Atelectasis: Types and pathogenesis in adults

Atelectasis: Types and pathogenesis in adults

Author
Paul Stark, MD
Section Editor
Nestor L Muller, MD, PhD
Deputy Editor
Geraldine Finlay, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Mar 2013. | This topic last updated: Apr 8, 2013.
INTRODUCTION Atelectasis describes the loss of lung volume due to the
collapse of lung tissue. It can be classified according to the pathophysiologic
mechanism (eg, compressive atelectasis), the amount of lung involved (eg, lobar,
segmental, or subsegmental atelectasis), or the location (ie, specific lobe or segment
location).
The classification of atelectasis according to the pathophysiologic mechanism is
reviewed here, as are the mechanisms of each type of atelectasis. Radiologic
manifestations of atelectasis are described separately. (See "Radiologic patterns of
lobar atelectasis" .)
TYPES OF ATELECTASIS Atelectasis can be divided pathophysiologically into
obstructive and nonobstructive atelectasis.
Obstructive atelectasis Obstructive (ie, resorptive) atelectasis is a consequence
of blockage of an airway [ 1 ]. Air retained distal to the occlusion is resorbed from
nonventilated alveoli, causing the affected regions to become totally airless and then
collapse. The rate at which this occurs depends upon several factors, particularly the
amount of collateral ventilation and the composition of inspired gas.
Obstruction of a segmental bronchus is less likely to result in segmental atelectasis
than obstruction of a lobar bronchus is to produce lobar atelectasis. This difference is
the consequence of collateral ventilation between segments within a lobe. Collateral
ventilation occurs via three distinct channels (the pores of Kohn, canals of Lambert,
and fenestrations of Boren) and all of these channels must be obliterated for
obstructive atelectasis to occur. Such collateral ventilation does not occur between
lobes, unless the interlobar fissures are incomplete (which is the case in 50 percent
of normal persons) [ 2 ]. Of note, collateral ventilation is age-dependent:
Children have poorly developed collateral pathways and, therefore,
obstructive atelectasis can occur readily. This is why atelectasis is common

in children who have aspirated a foreign body. (See "Airway foreign bodies
in children", section on 'Radiologic evaluation' .)
In contrast, elderly adults with emphysema have extensive collateral
ventilation through fenestrae of Boren, which are larger than the pores of
Kohn. This explains why an obstructing lesion, such as a tumor, may have a
long latent period in adults before it causes atelectasis [ 3 ].
Patients who are breathing gas with a high fraction of inspired oxygen (FiO 2 )
develop atelectasis more rapidly than patients who are breathing gas with a lower
FiO 2 . Under normal conditions, the ambient air contains 79 percent inert nitrogen,
which is in equilibrium with the nitrogen that is dissolved in pulmonary arteriolar and
capillary blood. After complete occlusion of a bronchus, intraalveolar oxygen distal to
the obstruction is rapidly reabsorbed along a steep pressure gradient into
deoxygenated mixed venous blood. The pressure gradient forcing nitrogen into the
mixed venous blood is minimal. Thus, nitrogen disappears slowly and acts like an
alveolar splint or scaffolding, delaying the formation of atelectasis for several hours.
In contrast, in patients who inhale gas with a high FiO 2 , the alveolar nitrogen is
washed out. With less nitrogen in the alveoli at the moment of bronchial obstruction,
atelectasis develops more rapidly, sometimes within minutes.
Nonobstructive atelectasis Nonobstructive causes of atelectasis include loss of
contact between the parietal and visceral pleurae, parenchymal compression,
surfactant dysfunction, replacement of lung tissue by scarring or infiltrative disease,
and strong vertical acceleration forces.
Relaxation Relaxation (ie, passive) atelectasis ensues when contact between the
parietal and visceral pleurae is eliminated ( image 1 ) [ 2 ]. While this is usually due
to a pleural effusion or pneumothorax, a large emphysematous bulla can have a
similar effect. In this case, the visceral and parietal pleurae separate as the residual
physiologic elastic recoil of normal lung parenchyma retracts the normal lung away
from the bulla.
Normal lung usually preserves its shape, even when its volume is decreased. This
quality is called form elasticity and is the reason why relaxation atelectasis is more
likely to be generalized than localized. Less frequently, the lobes of the lung may
behave independently. As examples, the middle and lower lobes may shrink more
than the upper lobe in the presence of a pleural effusion, while the upper lobe may
be affected more by a pneumothorax [ 4 ]. The loss of contact between the visceral
and parietal pleurae may be local in this setting, which may cause local rather than
generalized atelectasis.
Compressive Compressive atelectasis occurs when a space occupying lesion of
the thorax (eg, loculated pleural effusion, elevated hemidiaphragm, or solid mass of
the chest wall, pleura, or parenchyma) presses on the lung and causes the lung
volume to diminish to less than the usual resting volume (ie, the functional residual
capacity) [ 1 ]. Compressive atelectasis has a lot in common with relaxation

atelectasis (ie, both eliminate contact between the pleurae), except compressive
atelectasis is more likely to be local [ 2 ].
Adhesive Adhesive atelectasis is a consequence of alveolar instability due, in
part, to surfactant dysfunction [ 1 ]. In the normal lung, surfactant reduces the
surface tension of alveoli and decreases the tendency of alveoli to collapse.
Decreased production or inactivation of surfactant leads to alveolar instability and
collapse. Adhesive atelectasis is a significant problem in respiratory distress
syndrome of premature infants, acute respiratory distress syndrome (ARDS) in
adults, acute radiation pneumonia, and posttraumatic lung contusion [ 2 ].
Cicatrization Cicatrization (ie, cicatriceal atelectasis) results from diminution of
lung volume due to severe parenchymal scarring [ 1 ]. Common underlying etiologies
include granulomatous disease (eg, sarcoidosis), necrotizing pneumonia, and
radiation pneumonia [ 2 ].
Replacement Replacement atelectasis occurs when the alveoli of an entire lobe
are filled by tumor (eg, bronchioloalveolar cell carcinoma), with ensuing loss of
volume.
Acceleration atelectasis This type of atelectasis has been described in pilots
subjected to very high, vertical accelerative forces between 5G and 9G: at 5G, up to
50 percent of pulmonary airways are distorted and closed due to gravitational forces.
The atelectasis is exacerbated by breathing a high fractional concentration of oxygen.
Decreases in vital capacity are a reflection of this type of atelectasis in pilots.
Acceleration atelectasis can cause symptoms like chest pain, coughing, and dyspnea
[ 5 ].
Rounded Rounded atelectasis (also called folded lung, Blesovskys syndrome, or
atelectatic pseudotumor) is a distinct form of atelectasis associated with pleural
disease, particularly following asbestos exposure. It is discussed separately.
(See "Radiologic patterns of lobar atelectasis", section on 'Rounded atelectasis' .)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education
materials, The Basics and Beyond the Basics. The Basics patient education pieces
are written in plain language, at the 5 th to 6 th grade reading level, and they answer
the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short,
easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade
reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on patient info and the
keyword(s) of interest.)
Basics topic (see "Patient information: Atelectasis (The Basics)" )

SUMMARY AND RECOMMENDATIONS

Atelectasis describes the loss of lung volume due to the collapse of lung
tissue. It can be classified as obstructive or nonobstructive.
(See 'Introduction'above.)
Obstructive (ie, resorptive) atelectasis results from the blockage of an airway.
It is more common after obstruction of a lobar bronchus than of a
segmental bronchus and it occurs more rapidly among patients who are
breathing gas with a high fraction of inspired oxygen (FiO 2 ).
(See 'Obstructive atelectasis' above.)
Nonobstructive causes of atelectasis include loss of contact between the
parietal and visceral pleurae (ie, passive atelectasis), parenchymal
compression (ie, compressive atelectasis), surfactant dysfunction (ie,
adhesive atelectasis), replacement of lung tissue by scarring (ie, cicatriceal
atelectasis) or infiltrative disease (ie, replacement atelectasis), and strong
acceleration forces in pilots and astronauts. (See 'Nonobstructive
atelectasis' above.)
Rounded atelectasis is a distinct form of atelectasis associated with pleural
disease, particularly following asbestos exposure. It is discussed separately.
(See "Radiologic patterns of lobar atelectasis", section on 'Rounded
atelectasis' .)

Atelectasis
From Wikipedia, the free encyclopedia

This article needs additional citations for verification. Please help improve this
article by adding citations to reliable sources. Unsourced material may be challenged
and removed. (May 2008)

Atelectasis

Atelectasis of a patient's right lung

Classification and external resources

Specialty

Pulmonology

ICD-10

J98.1

ICD-9-CM

518.0

DiseasesDB

10940

MedlinePlus

000065

eMedicine

med/180

MeSH

D001261

Atelectasis (from Greek: , "incomplete" + , "extension") is defined as the

collapse or closure of the lung resulting in reduced or absent gas exchange. It may affect
part or all of one lung.[1] It is a condition where the alveoli are deflated, as distinct
frompulmonary consolidation.
It is a very common finding in chest x-rays and other radiological studies. It may be caused
by normal exhalation or by several medical conditions. Although frequently described as a
collapse of lung tissue, atelectasis is not synonymous with a pneumothorax, which is a more
specific condition that features atelectasis. Acute atelectasis may occur as a post-operative
complication or as a result ofsurfactant deficiency. In premature neonates, this leads to infant
respiratory distress syndrome.
Contents
[hide]

1 Classification
o

1.1 Chronic atelectasis

1.2 Absorption (resorption) atelectasis

2 Signs and symptoms

3 Causes

4 Diagnosis

5 Treatment

6 See also

7 References

8 External links

Classification[edit]
Atelectasis may be an acute or chronic condition. In acute atelectasis, the lung has recently
collapsed and is primarily notable only for airlessness. In chronic atelectasis, the affected
area is often characterized by a complex mixture of airlessness, infection, widening of the
bronchi (bronchiectasis), destruction, and scarring (fibrosis).

Chronic atelectasis[edit]

Atelectasis of the middle lobe on a sagittal CT reconstruction

Chronic atelectasis may take one of two formsmiddle lobe syndrome or rounded
atelectasis. In right middle lobe syndrome, the middle lobe of the right lung contracts, usually
because of pressure on the bronchus from enlarged lymph glands and occasionally a tumor.
The blocked, contracted lung may develop pneumonia that fails to resolve completely and
leads to chronic inflammation, scarring, andbronchiectasis.
In rounded atelectasis (folded lung syndrome), an outer portion of the lung slowly collapses
as a result of scarring and shrinkage of the membrane layers covering the lungs (pleura).
This produces a rounded appearance on x-ray that doctors may mistake for a tumor.
Rounded atelectasis is usually a complication of asbestos-induced disease of the pleura, but
it may also result from other types of chronic scarring and thickening of the pleura.

Absorption (resorption) atelectasis[edit]

The atmosphere is composed of 78% nitrogen and 21% oxygen. Since oxygen is exchanged
at the alveoli-capillary membrane, nitrogen is a major component for the alveoli's state of
inflation. If a large volume of nitrogen in the lungs is replaced with oxygen, the oxygen may
subsequently be absorbed into the blood, reducing the volume of the alveoli, resulting in a
form of alveolar collapse known as absorption atelectasis.[2]

Signs and symptoms[edit]

May have no signs and symptoms or they may include: [3]

cough, but not prominent;

chest pain (not common);

breathing difficulty (fast and shallow);

low oxygen saturation;

pleural effusion (transudate type);

cyanosis (late sign);

increased heart rate.

increased temperature.

It is a common misconception that atelectasis causes fever. A study of 100 post-op patients
followed with serial chest X-rays and temperature measurements showed that the incidence
of fever decreased as the incidence of atelectasis increased.[4] A recent review article
summarizing the available published evidence on the association between atelectasis and
post-op fever concluded that there is no clinical evidence supporting this dogma. [5]

Causes[edit]
The most common cause is post-surgical atelectasis, characterized by splinting, i.e.
restricted breathing after abdominal surgery. Smokers and the elderly are at an increased
risk. Outside of this context, atelectasis implies some blockage of a bronchiole or bronchus,
which can be within the airway (foreign body, mucus plug), from the wall (tumor,
usuallysquamous cell carcinoma) or compressing from the outside (tumor, lymph
node, tubercle). Another cause is poor surfactant spreading during inspiration, causing the
surface tension to be at its highest which tends to collapse smaller alveoli. Atelectasis may
also occur during suction, as along with sputum, air is withdrawn from the lungs. There are
several types of atelectasis according to their underlying mechanisms or the distribution of
alveolar collapse; resorption, compression, microatelectasis and contraction atelectasis.

Diagnosis[edit]

Atelectasis of the right lower lobe seen on chest X-ray

chest X-ray

Post-surgical atelectasis will be bibasal in pattern.

computed tomography

bronchoscopy

Treatment[edit]
Treatment is directed at correcting the underlying cause. Post-surgical atelectasis is treated
by physiotherapy, focusing on deep breathing and encouraging coughing. An incentive
spirometer is often used as part of the breathing exercises. Ambulation is also highly
encouraged to improve lung inflation. People with chest deformities or neurologic conditions
that cause shallow breathing for long periods may benefit from mechanical devices that
assist their breathing. One method is continuous positive airway pressure, which delivers
pressurized air or oxygen through a nose or face mask to help ensure that the alveoli do not
collapse, even at the end of a breath. This is helpful, as partially inflated alveoli can be
expanded more easily than collapsed alveoli. Sometimes additional respiratory support is
needed with a mechanicalventilator.
The primary treatment for acute massive atelectasis is correction of the underlying cause. A
blockage that cannot be removed by coughing or by suctioning the airways often can be
removed by bronchoscopy. Antibiotics are given for an infection. Chronic atelectasis is often
treated with antibiotics because infection is almost inevitable. In certain cases, the affected
part of the lung may be surgically removed when recurring or chronic infections become
disabling or bleeding is significant. If a tumor is blocking the airway, relieving the obstruction
by surgery, radiation therapy, chemotherapy, or laser therapy may prevent atelectasis from
progressing and recurrent obstructive pneumonia from developing.

See also[edit]

1.
o
o
o
o
o
o

Alveolar capillary dysplasia

Tympanic membrane atelectasis: Retraction of the ear drum into the middle ear can
also be referred to as atelectasis.
Flat-chested kitten syndrome or FCKS: atelectasis in neo-natal kittens

Complications may include the following:

Acute pneumonia.
Bronchiectasis.
Hypoxemia and respiratory failure.
Postobstructive drowning of the lung.
Sepsis.
Pleural effusion and empyema.