Consolidation syndrome

Definition
Alveoli fill with fluid or blood cells, as in:
- pneumonia,
- severe pulmonary edema, or
- pulmonary hemorrhage/ pulmonary infarction

Cross-sectional view of alveolar consolidation in pneumonia

 Clasification

Consolidation syndrome with free bronchi –pneumonia,

bronchopneumonia , pulmonary infarction-
“consolidation syndrome”

Consolidation syndrome with obstructed bronchi –

atelectasis
“retractile consolidation syndrome”
Comparative: atelectasis/pneumonia
Consolidation syndrom due to:
inflammatory- infections disease
pneumonia, bronchopneumonia
Community-acquired pneumonia (CAP)
Nursing home–acquired pneumonia
Hospital-acquired pneumonia
Ventilator-associated pneumonia

pulmonary infarction

tumoral (atelectasis)
Community-acquired pneumonia (CAP)
Typical bacterial pathogens that cause CAP include:
– Streptococcus pneumoniae : The most common overall pathogen 
– Staphylococcus
– Haemophilus influenzae
– Moraxella catarrhalis
– Klebsiela pn (bacil Friendlander)

Atypical CAP pathogens:

– Mycoplasma pneumoniae
– Chlamydia pneumoniae
– Legionella pneumophila- Legionnaires disease

The most common viral pathogens:

– Human rhinovirus and 
– Influenza
Community-acquired pneumonia (CAP)
Typical bacterial pathogens that cause CAP include:
Pneuomococcal
– Streptococcus pneumoniae : The most common overall pathogen 
– Staphylococcus
– Haemophilus influenzae
pneumonia“typical”
– Moraxella catarrhalis CAP  
– Klebsiela pn (bacil Friendlander)

Atypical CAP pathogens:

– Mycoplasma pneumoniae
– Chlamydia pneumoniae
– Legionella pneumophila- Legionnaires disease

The most common viral pathogens:

– Human rhinovirus and 
– Influenza
Community-acquired pneumonia (CAP)
Typical bacterial pathogens that cause CAP include:
Pneuomococcal
– Streptococcus pneumoniae : The most common overall pathogen 
– Staphylococcus pneumonia“typical
– Haemophilus influenzae
– Moraxella catarrhalis
” consolidation
Lobar CAP 
– Klebsiela pn (bacil Friendlander)

Atypical CAP pathogens:

– Mycoplasma pneumoniae
– Chlamydia pneumoniae
– Legionella pneumophila- Legionnaires disease

The most common viral pathogens:

– Human rhinovirus and 
– Influenza
Community-acquired pneumonia (CAP)
Typical bacterial pathogens that cause CAP include:
– Streptococcus pneumoniae : The most common overall pathogen 
– Staphylococcus
– Haemophilus influenzae
– Moraxella catarrhalis
– Klebsiela pn (bacil Friendlander)

Atypical CAP pathogens:

– Mycoplasma pneumoniae
– Chlamydia pneumoniae
“Atypical”
– Legionella pneumophila- Legionnaires diseasepneumonia 
Usually -Interstitial
The most common viral pathogens: pneumonia without
– Human rhinovirus and  consolidation
– Influenza
Pneumococcal Pneumonia
 Evolution
Acute onset
24-48 hours

Consolidation
syndrome
7-10 days

Resolution stage
(crisis or lisis)
Crisis – evolution marked by the defervescence and formation of anticapsule antibodies
 Clinical manifestations
• Classically: is heralded by sudden onset with

shaking chills
followed by

fever
Sustained, 390 – 400C
Untreated lasts 5-10 days
 Clinical manifestations
Cough: productive, with rusty suptum– mucofibrinous, aerated,
viscous
Chest pain
Stitch – similar to a pointed knife hit, acute, severe, accentuated
with respiratory movements and cough,under the nipple/or
base, sitting on the affected side, if it’s accompanied by
shivering and temperature raise it’s almost pathognomonic.
Pleuretic chest pain - ex.: diafragmatic pleura → pain iradiated
to shoulder; children iradiated pain in abdominal area with
clinical presentation like peritonities.
Dispneea with tachipneea
 Clinical manifestations
Eldery more insidious course (confusion, low
grade of fever)
Immunocompromised patients- signs of septic
shock
 Clinical examination
GENERAL SURVEY
•APPARENT STATE OF HEALTH : accutely ill
•POSTURE (DECUBITUS): lateral to the affected side – due to intense
chest pain
•FACIES: flushed skin
•HEIGHT AND WEIGHT:
•NUTRITIONAL STATUS:
•SPEECH AND MENTAL EVALUATION: posible confusion in eldery
patient
•ORTHOSTATISM AND GAIT:
 Clinical exam
Skin:
• Cyanosis
• Labial Herpes may be present

Vital signs
• Increased heart rate, cardiac output,
blood pressure
 Respiratory clinical exam

INSPECTION:
Increased respiratory rate with tahipneea and polipnea

Decreased chest expansion

(due to chest pain) unilateral, affected side

Trachea:
Midline
Midline
 Clinical exam- normal

Percussion:
Resonant

Palpation:
Tactile Fremitus: Normal
 Clinical exam

Percussion:
ResonantDull over the airless area

Palpation:
Tactile Fremitus: Normal
 Clinical exam

Percussion:
ResonantDull over the airless area

Palpation:
Tactile Fremitus : Normal
Increase in tactile fremitus
usually correlate with a bronchial breath
sounds and transmitted voice sounds
 Clinical exam
Palpation: Transmitted voice sounds
Normally,
• Spoken words muffled and indistinct

• Spoken “ee” heard as “ee”

• Whispered words faint and indistinct, if heard at all

 Clinical exam
Palpation: Transmitted voice sounds
Normally, Bronchophony
• Spoken words
Spokenmuffled
words and indistinct
louder, clearer

• Spoken “ee” heard as “ee”

• Whispered words faint and indistinct, if heard at all

 Clinical exam
Palpation: Transmitted voice sounds
Normally, Bronchophony
• Spoken words
Spokenmuffled
words and indistinct
louder, clearer

• Spoken “ee” heardEgophony

as “ee”
Spoken “ee” heard as “ay”
• Whispered words faint and indistinct, if heard at all
 Clinical exam
Palpation: Transmitted voice sounds
Normally, Bronchophony
• Spoken words
Spokenmuffled
words and indistinct
louder, clearer

• Spoken “ee” heardEgophony

as “ee”
Spoken “ee” heard as “ay”
• Whispered words faint and indistinct, if heard at all
Whispered pectoriloquy
Whispered words louder, clearer
Clinical exam
Auscultation:
Breath Sounds
Turbulent air flow in the central airways produces the tracheal and bronchial
breath sounds. As these sounds pass through the lungs to the periphery, lung
tissue filters out their higher-pitched components and only the soft and lower-
pitched components reach the chest wall, where they are heard as vesicular
breath sounds.
Normally,
– tracheal and bronchial sounds may be heard over
the trachea and mainstem bronchi;
– vesicular breath sounds predominate throughout
most of the lungs
Clinical exam
Auscultation:
Breath Sounds
Turbulent air flow in the central airways produces the tracheal and bronchial breath
sounds. As these sounds pass through the lungs to the periphery, lung tissue filters
When lung tissue
out their higher-pitched loses its and
components air, itonly
transmits
the soft high-pitched sounds
and lower-pitched
componentsmuch better.
reach If the
the chest tracheobronchial
wall, tree isasopen,
where they are heard bronchial
vesicular breath sounds.
breath sounds may replace the normal vesicular sounds over
Normally,airless areas of the lung.
– tracheal and bronchial sounds may be heard over
the trachea and mainstem bronchi

Bronchial or bronchovesicular over the

– vesicular breath sounds predominate throughout
involved area
most of the lungs
 Clinical exam
Auscultation: Added sounds
Normal:
None, except perhaps a few transient inspiratory
crackles at the bases of the lungs
 Clinical exam
Auscultation: Added sounds
Normal:
Late inspiratory crackles
None, except perhaps a few transient inspiratory
over the involved area
crackles at the bases of the lungs
 “The most dry of moist rales”
 HIGH PITCH
 “RUBBING THE HAIR NEAR THE EAR”
 IN THE SECOND HALF OF INSPIRATION
 INCREASES AFTER COUGH
 ALVEOLI
 Evolution
Acute onset
24-48 hours

Chills and fever

Consolidation
Cough and chest pain syndrome
7-10 days
Clinical exam: Fever mild and
increased vesicular sustained
or bronchovesicular Decrease simpt
Resolution stage
sound (crisis or lisis)
Clinical exam: clasical
consolidation sdr - Crisis – evolution marked by
progressive the defervescence and
improvement formation of anticapsule
antibodies
Clinical exam: transient
incresed of fine crackles (less
dry)
 Evolution
Complications:
- Death in crizis
- Sepsis→ bacteraemia: pericarditis, endocarditis,
meningitis, brain abscess, nephritis
- Lung abscess
- Pleural effusion
– parapneumonic effusion (in the same time with
consolidation sdr) or
– methapneumonic pleural effusion -> empyema
 Laboratory tests
• Inflammatory syndrom:
leucocytosis neutrofilie,
↑ ESR, ↑ fibrinogen, ↑ CRP

• Biochemistry:↑indirect bilirubin, ↑ creatinin, ↑ uree (±oligurie)

• SPUTUM:
-Microbiological: smear, culture = pneumococ
-Cells: Red blood cells, epithelial cells, leucocytes
 Radiologic Findings

Chest radiograph
• Increased density – with lobar topography
“triagular” form with apex near to the pulmonary hil
• Air bronchograms
• Pleural effusions
CT scan
• Consolidation and bronchograms may be
seen
Figure 15-5. Chest X-ray film of a 20-year-old woman
with severe pneumonia of the left lung.
Figure 15-6. Air bronchogram. The branching linear lucencies within the consolidation in the
right lower lobe are particularly well demonstrated in this example of staphylococcal
pneumonia. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995,
Mosby.)
Figure 15-7. Air bronchogram shown by CT in a patient with pneumonia. (From
Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995,
Mosby.)
Strep. pneumoniae
pneumonia.
Right upper-lobe
consolidation
demonstrating a
pronounced air
bronchogram and absence
of
volume change.
Strep. pneumoniae
pneumonia.
Bilateral lower-zone
consolidation (arrows).
Although pneumococcal
pneumonia is typically
unifocal, multifocal
involvement is not
uncommon.
Strep. pneumoniae
pneumonia.
Very extensive
consolidation affecting
more than one lobe in
the right lung. The
central lucency is due to
cavitation — an unusual
feature in pneumococcal
pneumonia.
 Staphylococcal pneumonia
• Acute onset

• Sever evolution with respiratory failure- dispnee and cianosis

• Remitent fever (fluctuations > 1º but no below 37°C)

• Mucopurulent/hemoptoic sputum

• Clincal exam: consolidation sy

• Typical radiographic features are unilateral /bilateral consolidation
• Early in the disease course, the chest radiograph may reveal
minimal infiltrates, but within hours, infiltrates progress rapidly
• Pleural effusion, pneumatoceles, and pneumothorax are also
common
Staph. aureus pneumonia.
This cavitary pneumonia
was
a community-acquired
infection occurring two
weeks after an influenza
A infection.
Staph. aureus pneumonia —
pneumatoceles.
Appearances following
incomplete resolution of a
staphylococcal pneumonia.
There are several thin-walled
cysts consistent with
pneumatoceles. Such
pneumatoceles are common in
children but unusual in adults.
Staph. aureus
infection in a drug
abuser.
Multiple disseminated
nodular
consolidations,
confluent in the right
lower zone; several
have cavitated. The
appearances are
typical of
haematogenous
dissemination.
Pneumonia with KLEBSIELLA PNEUMONIAE
(Friedlander)

• very severe illness - sepsis/shock/respiratory failure

• productive cough with an abundant, thick, tenacious, and

blood-tinged sputum sometimes called currant jelly sputum

• increased tendency exists toward abscess formation,

cavitation, empyema, and pleural adhesions.
 Gram-negative
pneumonia
(Haemophilus
influenzae)
showing a typical
bronchopneumonic
pattern of
heterogeneous localized
consolidation. Such
infections are commonly
basal.
 General Management of Pneumonia

• Oxygen therapy protocol

• Bronchopulmonary hygiene therapy protocol
• Antibiotics

• Analgesic agents
TUBERCULOSIS
 Primary tuberculosis in a child. There is homogeneous consolidation of the
right middle lobe which partially obscures hilar adenopathy. Additional right
paratracheal node enlargement is present.
Post-primary tuberculosis. There is gross mid- and upper-zone disease characterized
by areas of consolidation and cavitation. The cavitation is particularly extensive on
the right where some of the cavities contain air–fluid levels.
 Post-primary tuberculosis: tuberculous bronchopneumonia. Numerous 5 mm nodular
shadows are present in both lungs, sparing the right apex. These are consistent with acinar
consolidation following the endobronchial spread of tubercle bacilli from the left upper-zone
cavity.
 Post-primary tuberculosis: miliary tuberculosis in an adult man. Diffuse
nodulation is present in all zones. Nodules are approximately 1 mm in diameter and
well defined.
 Post-primary tuberculosis: tuberculoma. A localized view of the left upper zone in a patient
who has had a thoracoplasty. The uppermost 20 mm nodule is well defined and proved to be a
tuberculoma at surgery. The less well-defined lower nodule had developed over 1 year and was
a bronchial carcinoma. Note the scattered small calcified nodules.
Measles pneumonia. An example of a widespread primary viral pneumonia with
extensive bilateral confluent consolidation.
Consolidation syndrome in pulmonary
infarction
Respiratory symptoms - acute onset
• Pleuritic chest pain is reported to occur in as many as 84%
of children and adults with pulmonary emboli. Its presence
suggests that the embolus is located more peripherally
and, thus, may be smaller.
• Tachypnea and dyspnea are observed in as many as 60% of
adult patients with pulmonary emboli but are generally less
frequent in children.
• Cough is present in approximately 50% of children with
pulmonary emboli. Hemoptysis is a feature in a minority of
children with pulmonary emboli, occurring in about 30% of
cases.
Pulmonary findings
• Tachypnea
• Consolidation sy
• Cyanosis and hypoxemia are not prominent features of pulmonary
embolism. If present, cyanosis suggests a massive embolism leading
to a marked V/Q mismatch and systemic hypoxemia
• A pleural rub is often associated with pleuritic chest pain and
indicates an embolism in a peripheral location in the pulmonary
vasculature.
• Signs that indicate pulmonary hypertension and right ventricular
failure include a loud pulmonary component of the second heart
sound, right ventricular lift, distended neck veins, and hypotension.
An increase in pulmonary artery pressure is reportedly not evident
until at least 60% of the vascular bed has been occluded.
Cardiovascular findings include the following:
• A gallop rhythm signifies ventricular failure.
• Peripheral edema is a sign of congestive heart failure.
• Various heart murmurs may be audible, including a
tricuspid regurgitant murmur signifying pulmonary
hypertension.
Other signs include the following:
• Fever is an unusual sign that is nonspecific.
• Diaphoresis is a manifestation of sympathetic arousal.
Consolidation syndrome with
obstructed bronchi
(retractile consolidation
syndrome)
 Atelectasis
• Atelectasis (from Greek: incomplete +
extension) is defined as the lack of gas
exchange within alveoli, due to alveolar
collapse or fluid consolidation; simplier, it
means collapse of one/ part of a lung.
• (It is a condition where the alveoli are
deflated, as distinct from pulmonary
consolidation {with free bronchi})
 Causes
• post-surgical – most common
• blockage of a bronchiole or bronchi, which can be within
the airway (foreign body, mucus plug), from the wall
(tumor) or compressing from the outside (tumor, lymph
node, tubercle)
• poor surfactant spreading during inspiration, causing the
surface tension to be at its highest which tends to collapse
smaller alveoli (newborn respiratory distress syndrome)

• Collapse of lung by massive pneumothorax do not fit into

the definition of atelectasis!
Comparative: atelectasis/pneumonia
Clinical syndrome
 Inspection
• Static: localized, asymmetric modifications
– affected hemi thorax smaller;
– retractions: of supraclavicular area, intercostal
spaces
• Dinamic: not typical
– Tachypneea as a sign of respiratory failure or
distress
– Retraction remains fixed with deep breathing
 Palpation
• Static:
– Confirms the asymmetry and retractions remarked
at I
– Confirms the smaller diameter of involves hemi
thorax

• Dinamic:
– ↓/ absent tactile fremitus
– ↓ expansions of apices/ bases of lung in affected
region
 Percussion
• Dullness in the affected area
• Hyper resonance, even tympanic sounds in
area surrounding it/ opposite lung
 Auscultation
• No modification in transmission of voice,
normal or whispered
• ↓ or abolished vesicular sound
• Eventually rales, as with etiology, most
common bronchial rales (ronchi)
 Chest X ray
• Homogenous density with concavity towards the
exterior
– involves 1 segment, / one lobe,/ the entire lung
– With a smaller extension than the respective region
(in normal conditions)
• Narrow and oblique intercostal spaces
• Mediastin shifted toward involved side
• Ascended diaphragm
• Inspiratory movement of mediastin toward the
involved side
Combined right middle and right
lower-lobe collapse in a 66-year-old
woman with breathlessness following
abdominal surgery. The frontal chest
radiograph shows combined right
middle lobe and right lower-lobe
collapse. Arrows indicate the minor
fissure. Arrowheads indicate the major
fissure. The multilobar collapse
simulates a right pleural effusion, but
the marked inferior hilar displacement,
the marked depression of the right
major fissure, and the ipsilateral
mediastinal shift are important clues
that this is a volume-losing process. A
decubitus view showed only minimal
right pleural fluid
Figure 19-22 Bilateral lower-lobe
collapse, presumed due to mucoid
impaction, in a 63-year-old man
following abdominal surgery. (A) The
frontal chest radiograph shows the
triangular outlines of the collapsed
lower lobes (‘sail sign’) (arrows). Both
hila are depressed. The medial
portions of the diaphragm are
obscured. The collapsed left lower lobe
is almost exactly superimposed on the
heart. (B) A lateral chest radiograph
shows the collapsed lobes overlying
the spine (arrows). The posterior
portions of both hemidiaphragms are
obscured.