atelectasis and collapse in cxr

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

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

基本功

品質

姿勢

資訊

判讀前

解剖學

病灶

多樣性

判讀

解剖學

Lines

and

Stripes

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)

Apex

Large Airway

Retrocardiac

Lung Bases

盲點

DIRECT SIGNS

INDIRECT SIGNS

SILHOUETTE SIGN

Increased opacity

Displacement of

interlobar fissures

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

S1 ApicalS2 Posterior

S4 Medial

S5 Lateral

S1 Apical

S2 Posterior

S3 Anterior

S10 posterior

S6 Superior

S9 Lateral

S8 Anaterior

右肺前 後

左肺S1+2 Apicoposterior

S3 Anterior

S3 Superior

S3 Inferior

S6 Superior

S7+S8Anterior-medial

S9 LateralS10 Posterior

前 後

M-AA

P

S

P L

S

M

The Anatomy of Lower Lobes of Lung

M-A-L-P

L

Propeller-like configuration of the major fissures

RadioGraphics 2001; 21:861–874

Right Upper Lobe

Right Middle Lobe

Right Lower Lobe

Left Upper Lobe

Left Lower Lobe

Silhouette sign

判斷silhouette sign的重要landmarks

RML-RB5Lingular-LB5

RLLLLL

RUL-RB3

LUL-LB3

LUL-LB1+2

LLL

Silhouette Sign Locations

Silhouette Sign Locations

阻塞

結疤

壓力

Resorption/Obstructive Atelectasis

Causes of central airway obstructionNeoplasm

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

StrictureEndobronchial TB, inflammation (TB, sarcoidosis)

External compressionLAP, mass, aneurysm, cardiomegaly ( especially LAE )

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

Causes of peripheral airway obstruction

Mucus plug AE COPD, asthma, emphysema, BO

Diaphragm 手術 Severe chest or abdominal pain

CNS depressants use

InflammatoryBronchopneumonia

Bronchitis

Bronchiectasis

Resorption/Obstructive Atelectasis

Relaxation Atelectasis

肺內或肺外space-occupying lesionLung tumor

Pneumothorax Bulla

Pleural effusionhemothorax, malignant/benign

Diaphragmatic hernia

Pleural masses Metastasis Mesothelioma

Pneumothorax

Adhesive Atelectasis

Mechanism surfactant deficiency

Causes

ARDS, smoke inhalation

RDS of newborn (prototype)

Pulmonary thromboembolism.CXR: subsegmental atelectasis + pleural effusion

Clinical symptoms and signs

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

Signs of Atelectasis

Acute atelectasis

anatomic structure位移為主

Chronic atelectasis

compensatory hyperinflation

Increased opacity

Displacement of

interlobar fissures

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

Hilar Displacement

Upper lobe collapse elevated

Lower lobe collapse depressed

RML or lingular division collpase

no change

Diaphragm Elevation

lower lobe collapse (volume↑)

Lung collapse, subpulmonic effusion

Diaphragm eventration, paralysis

Abdominal hernia, abdominal mass

Indirect SignMediastinal structure deviation

Trachea, HeartNarrowing of intercostal space

More frequently encountered in children

Mainly in acute atelectasisJuxtaphrenic peak (JP) sign:

Upper lobe collapse, esp. R’t side Stretching of the

inferior pulmonary ligament

Increased

opacity

Fissure

displacement

Trachea

deviation

Hilum

elevation

Narrowing

of ICS

Compensatory

hyperonflation

Lobar Collapse

RUL collapse

RML collapse

RLL collapse

Bilobar collapse

(RML+RLL)

LUL collapse

Upper division collapse

Lingular lobe collapse

LLL collapse

Lingular division

+ LLL collapse

必

背

RUL Collapse: PA view

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

RUL Collapse Lateral view

Minor fissure

Shift upward

Superior half of the major fissure

Shift forward

Nearly complete

RUL collapse

Complete

RUL Collapse

Reverse S Sign of 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.

Golden

Reverse

S sign

Reverse S sign of Golden

RUL collapse with

central tumor

RML Collapse: PA view

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

RML Collapse Lateral view

Easier identification

Minor Fissure:

Inferior displacement

Lower part of the major fissure:

Anterior shift

Minor fissure

Major

fissure

Right Middle Lobe Collapse

RML Collapse

RML Collapse

RML Collapse – Lordotic View

Image of Disease of the CHEST, Armstrong P. 3rd edition

RML

atelectasis

Pectus

excavatum

sternum

RLL Collapse PA view

R’t heart border is visible

Inferior and medial shift of

the major fissure

Upper triangle sign

Minor fissure

Major

fissure

RLL Collapse

RLL Atelectasis

RLL Collapse

UpToDate: Radiologic patterns of lobar atelectasis

Upper triangle sign

Collapse of Upper Division of LUL

Similar to RUL collapse

Obscured aortic arch

LUL upper division atelectasis

Lingual

Lobe

Collapse

類似RMLCollapse

Left Upper Lobe Collapse

LUL

Atelectasis

Luftsichel

sign

Luftsichel sign (LUL collaspe)

(Luft = air; sichel = crescent)

Aortic KnobSuperior segment

of LLL LB6 hyperinflation

produces a crescent

of lucency along the

mediastinum and

aortic knuckle.

LUL collapse

Loss of aortic knob shadow

Loss of upper portion of L’t heart border

Ground-glass shadow

on left upper lung field

Forward

displacement

of major fissure

LUL collapse

LUL collapse

陳X秀珍 35710895 96/10/15

LLL collapse

Increased opacity

Diaphragm shadow disappear

D-aorta border disappear

Flat waist sign

Top-of-knob sign

LLL collapse

Major

fissure

Left Lower Lobe Atelectasis

LLL atelectasis

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mediastinalshift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。

Left lower lobe collapse

LLL collapseTop-of-the-knob sign

當severe LLL 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

Multilobar Atelectasis

RML + RLLRUL + RML

Less common

RUL + RLL

Very rare

Lingular + LLL

Total collapse

Bilobar Collapse RML + RLL

Cause: obstruction in RIMBP-A view

R’t lower heart borderR’t hemidiaphragm

Lat view

R’t hemidiaphragm

IVC

RML + RLL Collapse

陳x亨 3580033-0 97/03/10

SCLC with RIMB obstruction

RLL collapse vs. Bi-lobar collapse

RLL collapse Bi-lobar collapse

Still visible R’t lower heart border

Lingular Division

LLL Collapse

RML + RLL

bilobar collapse

Total lung collapse

Causes:

Obstruction: tumor, foreign body, sputum

Total pneumonectomy

D/D with massive pleural effusionMassive 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

Total Lung Collapse,

Left

Massive Pleural

Effusion, L’t

s/p pneumonectomy

Right lung herniation

Esophageal ca with left main bronchus metastasis, total left atelectasis

Discoid atelectasis

A: R/O linear scars or subsegmental collapse

B: CXR taken 48 hrs later, confirm the diagnosis of subsegmental atelectasis

Discoid Atelectasis

Discoid atelectasis showing typical band-like shadow

Image of Disease of the CHEST, Armstrong P. 3rd edition

Round Atelectasis

Passive atelectasis due to PE

Infolding of visceral pleura

Fibrinous parietal pleural adhesion maintain the infoldingand tilting lung

當pleural effusion吸收後，collapsed

lung會re-expand，除了round

atelectasis處

Pleuropulmonary fibrosis with organization and contraction

Round Atelectasis

Round Atelectasis

Round Atelectasis

Mass like density

Pleural based

Base of lungs

Blunting of costophrenic angle Pleural thickening Pulmonary vasculature curving into the density Esophageal surgical clips.

Round atelectasis

Image of Disease of the CHEST, Armstrong P. 3rd edition

Comet tail sign

Round atelectasis

Comet tail sign

Image of Disease of the CHEST, Armstrong P. 3rd edition

Image of Disease of the CHEST, Armstrong P. 3rd edition

Are you ready?

LLL Atelectasis

•Inhomogeneous cardiac density

•Left hilum pulled down

•Non-visualization of left diaphragm

•Triangular retrocardiac

atelectatic LLL

LLL Atelectasis

•Loss of left diaphragmatic silhouette in PA view

LUL Atelectasis

•Hazy density over left upper lung field

•Loss of left heart silhouette

•Tracheal shift to left

LUL Atelectasis

A: Forward movement of oblique fissureC: Atelectatic LULB: Herniated right lung

RUL Atelectasis

1. Density in the right upper lung field

2. Right hilum pulled up

3. Smaller right hemithorax

RUL Atelectasis

RML + RLL atelectasis

RLL Atelectasis

LUL Atelectasis

1.Mediastinal shift to left

2.Density left upper lung field

3.Loss of aortic knob and left hilarsilhouettes

4.Compensatory hyperinflation of right lung

RML Collapse Neck LAP

Loss of R’t heart border

TB adenitis with RML collapse