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Atelectasis and collapse in CXR
Here are the key findings for RUL atelectasis: 1. Increased opacity in the right upper lung zone 2. Elevation of the minor fissure 3. Mediastinal shift to the right This combination of findings is suggestive of collapse or atelectasis of the right upper lobe. The elevated minor fissure and mediastinal shift are indirect signs of volume loss in the right upper lobe.
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Atelectasis and collapse in CXR
- 1. Atelectasis Collapse Adapted from 黃立果學長的CXR 教學 吳文碩 醫師 Wen-Shuo Wu, M.D. 台北榮民總醫院胸腔部 陽明大學醫學系 兼任講師
- 2. 本學期 CXR 教學進度表 2015.03.10 Normal CXR 2015.03.17 Atelectasis/Collapse 2015.03.24 休假一次 PGY大會 2015.03.31 Alveolar Consolidation 2015.04.07 Solitary Pulmonary Nodule and Mass 2015.04.14 Multiple Pulmonary Nodules and Masses 2015.04.21 Cavitary and Cystic Lesions 2015.04.28 Interstitial Pattern/Diffuse Lung Diseases 2015.05.05 Mediastinal and Hilar Lesions part I 2015.05.12 Mediastinal and Hilar Lesions part I 2015.05.19 Cardiovascular disease 2015.05.26 Chest Wall, Diaphragm, and Pleural Lesions 2015.06.02 CXR in ICU
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- 13. 系統性的判讀 每個人可以建立自己的讀片順序 蕭主任游泳姿勢說 1. 胸廓及其外軟組織 2. 橫膈及腹部器官 3.縱膈 4. 大氣道 5. 肺門 6. 肺區(肺裂、肺紋及支氣管分支) Felson: There Are Many Lung Lesions 1. T(thorax):胸廓及其外軟組織 2. A(abdomen):橫膈及腹部器官 3. M(mediastinum):縱膈，含大氣道和肺門 4. L(單側肺區):肺裂、肺紋及支氣管分支 5. L(兩側肺區左右比較)
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- 17. Increased opacity Displacement of interlobarfissures Bronchovascular crowding Hilar displacement Obscured heart or diaphragm borders Diaphragm elevation Displacement of mediastinal structures Compensatory hyperexpansion Narrowing of intercostal spaces Juxtaphrenic peak (JP sign) Direct Signs Indirect Signs
- 19. S1 Apical S2 Posterior S4Medial S5 Lateral S1 Apical S2 Posterior S3 Anterior S10 posterior S6 Superior S9 Lateral S8 Anaterior 右肺前 後
- 20. 左肺 S1+2 Apicoposterior S3 Anterior S3Superior S3 Inferior S6 Superior S7+S8 Anterior-medial S9 LateralS10 Posterior 前 後
- 21. M-A A P S P L S M The Anatomyof Lower Lobes of Lung M-A-L-P L
- 22. Propeller-like configuration ofthe major fissures RadioGraphics 2001; 21:861–874
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- 34. Resorption/Obstructive Atelectasis Causes ofcentral airway obstruction Neoplasm Lung cancer (most common cause) Metastatic cancer(腎細胞癌、乳癌、黑色素瘤、鼻咽喉癌), lymphoma Less frequent: broncholith, bronchial stenosis; bronchial carcinoid, lipoma, granuloma) Foreign body; mucus plugs Stricture Endobronchial TB, inflammation (TB, sarcoidosis) External compression LAP, mass, aneurysm, cardiomegaly ( especially LAE )
- 35. Peripheral airway obstruction Subsegmental:又叫做discoid (plate-like) atelectasis Horizontal or oblique line in middle or lower lung Negative bronchoscopy exam Opacity is less uniform (containing gas) Resorption/Obstructive Atelectasis
- 36. Causes of peripheralairway obstruction Mucus plug AE COPD, asthma, emphysema, BO Diaphragm 手術 Severe chest or abdominal pain CNS depressants use Inflammatory Bronchopneumonia Bronchitis Bronchiectasis Resorption/Obstructive Atelectasis
- 37. Relaxation Atelectasis 肺內或肺外 space-occupying lesion Lungtumor Pneumothorax Bulla Pleural effusion hemothorax, malignant/benign Diaphragmatic hernia Pleural masses Metastasis Mesothelioma
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- 40. Adhesive Atelectasis Mechanism surfactantdeficiency Causes ARDS, smoke inhalation RDS of newborn (prototype) Pulmonary thromboembolism. CXR: subsegmental atelectasis + pleural effusion Clinical symptoms and signs
- 42. Cicatrization Atelectasis 肺組織間質中發生纖維化或是瘢痕(scar)引 起肺泡無法正常膨脹，可分局部性及廣泛性。 局部性結痂性肺萎陷 肺結核放射性肺炎 廣泛性結痂性肺萎陷 塵肺症(pneumoconiosis) 原發性肺纖維化 (Idiopathic pulmonary fibrosis) 常合併有traction bronchiectasis
- 44. Signs of Atelectasis Acuteatelectasis anatomic structure位移為主 Chronic atelectasis compensatory hyperinflation
- 45. Increased opacity Displacement of interlobarfissures Bronchovascular crowding Hilar displacement Obscured heart or diaphragm borders Diaphragm elevation Displacement of mediastinal structures Compensatory hyperexpansion Narrowing of intercostal spaces Juxtaphrenic peak (JP sign) Direct Signs Indirect Signs
- 46. Hilar Displacement Upper lobecollapse elevated Lower lobe collapse depressed RML or lingular division collpase no change
- 47. Diaphragm Elevation lower lobecollapse (volume↑) Lung collapse, subpulmonic effusion Diaphragm eventration, paralysis Abdominal hernia, abdominal mass
- 48. Indirect Sign Mediastinal structuredeviation Trachea, Heart Narrowing of intercostal space More frequently encountered in children Mainly in acute atelectasis Juxtaphrenic peak (JP) sign: Upper lobe collapse, esp. R’t side Stretching of the inferior pulmonary ligament
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- 50. Lobar Collapse RULcollapse RML collapse RLL collapse Bilobar collapse (RML+RLL) LUL collapse Upper division collapse Lingular lobe collapse LLL collapse Lingular division + LLL collapse
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- 53. RUL Collapse: PAview Elevation of minor fissure Complete RUL collapse: widening of the superior mediastinum Indirect sign (hilum elevation) may be evident Specific signs of RUL collapse Reverse S sign J-P sign
- 54. RUL Collapse Lateralview Minor fissure Shift upward Superior half of the major fissure Shift forward
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- 61. Reverse S Signof Golden On in PA view of RUL collapse + R’t hilar tumor Bronchogenic cancer, mediastinal tumor, or enlarged LAP. The upper part: The elevated minor fissure The lower part: The tumor mass responsible for collapse.
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- 63. Reverse S signof Golden RUL collapse with central tumor
- 64. RML Collapse: PAview R’t lower heart border 不清楚 Maybe a faint shadow on the PA view Lordotic view is helpful Relatively small shrinkage in volume Usually no indirect signs
- 65. RML Collapse Lateralview Easier identification Minor Fissure: Inferior displacement Lower part of the major fissure: Anterior shift
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- 67. Right Middle LobeCollapse
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- 70. RML Collapse –Lordotic View
- 71. Image of Diseaseof the CHEST, Armstrong P. 3rd edition RML atelectasis Pectus excavatum
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- 73. RLL Collapse PAview R’t heart border is visible Inferior and medial shift of the major fissure Upper triangle sign
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- 79. UpToDate: Radiologic patternsof lobar atelectasis Upper triangle sign
- 80. Collapse of UpperDivision of LUL Similar to RUL collapse Obscured aortic arch
- 81. LUL upper divisionatelectasis
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- 83. Left Upper LobeCollapse
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- 85. Luftsichel sign (LULcollaspe) (Luft = air; sichel = crescent) Aortic Knob Superior segment of LLL LB6 hyperinflation produces a crescent of lucency along the mediastinum and aortic knuckle.
- 86. LUL collapse Loss ofaortic knob shadow Loss of upper portion of L’t heart border
- 87. Ground-glass shadow on leftupper lung field Forward displacement of major fissure LUL collapse
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- 89. LLL collapse Increased opacity Diaphragmshadow disappear D-aorta border disappear Flat waist sign Top-of-knob sign
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- 91. Left Lower LobeAtelectasis
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- 93. Flat waist sign(LLL collapse) 平腰徵 正常左邊的心臟邊緣 成凹陷狀，而當 severe LLL collapse 時，除了mediastinal shift之外，心臟還會 作輕微的right anterior oblique rotation (leftward rotation)，以致於左 側心臟的normal concavity消失，因而 呈平坦狀。
- 94. Left lower lobecollapse
- 95. LLL collapse Top-of-the-knob sign 當severeLLL collapse 時，anterior junctional line會向左位移，在left upper mediastinum可 見一條幾乎垂直的 vertical interface，會跨 過aortic knob UpToDate: Radiologic patterns of lobar atelectasis
- 96. Multilobar Atelectasis RML +RLL RUL + RML Less common RUL + RLL Very rare Lingular + LLL Total collapse
- 97. Bilobar Collapse RML+ RLL Cause: obstruction in RIMB P-A view R’t lower heart border R’t hemidiaphragm Lat view R’t hemidiaphragm IVC
- 100. RML + RLLCollapse 陳x亨 3580033-0 97/03/10 SCLC with RIMB obstruction
- 101. RLL collapse vs.Bi-lobar collapse RLL collapse Bi-lobar collapse Still visible R’t lower heart border
- 102. Lingular Division LLL Collapse RML+ RLL bilobar collapse
- 103. Total lung collapse Causes: Obstruction:tumor, foreign body, sputum Total pneumonectomy D/D with massive pleural effusion Massive effusion: Volume expansion Mediastinum(trachea) shift to contralateral side Total collapse: Volume reduction Thoracic cage retraction ICS narrowing Mediastinum(trachea) shift to the same side
- 104. Total Lung Collapse, Left MassivePleural Effusion, L’t
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- 106. Right lung herniation Esophageal cawith left main bronchus metastasis, total left atelectasis
- 107. Discoid atelectasis A:R/O linear scars or subsegmental collapse B: CXR taken 48 hrs later, confirm the diagnosis of subsegmental atelectasis
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- 110. Discoid atelectasis showing typicalband-like shadow Image of Disease of the CHEST, Armstrong P. 3rd edition
- 111. Round Atelectasis Passive atelectasis dueto PE Infolding of visceral pleura Fibrinous parietal pleural adhesion maintain the infolding and tilting lung 當pleural effusion吸 收後，collapsed lung會re-expand， 除了round atelectasis處 Pleuropulmonary fibrosis with organization and contraction
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- 114. Round Atelectasis Mass likedensity Pleural based Base of lungs Blunting of costophrenic angle Pleural thickening Pulmonary vasculature curving into the density Esophageal surgical clips.
- 115. Round atelectasis Image ofDisease of the CHEST, Armstrong P. 3rd edition Comet tail sign
- 116. Round atelectasis Comet tailsign Image of Disease of the CHEST, Armstrong P. 3rd edition
- 117. Image of Diseaseof the CHEST, Armstrong P. 3rd edition
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- 119. LLL Atelectasis •Inhomogeneous cardiac density •Lefthilum pulled down •Non-visualization of left diaphragm •Triangular retrocardiac atelectatic LLL
- 120. LLL Atelectasis •Loss ofleft diaphragmatic silhouette in PA view
- 121. LUL Atelectasis •Hazy densityover left upper lung field •Loss of left heart silhouette •Tracheal shift to left
- 122. LUL Atelectasis A: Forwardmovement of oblique fissure C: Atelectatic LUL B: Herniated right lung
- 123. RUL Atelectasis 1. Densityin the right upper lung field 2. Right hilum pulled up 3. Smaller right hemithorax
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- 125. RML + RLLatelectasis
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- 127. LUL Atelectasis 1.Mediastinal shiftto left 2.Density left upper lung field 3.Loss of aortic knob and left hilar silhouettes 4.Compensatory hyperinflation of right lung
- 128. RML Collapse Neck LAP Loss ofR’t heart border TB adenitis with RML collapse