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Atelectasis Clinical Presentation

  • Author: Tarun Madappa, MD, MPH; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Feb 11, 2016
 

History

Atelectasis may occur postoperatively following thoracic or upper abdominal procedures.

Although atelectasis is considered to be the most common cause of early postoperative fever, the existing evidence is contradictory. In a study by Mavros et al, they found no clinical evidence supporting the concept that atelectasis is associated with early postoperative fever.[5]

Most symptoms and signs are determined by the rapidity with which the bronchial occlusion occurs, the size of the lung area affected, and the presence or absence of complicating infection.

Rapid bronchial occlusion with a large area of lung collapse causes pain on the affected side, sudden onset of dyspnea, and cyanosis. Hypotension, tachycardia, fever, and shock may also occur.

Slowly developing atelectasis may be asymptomatic or may cause only minor symptoms. Middle lobe syndrome often is asymptomatic, although irritation in the right middle and right lower lobe bronchi may cause a severe, hacking, nonproductive cough.

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Physical

The physical examination findings may demonstrate dullness to percussion over the involved area and diminished or absent breath sounds. Chest excursion of the involved hemithorax may be reduced or absent. The trachea and the heart may be deviated toward the affected side.

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Causes

The primary cause of acute or chronic atelectasis is bronchial obstruction by the following:

  • Plugs of tenacious sputum
  • Foreign bodies
  • Endobronchial tumors
  • Tumors, a lymph node, or an aneurysm compressing the bronchi and bronchial distortion

External pulmonary compression by pleural fluid or air (ie, pleural effusion, pneumothorax) may also cause atelectasis.

Abnormalities of surfactant production contribute to alveolar instability and may result in atelectasis. These abnormalities commonly occur with oxygen toxicity and ARDS.

Resorptive atelectasis is caused by the following:

  • Bronchogenic carcinoma
  • Bronchial obstruction from metastatic neoplasm (eg, adenocarcinoma of breast or thyroid, hypernephroma, melanoma)
  • Inflammatory etiology (eg, tuberculosis, fungal infection)
  • Aspirated foreign body
  • Mucous plug
  • Malpositioned endotracheal tube
  • Extrinsic compression of an airway by neoplasm, lymphadenopathy, aortic aneurysm, or cardiac enlargement

Relaxation atelectasis is caused by the following:

  • Pleural effusion
  • Pneumothorax
  • A large emphysematous bulla

Compression atelectasis is caused by the following:

  • Chest wall, pleural, or intraparenchymal masses
  • Loculated collections of pleural fluid

Adhesive atelectasis is caused by the following:

  • Hyaline membrane disease
  • Acute respiratory distress syndrome
  • Smoke inhalation
  • Cardiac bypass surgery
  • Uremia
  • Prolonged shallow breathing

Cicatrization atelectasis is caused by the following:

  • Idiopathic pulmonary fibrosis
  • Chronic tuberculosis
  • Fungal infections
  • Radiation fibrosis

Replacement atelectasis is caused by alveoli filled by tumor or fluid.

Right middle lobe syndrome (also known as Brock syndrome) refers to recurrent right middle lobe collapse secondary to airway disease, infection, or a combination of the two. The right middle lobe bronchus is long and thin, has the poorest drainage or clearance of all the lobes of the lung, which can result in retained mucus, and is more prone to extrinsic compression by the lymphatic system. Individuals with middle lobe syndrome are often asymptomatic, although some present with recurrent productive cough and history of right-sided pneumonias.

Rounded atelectasis is caused primarily by asbestos-related pleural disease and uremic pleuritis.

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Contributor Information and Disclosures
Author

Tarun Madappa, MD, MPH Attending Physician, Department of Pulmonary and Critical Care Medicine, Christus Spohn-Shoreline Hospital

Tarun Madappa, MD, MPH is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, World Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Helen M Hollingsworth, MD Director, Adult Asthma and Allergy Services, Associate Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, Boston Medical Center

Helen M Hollingsworth, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American Thoracic Society, Massachusetts Medical Society

Disclosure: Nothing to disclose.

References
  1. Rosenbloom SA, Ravin CE, Putman CE, et al. Peripheral middle lobe syndrome. Radiology. 1983;. 149:17-21. [Medline]. [Full Text].

  2. Priftis KN, Mermiri D, Papadopoulou A, Anthracopoulos MB, Vaos G, Nicolaidou P. The role of timely intervention in middle lobe syndrome in children. Chest. 2005 Oct. 128(4):2504-10. [Medline].

  3. Chen HA, Lai SL, Kwang WK, Liu JC, Chen CH, Huang DF. Middle lobe syndrome as the pulmonary manifestation of primary Sjogren's syndrome. Med J Aust. 2006 Mar 20. 184(6):294-5. [Medline].

  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. [Medline].

  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. [Medline].

  6. Proto AV, Tocino I. Radiographic manifestations of lobar collapse. Semin Roentgenol. 1980 Apr. 15(2):117-73. [Medline].

  7. Kattan KR, Eyler WR, Felson B. The juxtaphrenic peak in upper lobe collapse. Semin Roentgenol. 1980 Apr. 15(2):187-93. [Medline].

  8. Partap VA. The comet tail sign. Radiology. 1999 Nov. 213(2):553-4. [Medline].

  9. [Urgent fiberoptic bronchoscopy for diagnostics and treatment of lung atelectasis]. Anesteziol Reanimatol. 2013 Nov-Dec. 51-4. [Medline].

  10. [Guideline] McCool FD, Rosen MJ. Nonpharmacologic airway clearance therapies: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan. 129(1 Suppl):250S-259S. [Medline].

  11. 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. [Medline].

  12. Kato K, Sato N, Takeda S, et al. Marked improvement of extensive atelectasis by unilateral application of the RTX respirator in elderly patients. Intern Med. 2009. 48(16):1419-23. [Medline].

 
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Atelectasis. Left lower lobe collapse. The opacity is in the posterior inferior location.
Atelectasis. Loss of volume on the left side; an elevated and silhouetted left diaphragm; and an opacity behind the heart, called a sail sign, are present.
Atelectasis. Left upper lobe collapse showing opacity contiguous to the aortic knob, a smaller left hemithorax, and a mediastinal shift.
Atelectasis. CT scan of a left upper lobe collapse with a small pleural effusion.
Complete atelectasis of the left lung. Mediastinal displacement, opacification, and loss of volume are present in the left hemithorax.
Atelectasis. Right lower lobe collapse.
Atelectasis. Both right lower lobe and right middle lobe collapse. The left lung is hyperexpanded.
Complete right lung atelectasis.
Atelectasis. A lateral chest x-ray film confirms the diagnosis of right middle lobe collapse. The minor fissure moves down, and the major fissure moves up, leading to a wedge-shaped opacity.
Atelectasis. The left upper lobe collapses anteriorly on a lateral chest x-ray film.
Atelectasis. Left upper lobe collapse. The top of the aortic knob sign is demonstrated.
Atelectasis. Left lower lobe collapse.
Atelectasis. Right middle lobe collapse shows obliteration of the right heart border.
Atelectasis. The azygous lobe of the right lung may be mistaken for a collapsed right upper lobe.
Atelectasis. Left lower lobe collapse. The sail sign is obvious.
Atelectasis. Left upper lobe collapse. The Luft Sichel sign is demonstrated clearly in this radiograph.
Atelectasis. Chest CT scan showing left upper lobe collapse.
Atelectasis. The right lower lobe collapses inferiorly and posteriorly.
Atelectasis. Right lower lobe collapse without middle lobe collapse, the right major fissure is shifted downward and is now visible.
Atelectasis. Right upper lobe collapse demonstrating Golden sign of S.
Atelectasis. Right middle lobe collapse showing obliteration of the right heart border.
Atelectasis. Right middle lobe collapse on a lateral chest x-ray film.
Atelectasis. Right upper lobe collapse and consolidation.
Atelectasis. Right upper lobe collapse.
Atelectasis. Right upper lobe collapse.
Atelectasis. Left lower lobe collapse on posteroanterior view.
The left lower lobe collapses toward the posterior and inferior aspects of the thoracic cavity; the atelectatic left lower lobe is present as a sail behind the cardiac shadow.
 
 
 
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