorrected, atelectasis will increase a patient's risk of developing by pneumonia.[pathwaymedicine.org]
Foreign Body Aspiration
  • It is commonly caused by the mucous plugs accompanying asthma , chronic bronchitis , bronchiectasis, postoperative states, and foreign body aspiration.[sharinginhealth.ca]
  • Causes Intraluminal mucus (e.g. postoperative, asthma, cystic fibrosis) foreign body aspiration Mural bronchial carcinoma Extramural peribronchial lymphadenopathy aortic aneurysm References and Links Journal Articles and Textbooks Talley NJ, O’Connor[lifeinthefastlane.com]
  • body aspiration resorptive atelectasis of an entire lung ("collapsed lung") can result from complete obstruction of the right or left main bronchus passive (relaxation) atelectasis occurs when contact between the parietal and visceral pleura is disrupted[radiopaedia.org]
  • Causes of this could include: Intraluminal pathology: sputum plug, foreign body, aspiration Mural pathology: eg. carcinoma Extramural pathology: eg. peribronchial lymphadenopathy, an enlarged left atrium, etc.[derangedphysiology.com]
Cyanosis
  • Atelectasis and Pneumothorax Lungs Pain Trouble breathing Faintness Cyanosis Mucus plug Tumor Inhaled foreign object Physical trauma to the lung Wound Overview Atelectasis and pneumothorax are conditions in which the lung or part of the lung collapses[nm.org]
  • Symptoms In acute atelectasis in which there is sudden obstruction of the bronchus, there may be dyspnea and cyanosis, elevation of temperature, a drop in blood pressure, or shock.[healthcentral.com]
  • CLINICAL PRESENTATION Rapidly developing atelectasis: Chest pain on the affected side, Dyspnoea, and Cyanosis. Hypotension, tachycardia, fever, and shock may also occur.[respiratoryupdates.wordpress.com]
  • Small number of affected alveoli or slowly manifesting atelectasis asymptomatic or minimal symptoms Large number of affected alveoli or rapid onset acute dyspnea , chest pain , tachypnea , tachycardia , and cyanosis Dull percussion note , diminished breath[amboss.com]
  • .  Marked respiratory distress  Dyspnea, tachycardia,  Tachypnea, pleural pain, and central cyanosis  Difficulty breathing in the supine position  Anxious 12.[slideshare.net]
Tachycardia
  • Hypotension, tachycardia, fever, and shock may also occur. Slowly developing atelectasis is usually asymptomatic sometimes causes minor symptoms.[respiratoryupdates.wordpress.com]
  • Small number of affected alveoli or slowly manifesting atelectasis asymptomatic or minimal symptoms Large number of affected alveoli or rapid onset acute dyspnea , chest pain , tachypnea , tachycardia , and cyanosis Dull percussion note , diminished breath[amboss.com]
  • .  Marked respiratory distress  Dyspnea, tachycardia,  Tachypnea, pleural pain, and central cyanosis  Difficulty breathing in the supine position  Anxious 12.[slideshare.net]

Workup

Diagnosis is mainly based on plain chest radiography as often the patient may show no signs and symptoms.

A complete physical examination should be done along with a few basic laboratory tests. Physical examination may reveal absence of breath sounds on the affected side of the hemi thorax. On percussion, dullness maybe demonstrated. Chest expansion may be reduced.

Oximetry may reveal low levels of oxygen. Chestradiographs show distinct signs of atelectasis. Usual radiological signs of collapse on chest x-ray result from airlessness of the lung causing opacification [7] and shrinkage.

Each segment or lobe of the lung when collapsed has a particular pattern of blurring normal boundaries (silhouette sign). Middle lobe or lingular lobe collapse causes blurring of the right and left heart border. Upper lobe collapse may obliterate the superior mediastinal border. However, in complete upper lobe collapse, prolapse of the apical segment of the lower lobe can restore the silhouette of the mediastinal boundaries, the luftsichel sign. A collapse of the whole lung [8] results in opacification and shift of mediastinal structures to the same side. Lower lobe collapse does not obliterate cardiac borders and causes a retrocardiac triangular opacity when completely collapsed [9].

CT scan findings are similar to those seen on chest radiographs but in transaxial planes.

Pneumoperitoneum
  • Lung ultrasonography was performed at 5 predefined time points: before induction of general anesthesia (GA), after induction of GA, after pneumoperitoneum insufflation, on arrival in the recovery room, and before recovery room discharge.[ncbi.nlm.nih.gov]
Pseudomonas
  • Pseudomonas aeruginosa was isolated from the sputum of the patient.[ncbi.nlm.nih.gov]
  • […] of atelectasis is an obstruction of a bronchus, one of the Selected Causes of Bronchiectasis Respiratory infections Respiratory infections Measles Whooping cough Adenoviral infection Bacterial infection-for instance, by Klebsiella, Staphylococcus, or Pseudomonas[generalhealthtopics.com]
Pleural Effusion
  • Changes in lung density due to atelectasis, pleural effusion and pneumonia/pneumonitis are observed in lung cancer patients.[ncbi.nlm.nih.gov]
  • Chest X-rays revealed the persistence of a partial collapse of the left inferior lobe associated with a pleural effusion. A chest ultrasound confirmed the presence of a lung consolidation and of a modest pleural effusion.[ncbi.nlm.nih.gov]
  • We present a case of whole-lung torsion after massive pleural effusion and atelectasis.[ncbi.nlm.nih.gov]
  • Effusion (see Pleural Effusion-Transudate , [[Pleural Effusion-Transudate]] and Pleural Effusion-Exudate , [[Pleural Effusion-Exudate]]): loss of contact between the visceral and parietal surfaces with deformation of shape of lung, resulting in atelectasis[mdnxs.com]
  • The second theory is more favoured while the multi-factorial aetiology suggests both mechanisms probably operate in different patients: Hanke and Kretzschmar underlying pleural effusion causes local atelectasis in the adjacent lung a cleft or infolding[radiopaedia.org]

Treatment

The main objective of the treatment is to treat and remove the underlying cause. Small areas of collapse can resolve without treatment.

Treatment mainly includes:

  • Chest physiotherapy that aims at improving breathing especially post-surgery to inflate the collapsed lung. Coughing, percussion on affected side will loosen mucus accumulation [10]. Deep breathing exercises are done with spirometry. Postural drainage should be done wherein the head should be positioned lower than the chest allowing mucus to drain out of the lungs.
  • Medications mainly antibiotics should be given to treat any chronic infection. Bronchodilators should be administered for easier breathing.
  • Bronchoscopy should be done for clearing of airways, by suctioning the mucus or to remove any small obstruction. Bronchoscopy can also be useful for removal of any small tumours of the lung.
  • Continuous positive pressure (CPAP) may be useful for low oxygen levels.

Prognosis

The mortality and morbidity of atelectasis mainly depends on the underlying primary pathology.

The collapsed part of the lung usually inflates once obstruction has been resolved or the cause been removed. Some amount of residual scarring or damage may be present [4].

It can be life threatening especially in premature babies, infants and patients with underlying respiratory problems. Thus, the morbidity and complications depends upon the extent of lung tissue collapse.

Certain complications can occur due to atelectasis e.g. pneumonia, hypoxemia and scarring.

Etiology

The exact etiology is uncertain. Depending upon the type of collapse, atelectasis can be obstructive or non-obstructive. Most common cause of atelectasis is post cardiac surgery.

Obstructive atelectasis is due to an obstruction in the airways. This occurs due to resorption of air distal to the obstruction. The site of obstruction could be central or peripheral. Main causes of blockage are:

  • Mucus accumulation post-surgery which results in an inability to cough, resulting in a collection of mucus and secretions. Anaesthesia and other drugs given during surgery can also cause mucus accumulation.
  • Foreign body inhalation like small objects, peanuts and small toys, mainly inhaled accidentally by children [1].
  • Lung tumours or any space occupying lesion.
  • Mucus plugs may also accumulate in cystic fibrosis and asthma [2].

Non obstructive atelectasis can occur due to different reasons as follows:

  • Chest injuries or any accidents causing trauma to the chest wall
  • Fibrotic collapse occurs due to fibrosis or scarring of the lungs in conditions like ankylosing spondylitis, silicosis and tuberculosis where severe destabilizing forces may be responsible for the collapse.

Compressive collapse occurs from relaxation of the lung due to pleural disease like pleural effusion, pneumothorax and hydropneumothorax.

  • Any inflammation of the lungs which can occur from any type of pneumonia can cause temporary atelectasis.
  • Adhesive collapse is where there is an abnormality in the surfactant resulting in collapse of the lungs [3].

Epidemiology

Atelectasis has no racial predilection, affects men and women equally. The mean age of clinical onset of this condition is around 60 years. It also occurs in premature babies and mainly presents as Acute Respiratory Distress Syndrome (ARDS). There is a high incidence of atelectasis in asbestos workers. Post-surgery atelectasis improves well.

Sex distribution
Age distribution

Pathophysiology

The factors maintaining normal lung expansion are the balance of mechanical and surface forces. The chest wall physio-mechanically coupled by forces through the pleurae is essential for normal lung expansion.The surfactant lining the alveoli aids ventilation via normal and collateral pathways and is essential for maintenance of lung inflation.

Disruption of these properties can lead to lung instability and collapse. It can occur due to resorption of gas distal to an airway obstruction. Relaxation of the lung due to uncoupling of lung and chest wall forces by fluid (pleural effusion) or gas (pneumothorax) and loss of surfactant in ARDS can cause atelectasis.

In an obstructed lobe, the oxygen is consumed raising the partial pressures of other gases above the normal. These gases dissolve in the blood and get absorbed eventually reducing the volume of the affected lobe. During resolution of pneumonia or post-operative conditions, secretions and mucus collect in the central bronchi. Due to a diminished cough reflex and reduced diaphragmatic motion and pain there is absorption of air distal to obstruction.

Shrinkage due to lung collapse results in compensatory hyperinflation. In a collapsed lung unit there is no ventilation, but perfusion continues producing a shunt effect. This results in hypoxemia which cannot be corrected by oxygen therapy. Refractory hypoxemia is therefore the basic pathophysiological abnormality.

Expansion of collapsed lobe can occur after the obstruction is removed as ventilation is restored.

Prevention

Atelectasis can be prevented by certain modifications in posture and habits. Smoking should be stopped. Small objects and toys should not be given to children to prevent obstruction.

Post-surgery deep breathing exercises should be done along with posture changes for easy drainage of mucus. Coughing should be encouraged post-surgery. In case of pain in chest, pain medication should be given. Position of lying down should not remain constant and frequently altered. Ambulation should be encouraged.

Summary

Atelectasis is the total or incomplete collapse of a part of the lung or the entire lung. This results in failure of expansion of the lungs due to deflated alveoli. It is a condition which results in airlessness with shrinkage of the lungs.

It can be congenital (atelectasis neonatorum) due to an inborn failure of lungs to expand and usually presents in premature babies. It can be acquired anytime during the lifetime wherein there is absorption of air secondary to obstruction, compression, contraction or surfactant loss.

Atelectasis occurs mainly secondary to other respiratory problems like cystic fibrosis, lung tumours, foreign body inhalation, pneumothorax and chest injuries. Atelectasis is frequently known as lung collapse and is the commonest complications post-surgery.

If only a small segment of the lung has collapsed, there may be no signs and symptoms. If not treated timely, it can cause severe complications as the oxygen supply to the body reduces.

Patient Information

Atelectasis is a medical condition where a part of or the entire lung tissue collapses resulting in reduced gaseous exchange. This leads to reduced oxygen levels in the body. Atelectasis results from either an obstruction in the airways or after a surgical operation. It can also occur if there is some external pressure from other tissues on the lungs.

It usually occurs secondary to some respiratory problem .In premature babies too, atelectasis can occur. The main cause for atelectasis is mucus accumulation in the lung thus resulting in no air in the air sacs which lead to reduced gaseous exchange. Most common conditions which cause atelectasis are any obstruction like tumours, or any foreign objects, any chronic infections in the lungs and trauma to the chest. Post surgery there is a high chance of developing atelectasis due to reduced coughing reflex.
Majority of the cases show no signs and symptoms unless a large segment of lung tissue is involved. There may be difficulty in breathing, chest pain and low fever.

A medical care provider will be able to confirm the condition by a physical examination as well as may advice to do a chest X-ray. Chest X-ray will confirm the diagnosis as atelectasis is very prominent on a radiograph. CT scan may be needed.

Treatment mainly involves removal of the cause of atelectasis, thus enabling the inflation of the lung. Chest physiotherapy should be done regularly for removal of the mucus. Deep breathing techniques are advised. Post-surgery posture should be frequently changed for easy drainage of any secretions. Coughing should be encouraged. Medications may be given for an infection.
Bronchoscopy is done to clear the air passages and remove any obstruction if present. If treatment not administered on time it can lead to severe complications which can ultimately lead to respiratory failure. Post any operation, proper care should be taken to avoid accumulation of secretions and postural modifications should be done. Patient should be encouraged to walk as much as possible.

The outlook depends on the primary cause, but with prompt treatment and removal of any obstruction atelectasis has a good recovery.

References

Article

  1. Priftis KN, Mermiri D, Papadopoulou A, Anthracopoulos MB, et al. The role of timely intervention in middle lobe syndrome in children. Chest. 2005 Oct;128(4):2504-10.
  2. Hendriks T, de Hoog M, Lequin MH, Devos AS, Merkus PJ. DNase and atelectasis in non-cystic fibrosis pediatric patients. Crit Care. 2005 Aug;9(4):R351-6.
  3. Franken EA Jr, Klatte EC. Atypical (peripheral) upper lobe collapse. Ann Radiol (Paris). 1977 Jan-Feb;20(1):87-93.
  4. Reinius H, Jonsson L, Gustafsson S, et al. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology. 2009 Nov;111(5):979-87.
  5. Mavros MN, Velmahos GC, Falagas ME. Atelectasis as a cause of postoperative fever: where is the clinical evidence? Chest. 2011 Aug;140(2):418-24.
  6. Chen HA, Lai SL, Kwang WK, Liu JC, et al. Middle lobe syndrome as the pulmonary manifestation of primary Sjogren's syndrome. Med J Aust. 2006 Mar 20;184(6):294-5.
  7. Herold CJ, Kuhlman JE, Zerhouni EA. Pulmonary atelectasis: signal patterns with MR imaging. Radiology. 1991 Mar;178(3):715-20.
  8. Proto AV. Lobar collapse: basic concepts. Eur J Radiol. 1996 Aug;23(1):9-22.
  9. Woodring JH, Reed JC. Radiographic manifestations of lobar atelectasis. J Thorac Imaging. Spring 1996;11(2):109-44.
  10. Pryor JA. Physiotherapy for airway clearance in adults. Eur Respir J. 1999 Dec;14(6):1418-24.

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Last updated: 2017-08-09 17:36