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Atelectasis and collapse in CXR

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Introduction of atelectasis and collapse characteristics in chest radiography.

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Atelectasis and collapse in CXR

  1. 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. 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
  3. 3. 基本功
  4. 4. 品質 姿勢 資訊 判 讀 前
  5. 5. 解剖學 病灶 多樣性 判 讀
  6. 6. 解剖學
  7. 7. Lines and Stripes
  8. 8. 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)
  9. 9. Apex Large Airway Retrocardiac Lung Bases 盲 點
  10. 10. DIRECT SIGNS INDIRECT SIGNS SILHOUETTE SIGN
  11. 11. 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
  12. 12. S1 Apical S2 Posterior S4 Medial S5 Lateral S1 Apical S2 Posterior S3 Anterior S10 posterior S6 Superior S9 Lateral S8 Anaterior 右肺前 後
  13. 13. 左肺 S1+2 Apicoposterior S3 Anterior S3 Superior S3 Inferior S6 Superior S7+S8 Anterior-medial S9 LateralS10 Posterior 前 後
  14. 14. M-A A P S P L S M The Anatomy of Lower Lobes of Lung M-A-L-P L
  15. 15. Propeller-like configuration of the major fissures RadioGraphics 2001; 21:861–874
  16. 16. Right Upper Lobe
  17. 17. Right Middle Lobe
  18. 18. Right Lower Lobe
  19. 19. Left Upper Lobe
  20. 20. Left Lower Lobe
  21. 21. Silhouette sign
  22. 22. 判斷silhouette sign的重要landmarks RML-RB5 Lingular-LB5 RLL LLL RUL-RB3 LUL-LB3 LUL-LB1+2 LLL
  23. 23. Silhouette Sign Locations
  24. 24. Silhouette Sign Locations
  25. 25. 阻塞 結疤 壓力
  26. 26. Resorption/Obstructive Atelectasis Causes of central 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 )
  27. 27. 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
  28. 28. Causes of peripheral airway 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
  29. 29. Relaxation Atelectasis 肺內或肺外 space-occupying lesion Lung tumor Pneumothorax  Bulla Pleural effusion hemothorax, malignant/benign Diaphragmatic hernia Pleural masses Metastasis Mesothelioma
  30. 30. Pneumothorax
  31. 31. Adhesive Atelectasis Mechanism surfactant deficiency Causes ARDS, smoke inhalation RDS of newborn (prototype) Pulmonary thromboembolism. CXR: subsegmental atelectasis + pleural effusion Clinical symptoms and signs
  32. 32. 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
  33. 33. Signs of Atelectasis Acute atelectasis anatomic structure位移為主 Chronic atelectasis compensatory hyperinflation
  34. 34. 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
  35. 35. Hilar Displacement Upper lobe collapse elevated Lower lobe collapse depressed RML or lingular division collpase no change
  36. 36. Diaphragm Elevation lower lobe collapse (volume↑) Lung collapse, subpulmonic effusion Diaphragm eventration, paralysis Abdominal hernia, abdominal mass
  37. 37. Indirect Sign Mediastinal structure deviation 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
  38. 38. Increased opacity Fissure displacement Trachea deviation Hilum elevation Narrowing of ICS Compensatory hyperonflation
  39. 39. 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
  40. 40. 必 背
  41. 41. 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
  42. 42. RUL Collapse Lateral view Minor fissure Shift upward Superior half of the major fissure Shift forward
  43. 43. Nearly complete RUL collapse
  44. 44. Complete RUL Collapse
  45. 45. 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.
  46. 46. Golden Reverse S sign
  47. 47. Reverse S sign of Golden RUL collapse with central tumor
  48. 48. 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
  49. 49. RML Collapse Lateral view Easier identification Minor Fissure: Inferior displacement Lower part of the major fissure: Anterior shift
  50. 50. Minor fissure Major fissure
  51. 51. Right Middle Lobe Collapse
  52. 52. RML Collapse
  53. 53. RML Collapse
  54. 54. RML Collapse – Lordotic View
  55. 55. Image of Disease of the CHEST, Armstrong P. 3rd edition RML atelectasis Pectus excavatum
  56. 56. sternum
  57. 57. RLL Collapse PA view R’t heart border is visible Inferior and medial shift of the major fissure Upper triangle sign
  58. 58. Minor fissure Major fissure
  59. 59. RLL Collapse
  60. 60. RLL Atelectasis
  61. 61. RLL Collapse
  62. 62. UpToDate: Radiologic patterns of lobar atelectasis Upper triangle sign
  63. 63. Collapse of Upper Division of LUL Similar to RUL collapse Obscured aortic arch
  64. 64. LUL upper division atelectasis
  65. 65. Lingual Lobe Collapse 類似RML Collapse
  66. 66. Left Upper Lobe Collapse
  67. 67. LUL Atelectasis Luftsichel sign
  68. 68. Luftsichel sign (LUL collaspe) (Luft = air; sichel = crescent) Aortic Knob Superior segment of LLL LB6 hyperinflation produces a crescent of lucency along the mediastinum and aortic knuckle.
  69. 69. LUL collapse Loss of aortic knob shadow Loss of upper portion of L’t heart border
  70. 70. Ground-glass shadow on left upper lung field Forward displacement of major fissure LUL collapse
  71. 71. LUL collapse 陳X秀珍 35710895 96/10/15
  72. 72. LLL collapse Increased opacity Diaphragm shadow disappear D-aorta border disappear Flat waist sign Top-of-knob sign
  73. 73. LLL collapse Major fissure
  74. 74. Left Lower Lobe Atelectasis
  75. 75. LLL atelectasis
  76. 76. 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。
  77. 77. Left lower lobe collapse
  78. 78. LLL collapse Top-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
  79. 79. Multilobar Atelectasis RML + RLL RUL + RML Less common RUL + RLL Very rare Lingular + LLL Total collapse
  80. 80. 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
  81. 81. RML + RLL Collapse 陳x亨 3580033-0 97/03/10 SCLC with RIMB obstruction
  82. 82. RLL collapse vs. Bi-lobar collapse RLL collapse Bi-lobar collapse Still visible R’t lower heart border
  83. 83. Lingular Division LLL Collapse RML + RLL bilobar collapse
  84. 84. 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
  85. 85. Total Lung Collapse, Left Massive Pleural Effusion, L’t
  86. 86. s/p pneumonectomy
  87. 87. Right lung herniation Esophageal ca with left main bronchus metastasis, total left atelectasis
  88. 88. Discoid atelectasis  A: R/O linear scars or subsegmental collapse  B: CXR taken 48 hrs later, confirm the diagnosis of subsegmental atelectasis
  89. 89. Discoid Atelectasis
  90. 90. Discoid atelectasis showing typical band-like shadow Image of Disease of the CHEST, Armstrong P. 3rd edition
  91. 91. Round Atelectasis Passive atelectasis due to 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
  92. 92. Round Atelectasis
  93. 93. Round Atelectasis
  94. 94. 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.
  95. 95. Round atelectasis Image of Disease of the CHEST, Armstrong P. 3rd edition Comet tail sign
  96. 96. Round atelectasis Comet tail sign Image of Disease of the CHEST, Armstrong P. 3rd edition
  97. 97. Image of Disease of the CHEST, Armstrong P. 3rd edition
  98. 98. Are you ready?
  99. 99. LLL Atelectasis •Inhomogeneous cardiac density •Left hilum pulled down •Non-visualization of left diaphragm •Triangular retrocardiac atelectatic LLL
  100. 100. LLL Atelectasis •Loss of left diaphragmatic silhouette in PA view
  101. 101. LUL Atelectasis •Hazy density over left upper lung field •Loss of left heart silhouette •Tracheal shift to left
  102. 102. LUL Atelectasis A: Forward movement of oblique fissure C: Atelectatic LUL B: Herniated right lung
  103. 103. RUL Atelectasis 1. Density in the right upper lung field 2. Right hilum pulled up 3. Smaller right hemithorax
  104. 104. RUL Atelectasis
  105. 105. RML + RLL atelectasis
  106. 106. RLL Atelectasis
  107. 107. LUL Atelectasis 1.Mediastinal shift to left 2.Density left upper lung field 3.Loss of aortic knob and left hilar silhouettes 4.Compensatory hyperinflation of right lung
  108. 108. RML Collapse Neck LAP Loss of R’t heart border TB adenitis with RML collapse

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