AtelectaziileArapan Ilie

Atelectazia:Colaps saupierderea volumului pulmonarPoate afecta un plamn ntreg, un lob, segment, subsegment5 mecanisme de formare:PostobstructivNon-obstructiv de obicei datorat pierderii contactului dintre foiele pleurale

Atelectazia NU cauzeaz febrIn a 1995 study of 100 postoperative cardiac surgery patients receiving daily portable chest x-rays, no association could be found between fever and amount of atelectasis. This contradicts common textbook dogma but agrees with previous human study and animal experiments.Engoren, Milo. Lack of Association Between Atelectasis and Fever. Chest. Volume 107(1) January 1995pp 81-84

A 1988 study of 270 patients after elective intra-abdominal surgery found that neither the presence nor the absence of fever can assure clinicians of the presence or absence of a postoperative pathologic pulmonary complication such as atelectasis. Roberts J, Barnes W, Pennock M, Browne GD. Diagnostic Accuracy of Fever as a Measure of Postoperative Pulmonary Complications. Heart Lung. 1988 Mar;17(2):166-70

Semne XrayDirecte:Deplasarea fisurilorCreterea densitii lobilori pulmonariBronhograme aerice non arhitectonice(postobstructive) sau vaseIndirecte:Deplasareastructurilor hilareDeplasarea ipsilateral a mediastinuluingustarea ipsilateral a spaiilor intercostaleElevarea ipsilateral a hemidiafragmuluiHiperextensia plamnului sntosObscured structures adjacent to atelectasis

Semne tipice de atelectazie:

1) creterea densitii LSS(semn direct)

2) Deplasarea traheei spre stnga(semn indirect)

3) Semnul Felson(semn indirect)

Colaps lobar

Anatomie Poziia aproximativ a LSD, LM i LID la Xray toracic

Anatomie

AnatomiePoziia aproximativ a LSS i LIS la Xray toracic

Anatomie

Atelectazie de LSDSemne Rx:Elevarea hilului stng sau a fisurii miciLobul colabat se deplaseaz cranial i medialn neo central, fisure mic se deplaseaz cranial cu o convexitate lateral superior i convexitate medial inferior (semnul S a lui Golden)

Atelectazie de LSD: LSD atelectatic formeaz opacitate triunghiular(sgeata)Fisura mic elevat formeaz un S inversat (S-sign of Golden) mpreun cu masa hilar (M).

Atelectazie de LMLobul mediu ocup 10% din volumul total pulmonarTendin major de colapsRadiographic findings can be subtle:Opacitate triunghiular mic orientat lateralSemnul siluetei pe dreapta la nivelul corduluiInciden lateral: opacitate triunghiular cu vrful spre hil

tergerea conturului drept al cordului

Fisura mic cobort

Profil:Sgeile indic fisurile mare i mic paralele.LM este opacifiat ntre fisuri.

Atelectazii de LIDLID atelectatic se retrage posteromedial i inferiorFisura mare se deplaseaz n jos i devine vizibilPe profil, 1/3 posterioar a hemidiafragmului drept este acoperit de LID colabat. Pe Rx de fa hemidiafragmul poate arta normal din cauza expansiunii LM

Atelectazie de LIDOpacitate triunghiular n hemitoracele inferior drept.Marginea lateral este format de fisura mere (normal invizibil pe Rx de fa).Hilul drept deplasat caudal.

Atelectazie de LSSOpacitate tulbure n hemitoracele stng superior50% dintre pacieni au fisura mare completContururile trunchiului pulmonar i arterei pulmonare stngi sunt terseHilul stng i LIS sunt retractate caudal50% dintre pacieni au fisuramare incompletTongue of aerated lower lobe is pulled forward by atelectatic lobe, between the atelectasis and the aortic arch, forming a crescent-shaped lucency (Luftsichel sign)Elevare de hemidiafragm

Atelectazie LSS la un pacient cu fisur mare incomplet: opacitate bine definit.Deviaia traheei spre stnga i tracionarea hilului cranialSgeata indic transparena vertical delimitat ntre arcul aortei i marginea LSS colabat (Luftsichel).

Atelectazie de LISFracvent ntlnit dup chirurgie cardiacSemne Rx:Mrirea opacitii cardiaceDeplasarea caudal a hilului stngtergerea conturului medial a hemidiafragmului stngDeplasarea mediastinului poate cauza obliterarea parial a arcului aortic

Atelectazie complet a unui plmnHemitorax opacifiat completDeplasarea ipsilateral a mediastinuluiIpsilateral cardiomediastinal shift (n efuzie pleural masiv contralateral)Semnul Felson la cord, hil i mediastin

Deviarea traheei la stngaOpacifierea complet a hemitoraceluiDeplasarea cordului la stngaSemnul Felson

Mecanismele atelectaziei

ObstructiveNonobstructive

Atelectazii obstructiveCel mai frecvent tipRezult prin blocarea cilor aerienemucous plugging, foreign body, neoplasm, or inflammatory debrisDistal de blocare loc rezorbia aerului din alveolele neventilateNu se vizualizeaz bronhograma aeric

CauzeCarcinom bronhogen la pacienii cu istoric de atelectazii recurente, sau pneumonii recurente cu rezolvare incomplet dup tratament. Carcinoid bronhial(above considerations also apply here) Metastaze n bronii: mai frecvent carcinom renal, carcinom de sn, melanom, adenocarcinom de colon.

CauzeLymfom (stadii tardive i acompaniat de limfadenopatie hilar i mediastinal) sau alte cauze de limfadenopatii Tuberculoza/ alte afeciuni granulomatoase Dilatarea AS din stenoz mitral (atelectazie de LIS) Obstrucia cu corpi stini

Atelectazii nonobstructive1) Pasive2) Compresive3) Prin cicatrizare4) Adezive

n aceste forme de atelectazii broniile sunt drenate. De aceea bronhoscopia nu poate fi folosit ca metod de tratament.

PasivContactul ntre pleura parietal i visceral se pierde.1). Efuzie pleural2). Pneumotorax 3). Hidrotorax, hemotorax 4). Hernie diafragmal5). Mase pleurale(inclunznd metastazele i mezotelioma)

Passive atelectasis: Notice the crowded air bronchograms (arrows) in the setting of a left pleural effusion. Air bronchograms are not present in post-obstructive atelectasis.

CompresivCauzat de compresiunea plamnului din exteriorPoate fi cauzat de colecie pleural localizat, mas tumoral n peretele toracic, pleur sau parenchim

Compressive atelectasis: Chest x-ray showing a giant bulla occupying more than two thirds of the right hemithorax and compressing the underlying lung upward and toward the mediastinum. Crowded air bronchograms can be seen (arrows).

AdezivCauzat de aderena pereilor alveolari n lipsa surfactantuluiSurfactantul reduce tensiunea superficial n alveole

Adhesive atelectasis in infant with hyaline membrane disease: CXR reveals bilateral ground-glass appearance of the lungs (atelectasis) and air bronchograms standing (red arrow) out against the collapsed parenchyma.

Cicatrizare Secundar fibrozei parenchimului pulmonar cu imposibilitatea expansiei plmnilorEtiologia include:boli granulomatoaseSechele postTBPneumonia necrozantIradiereaPneumoconioze

Cicatrization atelectasis: Lung destruction in patient with chronic pulmonary tuberculosis.

Bibliografie:1) Sharma, Sat. Atelectasis. e-medicine, 2004. http://www.emedicine.com/med/topic180.htm#section~pictures2) Brad H. Thompson, M.D., William J. Lee, B.S., Jeffrey R. Galvin, M.D. and Jeffrey S. Wilson, M.D Lobar Anatomy ElectricLungAnatomy www.vh.org/adult/provider/radiology/LungAnatomy/LobarAnat/LobarAnat.html3) Daffner, RH. Clinical Radiology The Essentials. Williams and Wilkins, 1993, pp 80-85.4) Engoren, Milo. Lack of Association Between Atelectasis and Fever. Chest. Volume 107(1) January 1995pp 81-845) Roberts J, Barnes W, Pennock M, Browne GD. Diagnostic Accuracy of Fever as a Measure of Postoperative Pulmonary Complications. Heart Lung. 1988 Mar;17(2):166-706) Stark, Paul. Atelectasis: Types and Pathogenesis. UpToDate, 2004.7) Stark, Paul. Radiologic Patterns of Lobar Atelectasis. UpToDate, 2004.8) Weed HG, Baddour LM. Postoperative Fever. UpToDate, 2004.9) Federico Venuta and Tiziano de Giacomo. Giant Bullous Emphysema. CTSNET Experts' Techniques, General Thoracic Experts' Techniques. http://www.ctsnet.org/doc/6761

Post-obstructive atelectasis of RLL: The major fissure is visible as it has rotated into view. There are no air bronchograms seen within the atelectatic region of lung. The patient is intubated. The obstruction is likely due to mucous plugging.

*2nd most common form of atelectasisDuce la colaps generalizat*pneumotorax*