Atelectasis

Definition

Atelectasis is a partial or complete collapse of the entire lung or a specific area, or

lobe, of the lung.

Atelectasis occurs when the alveoli (small air sacs) within the lung become
deflated or fill with alveolar fluid.
Pathophysiology
Obstructive atelectasis - most common type
●Causes of obstructive atelectasis include foreign body, tumor, and mucous plugging.
●The rate at which atelectasis develops and the extent of atelectasis depend on several factors
(the extent of collateral ventilation, the composition of inspired gas)
●Obstruction of a lobar bronchus is likely to produce lobar atelectasis.
●Because of the collateral ventilation within a lobe or between segments, the pattern of atelectasis
often depends on collateral ventilation, which is provided by the pores of Kohn and the canals of
Lambert.
Nonobstructive atelectasis
●Caused by loss of contact between the parietal and visceral pleurae, compression, loss of
surfactant, and replacement of parenchymal tissue by scarring or infiltrative disease.
●Relaxation or passive atelectasis - when a pleural effusion or a pneumothorax
●The uniform elasticity of a normal lung leads to preservation of shape even when volume is
decreased.
●The middle and lower lobes collapse more than the upper lobe in the presence of pleural
effusion.
●The upper lobe is typically affected more by pneumothorax.
Pathophysiology
Compression atelectasis - the mechanism is similar to relaxation atelectasis (A large pleural-based lung
mass)
Adhesive atelectasis - surfactant deficiency (in acute respiratory distress syndrome (ARDS), radiation
pneumonitis, and blunt trauma to the lung)
Cicatrization atelectasis - caused by granulomatous disease or necrotizing pneumonia.

Replacement atelectasis - when the alveoli of an entire lobe are filled by tumor (eg, bronchioalveolar
cell carcinoma)
Middle lobe syndrome - extraluminal or intraluminal bronchial obstruction, primary Sjögren syndrome
Rounded atelectasis - folded atelectatic lung tissue with fibrous bands /high in asbestos workers (65-
70% of cases), uremic pleuritis/
Platelike atelectasis - most commonly, obstruction of a small bronchus (in states of hypoventilation,
pulmonary embolism, lower respiratory tract infection)
Platelike atelectasis
Rounded atelectasis
Replacement atelectasis Postoperative atelectasis
Etiology
● The primary cause of acute or chronic atelectasis is bronchial obstruction by
plugs of tenacious sputum; foreign bodies; endobronchial tumors; or tumors, a
lymph node, or an aneurysm compressing the bronchi and bronchial distortion.
● External pulmonary compression by pleural fluid or air
● Abnormalities of surfactant production
Resorptive atelectasis
Relaxation atelectasis
Compression atelectasis
Adhesive atelectasis
Cicatrization atelectasis
Risk factors: smoking, obesity, sleep apnea, or lung diseases such as asthma,
chronic obstructive pulmonary disease, or cystic fibrosis.
Postoperative atelectasis
Epidemiology

US frequency
Postoperative atelectasis is extremely common. Lobar atelectasis is also common.
The incidence and prevalence of this disorder are not well documented.
Race - no predilection
Sex - no
Age - The mean age at presentation for rounded atelectasis is 60 years.
Prognosis

Patient mortality depends on the underlying cause of atelectasis.

In postoperative atelectasis, the condition generally improves.

The prognosis of lobar atelectasis secondary to endobronchial obstruction

depends on treatment of the underlying malignancy.

Patient Education
Difficulty breathing is an immediate reason to seek medical care.
Atelectasis - one of the most common complications after surgery
Deep-breathing exercises
History
Anamnesis of thoracic or upper abdominal procedures
Most common cause of early postoperative fever
Rapid bronchial occlusion with a large area of lung collapse:
●pain on the affected side
●sudden onset of dyspnea
●cyanosis
●Hypotension, tachycardia, fever, and shock may also occur.
★Slowly developing atelectasis - asymptomatic or only minor symptoms
★Middle lobe syndrome - asymptomatic
★Irritation in the right middle and right lower lobe bronchi - a severe,
hacking, nonproductive cough
Physical examination
● Dullness to percussion over the involved area
● Diminished or absent breath sounds
● Reduced or absent chest excursion of the involved hemithorax
● Deviation of trachea and heart toward the affected side
Complications
● Acute pneumonia
● Bronchiectasis
● Hypoxemia and respiratory failure
● Postobstructive drowning of the lung
● Sepsis
● Pleural effusion and empyema
Differential diagnoses
Bronchogenic carcinoma must be excluded in all
patients older than 35 years.
A pneumothorax - the percussion note is hyper-
resonant and the heart and mediastinum are
pushed to the opposite side.
A massive pleural effusion
● Asbestosis
● Ascites
● Aspiration Pneumonitis and Pneumonia
● Bacterial Pneumonia
● Blunt Chest Trauma
● Community-Acquired Pneumonia (CAP)
● Diaphragmatic Paralysis
● Fungal Pneumonia
● Hypersensitivity Pneumonitis
● Idiopathic Pulmonary Fibrosis (IPF)
● Lung Abscess
● Non-Small Cell Lung Cancer (NSCLC)
● Pneumococcal Infections (Streptococcus pneumoniae)
● Pneumothorax Imaging
● Pulmonary Embolism (PE)
● Respiratory Failure
● Small Cell Lung Cancer (SCLC)
● Viral Pneumonia
Diagnosis
● Arterial blood gas evaluation - a low PaO2
● Chest radiographs and CT scans - May demonstrate direct and indirect signs of lobar
collapse (collapsed lung)
● Flexible fiberoptic bronchoscopy - Useful diagnostically and therapeutically
Bronchoscopy helps evaluate the cause of bronchial obstruction and helps clear mucous
plugs.
Only the subsegmental bronchi are visualized.
● Histologic Findings
Imaging Studies
Direct signs - displacement of fissures and 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 lobes
●silhouetting of the diaphragm or the heart border
Complete atelectasis of an entire lung:
●when complete collapse of a lung leads to opacification of the entire hemithorax
●an ipsilateral shift of the mediastinum
●the mediastinal shift separates atelectasis from massive pleural effusion

Complete atelectasis of the left lung. Mediastinal
displacement, opacification, and loss of volume are
present in the left hemithorax.
Tumor encasing and occluding the right upper lobe
bronchus and collapse of the right upper lobe, with
superior and medial displacement of the minor
fissure.

A right hilar bronchogenic carcinoma causing right
upper lobe collapse with upward displacement of
the minor fissure.
Left upper lobe collapse
Right middle lobe collapse
The minor fissure moves down, and the
major fissure moves up, leading to a
wedge-shaped/ triangular opacity. It is
termed the "tilted ice cream cone sign."
Treatment
● Flexible fiberoptic bronchoscopy
● Chest physiotherapy - Postural drainage, chest wall percussion and vibration, a forced expiration
technique (called huffing)
● Adequate oxygenation and re-expansion of lung segments
● Continuous positive airway pressure delivered via a nasal cannula or facemask
● Bronchodilators - To encourage sputum expectoration
● Surgical - Segmental resection or lobectomy (chronic atelectasis)

❖ Postoperative atelectasis - requires removal of the underlying cause, prevention is the best
approach, anesthetic agents associated with postanesthesia narcosis
❖ Nasotracheal suctioning
❖ A broad-spectrum antibiotic
❖ perioperative analgesia
❖ epidural analgesia
❖ N -acetylcysteine aerosols
Prophylactic maneuvers

● deep-breathing exercises
● coughing exercises
● incentive spirometry
Prophylactic measures should be taught and instituted before surgery and used
regularly, on an hourly basis, after surgery.
Early ambulation of patients after surgery is as effective as physical therapy.
Reference

https://emedicine.medscape.com/

https://www.uptodate.com/

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