Lobar Atelectasis Imaging

 Author: Sat Sharma, MD, FRCPC; Chief Editor: Eugene C Lin, MD

Overview

The term atelectasis, which is defined as diminished lung volume, is derived from the Greek
words ateles and ektasis, which mean incomplete expansion (see the image below).
Atelectasis may affect all or part of a lung, and it is one of the most common radiographic
abnormalities. Recognizing atelectasis on a chest radiograph is important because a sinister
underlying pathology may be present.[1, 2, 3, 4, 5, 6] Several types of atelectasis have been
described; each has a unique radiographic pattern. Atelectasis can be categorized as
obstructive or nonobstructive.

Gross anatomic specimen showing airless lungs, or atelectasis. Atelectasis refers

to either incomplete expansion of the lungs or the collapse of previously inflated
lungs, which produces areas of relatively airless pulmonary parenchyma.

Obstructive atelectasis

An obstruction between the alveoli and trachea causes reabsorption of alveolar gas, leading to
an obstructive atelectasis. The obstruction can occur at the level of the larger or smaller
bronchus, and it may be secondary to a foreign body, benign or malignant tumor, mucus plug,
and blood clot, as well as bronchial transection, fibrotic stenosis from granulomas or
inflammation, polychondritis, post brachytherapy or radiotherapy stenosis, and other
obstructive lesions.[7]

The development of atelectasis depends on several factors, including the extent of collateral
ventilation and the composition of inspired gas. Obstruction of a larger bronchus is likely to
produce lobar atelectasis, whereas the obstruction of a smaller bronchus causes segmental
atelectasis. The pattern of atelectasis often depends on collateral ventilation, which is
provided by the pores of Kohn and the canals of Lambert.

Right middle lobe (RML) syndrome, a form of chronic atelectasis, usually results from
bronchial compression and obstruction by surrounding lymph nodes or bronchial scarring.
Partial bronchial obstruction and recurrent infection may also lead to chronic atelectasis and
acute or chronic pneumonitis.
Nonobstructive atelectasis

Loss of contact between the parietal and visceral pleurae causes nonobstructive atelectasis.
The etiologies may be lung compression, the loss of surfactant, and scarring or infiltrative
disease of the lung. Several types of nonobstructive atelectasis are known to occur from a
variety of causes.

A pleural effusion or a pneumothorax eliminates contact between the parietal and visceral
pleurae, and relaxation or passive atelectasis results. The uniform elasticity of a normal lung
preserves the shape, even after atelectasis is present. The middle and lower lobes collapse
more than the upper lobes in the presence of a pleural effusion, whereas the upper lobes are
more affected by a pneumothorax.

Compression atelectasis occurs when any space-occupying lesion of the thorax compresses
the lung and forces air out of the alveoli. The mechanism is similar to relaxation atelectasis.

Adhesive atelectasis results from surfactant deficiency.Surfactant lowers the surface tension
of the alveoli and therefore plays an important role in preventing the alveoli from collapsing.
Decreased production or inactivation of surfactant, as observed in acute respiratory distress
syndrome (ARDS) and similar disorders, leads to alveolar instability and atelectasis.

Cicatrization atelectasis results as a sequela of severe parenchymal scarring and is usually

caused by granulomatous disease or necrotizing pneumonia. The lobar collapse from
cicatrization may be either obstructive if the bronchi are involved or nonobstructive because
of the fibrotic process in the lung parenchyma. Replacement atelectasis occurs when the
alveoli of an entire lobe are filled by tumor (eg, bronchioalveolar cell carcinoma), resulting in
a loss of volume.

Rounded atelectasis, also called folded-lung syndrome or Blesovsky syndrome, occurs as the
lung collapses and folds secondary to fibrous bands and adhesions to the visceral pleura.[8]
The incidence is high in asbestos workers (65-70% of cases). Patients are typically
asymptomatic, and the mean age at presentation is 60 years. Rounded atelectasis is a benign
disorder.

Preferred examination

Chest radiographs are generally sufficient to diagnose lobar atelectasis and to identify the
collapsed lobe. Chest radiographs are also useful in diagnosing platelike atelectasis,
postoperative atelectasis, and rounded atelectasis, as well as for following the course of the
atelectasis. For example, chest radiographs can be used to determine whether an intervention,
such as chest physiotherapy, has resulted in improvement.[9, 10]

However, in some situations, chest radiographic findings may not be diagnostic. This
generally occurs when a concomitant pleural fluid or large pulmonary masses are present. In
such cases, computed tomography (CT) scanning is a useful next imaging study. CT scanning
should be used to assess obstructive atelectasis; this modality is also helpful in evaluating the
mediastinum, chest wall, hilum, pleura, and adjacent lung.[11, 12, 13, 14, 15, 16]
Magnetic resonance imaging (MRI) has no particular value in the diagnosis of lobar
atelectasis, except for distinguishing obstructive from nonobstructive atelectasis.[17]

Limitations of techniques

A concomitant pleural effusion, pleural mass, or large lung mass may limit the usefulness of
chest radiography in the diagnosis of atelectasis.

When a basal opacity, an opacity of the hemithorax, and other signs of atelectasis are not
obvious, determining whether the opacity is a pleural effusion or a lobar collapse may be
difficult. In those situations, a CT scan can be of immense help. Intravenous contrast
enhancement is often required for appropriate imaging and for differentiating among various
causes of atelectasis.

The limitation of CT scanning may be in differentiating between obstructive and

nonobstructive causes of atelectasis. Furthermore, a CT scan may not be useful in
determining whether the obstructing lesion is a tumor, mucus plug, nonopaque foreign body,
or blood clot.

Radiography

Chest radiographs and CT scans show direct and indirect signs of lobar collapse. Direct signs
include displacement of fissures and opacification of the collapsed lobe. Indirect signs
include the following:

 Displacement of the hilum

 Mediastinal shift toward the side of collapse

 Loss of volume in the ipsilateral hemithorax

 Elevation of the ipsilateral diaphragm

 Crowding of the ribs

 Compensatory hyperlucency of the remaining lobes

 Silhouetting of the diaphragm or heart border

Complete atelectasis

Complete atelectasis of an entire lung is characterized by a complete collapse of a lung,

which leads to opacification of the entire hemithorax and an ipsilateral shift of the
mediastinum. The mediastinal shift separates atelectasis from a massive pleural effusion. (See
the images below.)
Chest radiograph demonstrating complete atelectasis of the left lung

Chest radiograph depicting complete right lung atelectasis.

Right upper lobe collapse

The collapsed right upper lobe (RUL) shifts medially and superiorly, resulting in elevation of
the right hilum and the minor fissure. The RUL may also collapse laterally, producing a
pleural-based opacity that may look like a loculated pleural effusion.

The minor fissure in an RUL collapse is usually convex at its superior aspect, but it may
appear concave because of an underlying mass lesion. This is called the Golden sign of S
(also known as the Golden S sign and the S sign of Golden).

Tenting of the diaphragmatic pleura, called the juxtaphrenic peak sign, is another helpful sign
of RUL atelectasis. (See the images below.)[18]

Image depicting a right upper lobe collapsing posteriorly and inferiorly.

Right upper lobe collapse. This chest radiograph shows volume loss in the upper
lobe, upward shifting of the horizontal fissure, and elevation of the right side of
the diaphragm.

Lateral chest radiograph demonstrating a right upper lobe collapsing anteriorly

and superiorly. The opacity is seen in the anterior and superior locations.

Right middle lobe collapse

RML collapse obscures the right heart border on a posteroanterior (PA) image. The lateral
view shows a triangular opacity overlying the heart because the major fissure shifts upward
and the minor fissure shifts downward. With worsening collapse, the opacity diminishes in
size, and it may be barely perceptible. (See the images below.)

Image depicting a right middle lobe collapsing medially.

Posteroanterior (PA) (left) and lateral chest (right) radiographs. A right middle
lobe collapse obliterates the right heart border on the PA image and projects as a
wedge-shaped opacity on the lateral view.

Right lower lobe collapse

The collapsed right lower lobe (RLL) shifts posteriorly and inferiorly, resulting in a triangular
opacity that obscures the RLL pulmonary artery. The major fissure, normally not visible on a
PA radiograph, is evident with an RLL collapse. The superior mediastinal structure shifts to
the right, causing a superior triangle sign. Laterally, the collapsed RLL obliterates the
posterior one third of the right hemidiaphragm and projects as an opacity over the normally
lucent area. (See the images below.)

Image depicting a right lower lobe collapsing anteriorly and superiorly.

Lateral chest radiograph demonstrating a right lower lobe collapse that results in
volume loss, obliteration of the right side of the diaphragm, and a posterior
opacity.

Concomitant RML and RLL atelectasis may appear as an elevated right hemidiaphragm or a
subpulmonic effusion. An attempt to identify the fissures usually leads to the accurate
diagnosis. (See the image below.)
Chest radiograph demonstrating a right lower lobe collapse and a right middle
lobe collapse. The left lung is hyperexpanded.

Left upper lobe collapse

An atelectatic left upper lobe (LUL) shifts anteriorly and superiorly. In one half of the cases,
a hyperexpanded superior segment of the left lower lobe (LLL) is positioned between the
atelectatic upper lobe and the aortic arch. This gives the appearance of a crescent of the
aerated lung, called the luftsichel sign.

On PA views, an atelectatic LUL produces a faint opacity in the left upper hemithorax,
obliterating the left heart border. On lateral views, the major fissure is displaced anteriorly
behind the sternum. (See the images below.)

Image depicting a right lower lobe collapsing anteriorly and superiorly.

Image depicting the lingula collapsing medially.

Left upper lobe collapse. This radiograph shows an opacity that is contiguous
with the aortic knob, a smaller left hemithorax, and a mediastinal shift. The
luftsichel sign involves hyperextension of the superior segment of the left lower

lobe, which then occupies the left apex.

Chest radiograph demonstrating a left upper lobe collapse, resulting in a veil-like

opacity that extends upward and outward from the hilum. Additional signs of loss
of volume in the left hemithorax and crowding of the ribs are also evident on this
radiograph.

Lateral chest radiograph demonstrating a left upper lobe collapsing anteriorly.

Left lower lobe collapse

On frontal views, an increased retrocardiac opacity obliterates the LLL pulmonary artery and
the left hemidiaphragm. The hilar structures shift downward, and the rotation of the heart
produces flattening of the cardiac waist, which is known as the flat-waist sign. The superior
mediastinum may shift and obliterate the aortic arch; this is the top-of-the-aortic-knob sign.

On the lateral radiographs, an opacity silhouettes the posterior third of the left diaphragm, and
an opacity is projected over the normally lucent area. (See the images below.)

Image depicting a left upper lobe collapsing superiorly and anteriorly.

Left lower lobe collapse. This chest radiograph shows volume loss on the left
side, an elevated and silhouetted left diaphragm, and an opacity behind the
heart (ie, sail sign).

Rounded atelectasis

In cases of rounded atelectasis, segmental or subsegmental atelectasis occurs secondary to

visceral pleural thickening and entrapment of the lung tissue.

Rounded atelectasis manifests as a subpleural mass, and bronchovascular structures radiate

out of the mass toward the hilum. An associated parietal pleural plaque may be present. The
swirl appearance of the bronchovascular shadows is called the comet-tail sign and establishes
the diagnosis.[19]
Degree of confidence

Chest radiography has the highest sensitivity when direct signs of atelectasis can be detected.
More specifically, the identification of a displaced fissure is of significant advantage in
diagnosing lobar collapse. The presence of several indirect signs further corroborates the
direct signs in the diagnosis of atelectasis.

False positives/negatives

Modest loss of volume may occur secondary to lobar consolidation; this may lead to the
erroneous diagnosis of lobar collapse.

A loculated pleural effusion or pleural effusion with passive collapse may be mistakenly
identified as a collapse secondary to an endobronchial lesion. False-negative results may
occur if the collapse does not involve the whole lobe; this situation may be secondary to an
incompletely obstructive bronchial lesion or partial ventilation of the lobe.

Platelike atelectasis or postoperative atelectasis may often be missed on chest radiographs

because it may be obscured by other thoracic structures. A false-negative diagnosis may also
occur if the patient cannot take a full breath or if the anteroposterior or lateral chest
radiograph is not available.

Computed Tomography

Radiographic changes of lobar collapse are more obvious on CT scans than on plain
radiographs. CT scans are additionally helpful in identifying and localizing an obstructing
bronchial lesion. Correlation with a chest radiograph helps in the evaluation, as does careful
examination of the mediastinum, hilum, and pleura.

The primary changes of lobar collapse seen on CT scan are as follows:

 Irregular narrowing or occlusion of a bronchus, indicating an obstructive

lobar collapse

 Lobe becoming pie shaped rather than hemispherical on cross-section.

 Possible projection of the lobe as a V-shaped structure where the apex is

situated at the origin of the affected bronchus

 Overall increased opacity of the lobe

 Possible bulge in the adjacent fissure (ie, the Golden sign of S), caused by
a mass

 Pattern of collapse affected by previous pleural adhesions and fluid or air

in the pleural space

 Possible infiltration of the entire lobe by the tumor, giving it a lobular,

rather than wedge-shaped, appearance
Right upper lobe collapse

The RUL is bordered medially by the mediastinum, superiorly by the chest wall, inferiorly by
the minor fissure, and posteroinferiorly by the superior portion of the oblique fissure.

On CT scanning, RUL collapse appears as a right paratracheal opacity, and the minor fissure
appears concave laterally. The RUL collapses against the mediastinum, and this is identified
as a wedge of uniform attenuation extending along the mediastinum to the anterior chest wall.
Concomitant hyperinflation of the middle and lower lobes is present. A bulge in the contour
of the collapsed RUL occurs secondary to an endobronchial tumor and gives an S-shaped
configuration. Endobronchial obstruction is readily identifiable on the CT scan. (See the
image below.)

This computed tomography scan shows a right upper lobe collapse secondary to
a right hilar mass. On bronchoscopy, an endobronchial lesion that occluded the
right upper lobe bronchus was seen.

Right middle lobe collapse

The RML is bounded medially by the right heart border; anteriorly and laterally by the chest
wall; posteriorly by the major fissure; and superiorly, the minor fissure.

As the RML collapses, the minor fissure shifts downward and the oblique fissure is displaced
forward. With a progressive loss of volume, the middle lobe collapses medially against the
right heart border. The collapsed middle lobe is a wedge-shaped opacity that extends laterally
from the hilum toward the lateral chest wall. It is bounded posteriorly by the RLL and
anteriorly by the hyperinflated RUL.

On CT scans, a triangular opacity along the right heart border, with the apex pointing
laterally, is a characteristic finding. This appearance resembles a tilted ice-cream cone.

Right lower lobe collapse

The RLL is bordered inferiorly by the hemidiaphragm, posteriorly and laterally by the chest
wall, medially by the heart and mediastinum, and anteriorly by the major fissure.

The RLL generally collapses in a posteromedial direction against the posterior mediastinum
and spine. An endobronchial lesion may result in a convex lateral contour of the collapsed
RLL. The major fissure is displaced posteromedially.
Left upper lobe collapse

The LUL is bounded medially by the mediastinum, inferiorly by the left heart border,
superiorly and laterally by the chest wall, and posteriorly by the major fissure.

CT scanning shows the inferior location of the collapsed lobe and the shift of the RUL across
the midline. LUL collapse occurs anterosuperiorly. As opposed to the RUL, the collapsed
LUL maintains more contact with the anterior and lateral chest wall. Hyperaeration of the
superior segment of the LLL may cause displacement and superior movement; these changes
may account for periaortic lucency or the luftsichel sign on PA images. The LUL maintains its
contact with the mediastinum and remains attached to the left hilum by a wedge of collapsed
tissue. The anterosuperior direction of the collapse projects a wedge-shaped triangular
opacity, with the apex pointing posteriorly. Endobronchial obstruction is easily identified on
CT scans.

Left lower lobe collapse

The LLL is bordered inferiorly by the hemidiaphragm, posteriorly and laterally by the chest
wall, medially by the heart and mediastinum, and anteriorly by the major fissure. The LLL
collapses medially toward the mediastinum and maintains contact with the hemidiaphragms.
The major fissure moves posteriorly. The LLL has an opacity situated against the posterior
mediastinum. CT scanning shows the atelectatic LLL in the inferior posterior location. (See
the image below.)

Computed tomography scan shows a left lower lobe collapse with a small pleural
effusion.

Passive atelectasis

Passive atelectasis is likely the most common form of atelectasis. It occurs secondary to the
presence of air or fluid in the pleural space. The CT scan easily depicts pleural effusion and
the underlying collapsed lung. Differentiation may be made easier with the use of contrast
medium. The pattern of collapse secondary to an endobronchial lesion is distorted in the
presence of pleural fluid. CT scanning may be of some help in distinguishing benign causes
from malignant causes of pleural effusion. An irregular or nodular pleural surface may
indicate an underlying malignancy.
Cicatrization atelectasis

Scarring or fibrosis from an inflammatory disease may lead to cicatrization collapse, the most
common example being previous tuberculosis.

In cicatrization atelectasis, an endobronchial lesion is not seen and the bronchial tree in the
collapsed lobe is hidden. Marked volume loss is present, and bronchiectatic changes
frequently occur in the involved lobe.

Chronic middle-lobe syndrome results in a patent bronchus. Significant bronchiectasis and

scarring may be observed in the collapsed lobe.

Adhesive atelectasis

Adhesive atelectasis occurs secondary to the loss of surfactant. A common cause is lung
collapse due to radiation pneumonitis. The CT scan appearance is a sharp line demarcating
the normal pulmonary parenchyma from the irradiated lung, which is generally
paramediastinal.

Replacement atelectasis

Replacement atelectasis is a form of volume loss in which the pulmonary parenchyma is

replaced by tumor infiltration. In this situation, the CT scan shows uniform attenuation
throughout the involved lobe. This finding generally mimics consolidation. The tumor may
grow into the edges and structures, such as the chest wall or mediastinum.

Rounded atelectasis

Rounded atelectasis is a form of chronic atelectasis that may appear as a mass lesion on chest
radiographs. Although this form is most commonly associated with asbestos exposure, other
benign conditions may also be present. These conditions include tuberculosis, uremic
pleuritis, pulmonary infarction, and other causes of pleuritis. Because of adhesions between
the visceral pleura and parietal pleura, the atelectatic lung becomes trapped and folds onto
itself.

In cases of rounded atelectasis, the CT scan results are diagnostic and definitive; therefore,
further investigations to exclude lung cancer are not required. The CT scan findings are a
peripheral oval or wedge-shaped attenuating area with smooth lateral edges and a medial
irregular or ill-defined border that points to the hilum. Distortion and displacement of the
blood vessels and bronchi appear in a characteristic curvilinear configuration that leads to the
rounded atelectasis (ie, comet-tail sign). In most cases, bronchograms are seen on the CT
scan, and calcification is also common. (See the image below.)
Computed tomography scan demonstrating rounded atelectasis in a patient
exposed to asbestos. This image shows a peripheral pleural-based opacity with
crowding of the bronchovascular structures in the comet-tail sign.

Degree of confidence

The common etiologies of lobar collapse include central endobronchial tumor, long-standing
infection, pleural disease, and previous irradiation. CT scanning may play an important role
in differentiating obstructive endobronchial lesions from other forms of collapse. By
identifying the exact location of an endobronchial lesion and the presence of peribronchial
spread, CT scans may be helpful in planning bronchoscopy and transbronchial biopsy.
Evaluation of the mediastinum, pleura, chest wall, and adrenal glands plays a role in the
staging process.

In evaluating patients with radiographically atypical forms of collapse, CT scans further help
in accurately delineating the collapse and in identifying any additional pathology.[20, 21] CT
scans are particularly helpful in patients who have a pleural effusion associated with
atelectasis, and these images have a significant advantage over plain radiographs in the
assessment of pleural malignancy. Finally, CT scans are especially useful in evaluating
patients with cicatrization atelectasis. These patients have underlying bronchiectasis and
present with atypical plain radiographic findings.

False positives/negatives

Determining the cause of an endobronchial obstruction on the basis of CT scans alone may be
difficult. CT scans may not be useful in distinguishing among an endobronchial malignancy,
a benign tumor, mucus plug, blood clot, and another nonopaque foreign body. Significant
lung collapse associated with pleural effusion may not have the characteristic findings of
lobar collapse; therefore, discerning whether an endobronchial lesion is present may be
difficult.

CT scans may not be accurate in identifying benign and malignant causes of pleural effusion.
CT scanning is also limited in differentiating a consolidation secondary to an infectious cause
from a replacement collapse in which a tumor has infiltrated the entire lobe.

CT scans do not obviate bronchoscopy, which is a mandatory procedure to accurately localize

an endobronchial lesion and to characterize its nature. Bronchoscopy may also serve a
therapeutic role.
Magnetic Resonance Imaging

The role of MRI in differentiating a central obstructing tumor from a peripheral collapsed
lung has been evaluated. T2-weighted sequences are useful in identifying an endobronchial
lesion.[17, 22] Because lipid-laden macrophages accumulate in the subacute phase of lobar
collapse, progressive lymphocytic infiltration and collagen deposition occur within the
pulmonary interstitium. In these situations in which the ratio of lung to fat in the collapsed
lung is greater than 1, T2-weighted MRIs are most useful in differentiating a tumor from lung
collapse.

MRI may have a role in the evaluation of adhesive atelectasis. T2-weighted sequences may
help in differentiating fibrosis secondary to an endobronchial obstruction from radiation-
induced pneumonitis. Furthermore, MRI may have a role in diagnosing rounded atelectasis
because MRIs may more accurately depict curvilinear vessels in the folded lung.[23]

Degree of confidence

MRI is an excellent imaging modality in situations in which intravenous contrast material

cannot be administered. MRIs may delineate the extent and the location of a tumor; this
modality may also have a role when CT scans are not helpful in differentiating between a
tumor and a collapsed lung.

In a study of 10 patients, MRI was useful in identifying a tumor due to a collapsed lung in 5
(50%) patients, as compared with CT scanning. In the same study, CT scanning successfully
differentiated between tumor and lung collapse in 8 (80%) of 10 patients. Interestingly, MRI
was successful in 2 cases in which differentiation was not possible with CT scanning.

Ultrasonography

Ultrasonography has a limited role in the evaluation of atelectasis. The only potential role for
this modality is in differentiating a basal lung collapse from a loculated pleural effusion.
However, there are data to support the use of bedside ultrasonography in cases in which the
clinical history and findings, as well as the radiologic studies of critically ill patients, are
inconclusive.[24, 25]

Degree of confidence

CT scanning is preferred to ultrasonography, because CT scanning is more accurate,

delineates the surrounding structures better, and is also more useful in identifying the cause of
atelectasis.