Diagnosis and treatment of atelectasis (collapse) of the lung. Treatment of pulmonary atelectasis

Lung atelectasis is a pathological process associated with a decrease in the airiness of the organ due to the collapse of a certain area. As a result, the organ is not able to perform such an initial function as gas exchange.

Features of the development of the disease

Atelectasis of the lung in newborns is considered primary, that is, the lung or part of it initially does not participate in gas exchange and breathing. Usually appears in premature babies, infants who have suffered severe hypoxia during birth or in the womb due to aspiration of the respiratory tract with meconium or amniotic fluid.

Sometimes congenital pneumonia develops due to transplantent infection from mother to child. Sometimes a collapsed lung appears in absolutely healthy children, in which case this process is called physiological and the organ straightens within two to three days.

Pathology in older children has almost the same etiology as in adults, but with one caveat - in most cases, the causes of pulmonary atelectasis are infectious lesions and allergic reactions. This is due to an incompletely formed immune system, which is susceptible to external attacks.

In addition, the duration of breastfeeding affects the duration of breastfeeding, since with mother's milk the child receives the necessary number of antibodies that protect his body.

The causes of atelectasis are divided into several groups:

The risk group includes people who are overweight, suffer from cystic fibrosis and bronchial asthma, and do not follow a healthy lifestyle.

Development mechanism and classification

What is atelectasis and how does the disease develop? In the collapsed area of the lungs, the lumen of the blood vessels increases, and venous congestion is noted. Fluid enters the alveoli in large quantities and edema develops.

The work of enzymes in the epithelium covering the wall of the respiratory tract is reduced, and the process of redox reactions is disrupted. Negative pressure increases, which shifts the mediastinal organs towards the affected area.

After a few days, an infection may develop - atelectatic pneumonia, the tissue is overgrown with connective tissue cells, collagen, and pneumosclerosis is formed.

Atelectasis of the lung is classified depending on the etiopathogenesis into:

By origin, atelectasis can be:

Primary.
Acquired.

By prevalence there are:

Focal.
Subtotal.
Total atelectasis.

Depending on the level of bronchial obstruction, atelectasis of the entire lung, lobar, subsegmental, discoid and lobular atelectasis are distinguished. Atelectasis can also be unilateral or bilateral.

According to the International Classification of Diseases, Tenth Revision (ICD-10), it refers to other respiratory disorders (J98).

Symptoms and diagnosis

The severity of the symptoms depends on the time during which the disease developed and the area of the collapsed area, as well as on the cause of the pathology. Common features are:

If a person has chronic atelectasis syndrome, cor pulmonale is formed, chest pain is possible due to the discrepancy between the required energy and the actual reserves of nutrients and oxygen. Swelling of the lower extremities appears, as blood stagnates in the circulation.

Hypoxia is formed, to which nervous tissue is most sensitive. The patient complains of constant headaches, malaise, chronic fatigue, weakness, and nausea. In newborn children, there is a violation of the shape of the chest, further lag in mental and physical development due to disturbances in metabolic processes.

When diagnosing, the doctor takes into account the symptoms and medical history of the patient; examining the patient, he notes a decrease in the size or deformation of the chest, a decrease in the intercostal spaces. When palpating the chest above the area of atelectasis, vocal tremors decrease.

On percussion, the lower edge of the lung moves upward, a clear pulmonary sound is replaced by a pronounced dullness. During auscultation, breathing is weakened and cannot be heard at all over the affected area. Sometimes moist rales are heard.

An objective research method is a plain chest x-ray. The X-ray shows:

darkening of areas of the lungs;
displacement of mediastinal organs;
the presence of a foreign object or tumor;
scoliosis;
changes in the diaphragm dome;
level of damage, that is, atelectasis of the upper, middle or lower lobe.

For better image quality and layer-by-layer study, magnetic resonance and computed tomography are used. Most patients undergo bronchoscopy – endoscopy of the bronchial wall. Additionally, tissue biopsy and mucus collection for microscopy are performed.

Spirography is necessary to clarify volumes and capacities, assess ventilation and respiratory failure. In case of cardiac dysfunction, ultrasound examination and electrocardiography are prescribed.

Treatment and prognosis

Treatment of pulmonary atelectasis is aimed at restoring airway patency and eliminating the clinical picture. It is initially necessary to undergo treatment in a hospital setting, comprehensively, taking into account the individual characteristics of the body.

With obstructive atelectasis, bronchial patency is restored, that is, the foreign body and accumulated mucus are removed, the cavity is washed with antibacterial agents and enzyme-containing substances.

Lung collapse, compression form implies a different approach to the patient. It is necessary to pump out fluid or air from the pleural space, remove a benign or malignant formation, or an enlarged lymph node.

In severe cases of respiratory failure or congenital collapse of an organ in an infant, artificial ventilation is required.

Based on biochemical blood tests, therapy is prescribed aimed at restoring water and electrolyte balance. In the absence of contraindications, solutions of glucose, sodium salts, calcium, magnesium, potassium and other minerals are administered intravenously.

To compensate for the lack of oxygen, physiotherapy is prescribed to improve blood circulation, tissue trophism, and prevent further replacement of lung tissue with connective tissue fibers.

Electrophoresis with medications, ultra-high-frequency irradiation, and diadynamic currents have a good effect on the lung area. The patient needs massage and breathing exercises to strengthen the muscles involved in the act of breathing.

The doctor is obliged to tell the patient about atelectasis, explain what it is, what consequences may occur if the recommendations are violated. It is the dialogue with the patient, the formation of ideas about the pathology that allows you to avoid further complications.

Atelectasis(collapse) lung- loss of airiness in an area of the lung, occurring acutely or over a long period of time. In the affected collapsed area, a complex combination of airlessness, infectious processes, bronchiectasis, destruction and fibrosis is observed.

Code according to the international classification of diseases ICD-10:

J98.1

Causes

Etiology and pathogenesis. Obstruction of the bronchial lumen by plugs of viscous bronchial secretion, tumor, mediastinal cysts, endobronchial granuloma or foreign body. Increased surface tension in the alveoli due to cardiogenic or non-cardiogenic pulmonary edema, surfactant deficiency, infection. Pathology of the bronchial tube walls: edema, swelling, bronchomalacia, deformation. Compression of the respiratory tract and/or the lung itself, caused by external factors (myocardial hypertrophy, vascular abnormalities, aneurysm, tumor, lymphadenopathy). Increased pressure in the pleural cavity (pneumothorax, effusion, empyema, hemothorax, chylothorax). Restriction of chest mobility (scoliosis, neuromuscular diseases, phrenic nerve palsy, anesthesia). Acute massive pulmonary collapse as a postoperative complication (unrecognized and unsanitized obstruction of the main bronchus).

Genetic aspects determined by the underlying disease (cystic fibrosis, bronchial asthma, congenital heart disease, etc.). Risk factors. Surgeries on the chest organs, COPD, tuberculosis, smokers, obese people and people with short and wide chests.

Pathomorphology. Capillary and tissue hypoxia causes fluid transudation. The alveoli are filled with bronchial secretions and cells, which prevents the atelectatic area from completely collapsing. The addition of infection causes fibrosis and bronchiectasis.

Symptoms (signs)

Clinical picture varies depending on the rate of development of bronchial occlusion, the volume of atelectasis and the presence of infection.

Diffuse microatelectasis, small atelectasis, slowly developing atelectasis and middle lobe syndrome (chronic atelectasis of the middle lobe of the right lung due to compression by lymph nodes) may be asymptomatic.

Extensive atelectasis due to acute occlusion is characterized by the following symptoms... Pain on the affected side, sudden shortness of breath and cyanosis. area.. Percussion: dullness of percussion sound over the area of atelectasis.. Auscultation... absence of respiratory sounds - with occlusion of the airways... bronchial breathing, if the airways are passable... moist rales with focal obstruction.. Decreased chest excursion. . Displacement of the apex beat.

Chronic atelectasis.. Shortness of breath.. Cough.. Percussion: dullness of percussion sound.. Auscultation: moist rales.. In case of infection: increased amount of sputum, rise in body temperature.. Recurrent bleeding from the affected area is possible.

Age characteristics. Early childhood: aspiration mechanism, pneumonia. Children: the most common causes are mediastinal cysts and vascular anomalies. Elderly: among the most common causes are lung tumors, cicatricial stenosis, and bronchiectasis.

Diagnostics

Special studies. X-ray of the chest in two projections.. triangular in shape, intense homogeneous shadow with clear boundaries, with the apex directed to the root of the lung, with a decrease in the volume of the affected area of the lung.. With atelectasis of the lobe or lung - persistent displacement of the mediastinum to the affected side, the dome of the diaphragm on the side lesions are raised, intercostal spaces are narrowed.. diffuse microatelectasis - an earlier manifestation of oxygen intoxication and acute respiratory distress syndrome: a “ground glass” picture.. rounded atelectasis - rounded shading with a base on the pleura, directed towards the root of the lung (“comet-shaped” tail of blood vessels and airways). It most often occurs in patients who have been in contact with asbestos and resembles a tumor. Right-sided middle lobe and lingular atelectasis merge with the borders of the heart on the same side (Armand-Delisle symptom). Bronchoscopy is indicated to assess airway patency. EchoCG to assess the condition of the heart in cardiomegaly. CT or MRI of the chest.

Treatment

Treatment

The regimen depends on the patient's condition. Physical activity should be encouraged.

Acute atelectasis (including acute postoperative massive collapse).. The main cause of atelectasis should be eliminated, bronchoscopy should be performed, especially in cases of obstruction of the bronchial lumen with viscous sputum or vomit.. In case of foreign body aspiration - endoscopic removal... Adequate oxygenation, humidification of the respiratory mixture .. In severe cases, mechanical ventilation with positive expiratory pressure or the creation of constant positive pressure in the respiratory tract in persons with neuromuscular weakness.. Postural drainage (the head of the bed is lowered so that the trachea is below the affected area), breathing exercises, early postoperative mobilization of the patient.. Physiotherapeutic procedures, massage.. Broad-spectrum antibiotics are prescribed from the first day.

Chronic atelectasis.. Postural drainage, breathing exercises (spirosimulator).. Ventilation of the lungs with positive expiratory pressure or the creation of constant positive pressure in the airways in persons with neuromuscular weakness.. Broad-spectrum antibiotics for purulent sputum.. Surgical resection atelectatic segment or lobe with recurrent infection and/or bleeding from the affected area. If the obstruction is caused by a tumor, then the choice of treatment method is determined by the nature and extent of the tumor, and the general condition of the patient.

Bronchodilators (salbutamol, fenoterol) are of auxiliary value.

Complication- lung abscess (rare).

Prevention. To give up smoking. Prevention of aspiration of foreign bodies and liquids, incl. vomit. In the postoperative period, the use of long-acting painkillers should be limited. Early postoperative mobilization of the patient. Breathing exercises.

ICD-10. J98.1 Pulmonary collapse

J98.1 Pulmonary collapse

Epidemiology

According to the American Journal of Respiratory and Critical Care Medicine, pulmonary atelectasis after inhalation anesthesia occurs in 87% of cases in American surgical patients, and in 54-67% in Canadian surgical patients. The incidence of this pulmonary complication after open cardiac surgery in developed countries is currently 15% with a patient mortality rate of 18.5%, which is 2.79% of the total mortality from complications of surgical interventions.

Over the past 20 years, the number of premature newborns, according to WHO, has been steadily increasing throughout the world. Premature births (occurring before the 37th week of gestation) account for 9.6% of 12.6 million births per year. However, this indicator differs in different regions, with the highest proportion of preterm births observed in Africa (11.8%), and the lowest in Europe (6.3%).

In the United States, neonatal respiratory distress syndrome is one of the five most common causes of infant death, accounting for 5.6% of deaths.

And congenital atelectasis is the cause of 3.4% of newborn deaths.

Atelectasis is also common in young children because their airways are narrower and many structures are still developing.

Causes of pulmonary atelectasis

There is no single cause of pulmonary atelectasis for all types of this pathology. Thus, those that differ in the size of the affected area - partial atelectasis (focal, isolated or segmental atelectasis) and total atelectasis or lung collapse - may have different etiologies.

Explaining the pathogenesis of pulmonary atelectasis, it should be recalled that the bronchopulmonary alveoli have the form of vesicles, separated by connective tissue septa, penetrated by a network of capillaries in which arterial blood undergoes oxygenation (that is, absorbs inhaled oxygen), and venous blood gives off carbon dioxide. With atelectasis, the ventilation of part of the lungs is disrupted, the partial pressure of oxygen in the air filling the alveoli drops, which leads to disruption of gas exchange in the pulmonary circulation.

Pulmonologists determine the types of atelectasis either depending on the characteristics of its localization in the airways - atelectasis of the right lung, atelectasis of the left lung, atelectasis of the lung lobe (lower, middle or upper), or taking into account its pathogenesis. Thus, primary atelectasis, also known as congenital atelectasis, occurs in newborns with abnormalities in the opening of the lungs (especially in cases of prematurity); It will be discussed in more detail further in the section Atelectasis in newborns.

Since the right middle lobe of the lungs is the narrowest and is surrounded by a large volume of lymphoid tissue, atelectasis of the middle lobe of the lung is considered the most common.

Obstructive atelectasis (partial in most cases) is diagnosed when collapse of the lung occurs due to aspiration of the airways by a foreign body (blocking the passage of air) or masses coming from gastroesophageal reflux disease; blockage of the bronchi with mucous exudate in obstructive bronchitis, severe tracheobronchitis, emphysema, bronchiectasis, acute and chronic eosinophilic and interstitial pneumonia, asthma, etc.

For example, atelectasis in tuberculosis (usually segmental) most often develops when the bronchi are obstructed by blood clots or caseous masses from cavities; Also, with tuberculosis, the bronchioles can press on the tissue of the overgrown granulomatous tissue.

The stages of total obstructive atelectasis at any localization transform into one another with a rapid deterioration in the patients’ condition - as oxygen, carbon dioxide and nitrogen are absorbed in the “blocked” alveoli and the general composition of blood gases changes.

Dysfunction of the lung tissue, which is caused by compression atelectasis, is the result of its extrathoracic or intrathoracic compression by hypertrophied lymph nodes, overgrown fibrous neoplasia, large tumors, effusion from the pleura, etc., which leads to collapse of the alveoli. Experts quite often observe atelectasis in lung cancer, thymomas or lymphomas localized in the mediastinum, bronchoalveolar carcinoma, etc.

In the case of total damage to the lung parenchyma, total atelectasis and lung collapse can be diagnosed. When, due to injuries to the chest, its tightness is broken with air entering the pleural cavity, tension pneumothorax develops with atelectasis (but atelectasis is not synonymous with pneumothorax).

And the so-called disc-shaped or lamellar atelectasis refers to compression, and it got its name from the image of a shadow on an x-ray - in the form of elongated transverse stripes.

Distensional atelectasis or functional (most often segmental and subsegmental, localized in the lower lobes) is etiologically associated with suppression of the activity of neurons in the respiratory center of the medulla oblongata (in case of injuries and brain tumors, with general inhalation anesthesia administered through a mask or endotracheal tube); with decreased diaphragm function in bedridden patients; with increased pressure in the abdominal cavity due to dropsy and increased gas formation in the intestines. In the first case, there are iatrogenic causes of atelectasis: with endotracheal anesthesia, the pressure and absorption of gases in the lung tissues change, causing collapse of the alveoli. As surgeons note, atelectasis is a common complication of various abdominal surgeries.

Some sources highlight contractile atelectasis (tightening), which is caused by a decrease in the size of the alveoli and an increase in surface tension during bronchospasms, injuries, surgical interventions, etc.

Atelectasis can be a symptom of a number of interstitial lung diseases that damage the tissue surrounding the alveoli: exogenous allergic alveolitis (allergic pneumonitis or pneumoconiosis), pulmonary sarcoidosis, bronchiolitis obliterans (cryptogenic forming pneumonia), desquamative interstitial pneumonia, pulmonary Langerhans histiocytosis, idiopathic pulmonary fibrosis, etc.

Risk factors

Risk factors for atelectasis include:

age under three or over 60 years;
long bed rest;
impaired swallowing function, especially in the elderly;
lung diseases (see above);
rib fractures;
premature pregnancy;
abdominal surgery under general anesthesia;
respiratory muscle weakness due to muscular dystrophy, spinal cord injury, or other neurogenic condition;
chest deformities;
the use of medications whose side effects affect the respiratory system (in particular, sleeping pills and sedatives);
obesity (excess body weight);
smoking.

Symptoms of pulmonary atelectasis

The first signs of incomplete lung function are shortness of breath and decreased expansion of the chest wall when inhaling.

If the pathological process has affected a small area of the lungs, the symptoms of pulmonary atelectasis are minimal and are limited to a feeling of lack of air and weakness. When the defeat is significant, the person turns pale; his nose, ears and fingertips become blue (cyanosis); stabbing pain appears on the affected side (not often). Fever and increased heart rate (tachycardia) may occur when atelectasis is accompanied by infection.

In addition, the symptoms of atelectasis include: irregular rapid shallow breathing; drop in blood pressure; cold feet and hands; decrease in temperature; cough (without sputum).

If atelectasis develops against the background of bronchitis or bronchopneumonia, and the lesion is extensive, there is a sudden exacerbation of all symptoms, and breathing becomes rapid, shallow and arrhythmic, often with wheezing.

Symptoms of atelectasis in newborns are manifested by wheezing, groaning exhalation, irregular breathing with apnea, flaring of the nostrils, cyanosis of the face and all skin, retraction of the skin in the spaces between the ribs - when inhaling (from the development of atelectasis). An increase in heart rate, a decrease in body temperature, muscle rigidity, and cramps are also noted.

Atelectasis in newborns

Atelectasis in newborns or primary atelectasis is the main cause of the so-called respiratory distress syndrome of newborns (ICD-10 code - P28.0-P28.1).

Congenital atelectasis occurs due to airway obstruction by amniotic fluid or meconium aspiration, which leads to increased pressure in the lungs and pleural cavity and damage to the alveolar epithelium. Also, this pathology may be a consequence of intrauterine underdevelopment of the tissues of the lungs and bronchi (Wilson-Mikiti syndrome), bronchopulmonary dysplasia (in children born at a gestational age of less than 32 weeks), congenital alveolar or alveolar-capillary dysplasia, intrauterine pneumonia, congenital disorder of surfactant secretion.

The last factor is of particular importance in the pathogenesis of congenital atelectasis. Normally, adhesion of the walls of the alveoli does not occur due to the surfactant produced by special cells of the basement membrane of the alveoli (alveolocytes of the second type), a protein-phospholipid substance with surface-active properties (the ability to reduce surface tension) that covers the alveolar walls from the inside.

Surfactant synthesis in the fetal lungs begins after the 20th week of embryonic development, and the surfactant system of the child’s lungs is ready for expansion at birth only after the 35th week. So any delays or abnormalities in fetal development and intrauterine oxygen starvation can cause a lack of surfactant. In addition, a connection between this disorder and mutations in the surfactant protein genes SP-A, SP-B and SP-C has been identified.

According to clinical observations, with a deficiency of endogenous surfactant, dysontogenetic disseminated atelectasis develops with edema of the lung parenchyma, excessive stretching of the walls of lymph vessels, increased capillary permeability and blood stagnation. Their natural result is acute hypoxia and respiratory failure.

In addition, atelectasis in newborns born prematurely, in cases of placental abruption, perinatal asphyxia, diabetes mellitus in pregnant women, as well as surgical delivery, may be a symptom of the presence of coagulated fibrillar hyaline protein fibers on the walls of the alveoli (hyaline membrane syndrome, pulmonary hyalinosis, endoalveolar neonatal hyalinosis or respiratory distress syndrome type 1). In full-term newborns and young children, atelectasis can be provoked by a genetically determined disease such as cystic fibrosis .

Complications and consequences

The main consequences and complications of atelectasis:

hypoxemia (decreased oxygen levels in the blood due to impaired respiratory mechanics and reduced pulmonary gas exchange);
decreased blood pH (respiratory acidosis);
increased load on the respiratory muscles;
pneumonia from atelectasis (with the development of an infectious inflammatory process in the atelectasis part of the lung);
pathological changes in the lungs (overextension of intact lobes, pneumosclerosis, bronchiectasis, cicatricial degeneration of part of the pulmonary parenchyma, retention cysts in the bronchi area, etc.);
asphyxia and respiratory failure;
narrowing of the lumen of the arterial and venous vessels of the lungs.

Diagnosis of pulmonary atelectasis

To diagnose atelectasis, the doctor records all complaints and symptoms and performs a physical examination of the patient, auscultating his lungs with a stethoscope.

To identify the cause, blood tests are necessary - general, biochemical, blood pH and its gas composition, fibrinogen, antibodies (including to Mycobacterium tuberculosis), rheumatoid factor, etc.

Instrumental diagnostics consists of spirometry (determining lung volume) and pulse oximetry (determining the level of blood oxygen saturation).

The main diagnostic method for this pathology is a chest x-ray in the proximal-distal and lateral projections. An x-ray for atelectasis makes it possible to examine the condition of the thoracic organs and see a shadow in the area of atelectasis. At the same time, the image clearly shows the damage to the trachea, the heart and the root of the lung itself, which have deviated to the side, changes in the intercostal distances and the shape of the vault of the diaphragm.

It is possible to detect lung atelectasis on high-resolution CT: to visualize and clarify the fine details of interstitial lung diseases. High-precision computer images help confirm a diagnosis, such as idiopathic pulmonary fibrosis, and avoid the need for a lung biopsy.

Bronchoscopy for atelectasis (in which a flexible bronchoscope is inserted into the lungs through the mouth or nose) is used to examine the bronchi and obtain a small sample of tissue. In addition, bronchoscopy is used for treatment purposes (see below). But if for histological examination more lung tissue is needed from a certain area identified by X-ray or CT, surgical endoscopic biopsy is resorted to.

Differential diagnosis

The differential diagnosis carried out during an X-ray examination of patients is designed to distinguish this pathology from pneumonia, chronic inflammatory process in the bronchi, bronchostenosis due to tuberculosis infection, pulmonary sequestration, cystic and tumor formations, etc.

Treatment of pulmonary atelectasis

Treatment for atelectasis varies depending on the etiology, duration and severity of the disease in which it develops.

Atelectasis in newborns is treated with an airway-opening tracheotomy, respiratory support (positive pressure breathing), and oxygen administration. Although high concentrations of oxygen used over a long period of time aggravate the damage to lung tissue and can lead to the development of retrolental fibroplasia in premature infants. In most cases, there is a need for artificial ventilation, which ensures oxygenation of the blood in the arteries.

Medicines for atelectasis in newborns - surfactant substitutes Infasurf, Survanta, Sukrim, Surfaxim - are injected into the child's trachea at regular intervals, and the dose is calculated depending on body weight.

If atelectasis is caused by airway obstruction, then the first step is to eliminate the causes of the blockage. This can be the removal of clots with an electric suction or by bronchoscopy (followed by rinsing the bronchi with antiseptic compounds). Sometimes postural drainage with cough is enough: the patient coughs while lying on his side, head below the chest, and with the cough everything that is blocking the airways comes out.

Antibiotics are prescribed to combat the infection that almost always accompanies secondary obstructive atelectasis - see. Antibiotics for pneumonia

When distensional atelectasis with hypoxia develops in bedridden patients, physiotherapeutic treatment is carried out using constant pressure while inhaling a mixture of oxygen and carbon dioxide; UHF sessions, electrophoresis with drugs. A positive effect is provided by breathing exercises for atelectasis (increasing the depth of breathing and its rhythm) and therapeutic massage for lung atelectasis, which allows accelerating the evacuation of exudate.

If the cause of atelectasis is a tumor, chemotherapy, radiation, and surgery may be necessary. Surgical treatment is also used in cases where, due to necrosis, the affected area of the lung must be removed.

According to doctors, emergency care for atelectasis can be provided only with urgent hospitalization. In a medical facility, patients are given injections of strophanthin, camphor, and corticosteroids. To stimulate breathing, medications from the group of respiratory analeptics can be used, for example, Nicotinic acid diethylamide (Niketamide) - parenterally 1-2 ml up to three times a day; drops are taken orally (20-30 drops two to three times a day); Etimizole (in the form of tablets - 50-100 mg three times a day; in the form of a 1.5% solution - subcutaneously or into the muscle). Side effects of both drugs include dizziness, nausea, increased anxiety and sleep disturbances.

Prevention

First of all, the prevention of atelectasis concerns patients who are undergoing surgery under inhalation anesthesia, or who have already had surgery. To prevent lung damage, you need to stop smoking and increase your water intake at least one and a half to two months before the planned surgical treatment. And for operated patients, breathing exercises and a sufficient level of air humidity in the premises are necessary. In addition, doctors do not recommend lying in bed and moving whenever possible (at the same time, this is a good way to prevent postoperative adhesions).

Doctors also strongly advise to properly treat respiratory diseases (especially in children) and prevent them from becoming chronic.

Atelectasis is a pathological condition in which the lung tissue loses its airiness and collapses, reducing (sometimes significantly) its respiratory surface. The result of the collapse of part of the lung is a decrease in gas exchange with an increase in the phenomena of oxygen starvation of tissues and organs, depending on the volume of the area that has lost its airiness.

Shutting down the right or left lower lobes reduces lung capacity by 20%. Atelectasis of the middle lobe reduces it by 5%, and one of the segments of any of the apical lobes - by 7.5%, forcing compensatory mechanisms to come into play, which manifest themselves in the form of symptoms characteristic of atelectasis.

At the same time, atelectasis should not be confused with zones of physiological hypoventilation of the lungs when a healthy person is at rest, which does not require active consumption of oxygen from the air.

The mechanism of formation of pulmonary atelectasis and its causes

1. Local narrowing of the lumen of the bronchial tree:

In cases of compression from the outside by a lung tumor located next to the bronchus;
With local enlargement of lymph nodes, which accompanies inflammatory and tumor processes;
During processes occurring in the wall of the bronchus (with increased mucus formation or discharge of pus, bronchial tumor with growth into the lumen of the vessel);
Entry of foreign bodies (aspiration from vomit, choking).

As a rule, this mechanism is realized with an additional reflex (contraction of the smooth muscles of the bronchi), which further narrows the airways.

2. Collapse of the lung tissue itself:

When the air pressure inside the alveoli decreases (violation of inhalation anesthesia technique);
Sudden change in ambient air pressure (fighter pilot atelectasis);
Decreased production or absence of surfactant, leading to increased surface tension of the inner wall of the alveoli, causing them to collapse (neonatal respiratory distress syndrome);
Mechanical pressure on the lung from pathological contents located in the pleural cavities (blood, hydrothorax, air), an enlarged heart or a large aneurysm of the thoracic aorta, a large focus of tuberculous lesions of lung tissue;
When interstitial pressure exceeds intra-alveolar pressure (pulmonary edema).

3. Suppression of the breathing center in the brain

Occurs with traumatic brain injuries, tumors, general (intravenous, inhalation) anesthesia, excessive oxygen supply during artificial ventilation, and overdose of sedatives.

4. Violation of the integrity of the bronchus due to a simultaneous rapid mechanical impact on it

It is observed during surgery (ligation of the bronchus as a method of surgical treatment for) or during its injury (rupture).

5. Congenital malformations

Hypoplasia and aplasia of the bronchi, the presence of tendon septa in the form of intrabronchial valves, esophageal-tracheal fistulas, defects of the soft and hard palate.

With all opportunities being equal, the following people have an increased risk of developing pulmonary atelectasis:

Smoking;
Having increased body weight;
Suffering from cystic fibrosis.

Classification of pulmonary atelectasis

Depending on the order of involvement of the lungs in the pathological process:

Primary (congenital)

It occurs in children, most often immediately after their birth, when the lungs do not fully expand with the first breath. In addition to the already described intrauterine anomalies in the development of the lungs and insufficient production of surfactant, the cause of its occurrence can be aspiration of amniotic fluid, meconium. The main difference between this form is the initial absence of air from the environment entering the collapsed area of lung tissue.

Secondary (acquired)

This form of atelectasis occurs as a complication of inflammatory and tumor diseases of organs, both respiratory and other systems, as well as with chest injuries.

Various forms of pulmonary atelectasis

According to the mechanism of occurrence, acquired forms of atelectasis are distinguished:

Obstructive atelectasis

It is observed when the cross-sectional area of the bronchus decreases for the reasons stated above. Obstruction of the lumen can be complete or partial. Sudden closure of the lumen when a foreign body enters requires immediate action to restore the patency of the bronchial tree for the reason that with each hour of delay the likelihood of straightening the collapsed section of the lungs decreases. Restoration of lung ventilation in cases where complete obstruction of the bronchus lasted more than three days does not occur.

Compression atelectasis

Occurs when there is a direct impact on the lung tissue itself. A more favorable form, in which complete restoration of pulmonary ventilation is possible even after a fairly long period of compression.

Functional (distensional) atelectasis

Occurs in areas of physiological hypoventilation (lower segments of the lungs):

In bedridden patients;
Those who have undergone severe and prolonged surgical interventions;
In case of overdose of barbiturates, sedatives;
With arbitrary limitation of the volume of respiratory movements, which is caused by severe pain (rib fracture, peritonitis);
In the presence of high intra-abdominal pressure (ascites of various origins, chronic constipation, flatulence);
With diaphragmatic paralysis;
Demyelinating diseases of the spinal cord.

Mixed atelectasis

With a combination of different mechanisms of origin.

Depending on the level of bronchial obstruction and the area of lung collapse, the following are distinguished:

Lung atelectasis (right or left). Compression at the level of the main bronchus.
Lobar and segmental atelectasis. Lesion at the level of the lobar or segmental bronchi.
Subsegmental atelectasis. Obstruction at the level of the bronchi of the 4th-6th order.
Discoid atelectasis. Disc-shaped atelectasis develops as a result of compression of several lobules located within the same plane.
Lobular atelectasis. Their cause is compression or obstruction of the terminal (respiratory) bronchioles.

Signs of pulmonary atelectasis

The severity of the symptoms, due to which one can suspect the occurrence of atelectasis in the lungs, depends on a number of reasons:

The rate of compression of lung tissue (acute and gradually increasing atelectasis are distinguished);
Volume (size) of the respiratory surface of the lungs turned off from ventilation;
Localizations;
The mechanism of occurrence.

Dyspnea

It is characterized by an increase in the frequency of inhalation and exhalation per minute, a change in their amplitude, and arrhythmia of respiratory movements. Initially, the feeling of lack of air occurs during physical activity. With increasing or initially large area of atelectasis, shortness of breath appears at rest.

Chest pain

Optional attribute. Appears most often when air enters the pleural cavities.

Change in skin color

Caused by excess carbon dioxide in tissues. In children, first of all, the nasolabial triangle turns blue. In adults, blueness of the fingers of the extremities (acrocyanosis) and the tip of the nose appears.

Changes in the performance of the cardiovascular system

Pulse increases (tachycardia);
After a short-term increase in blood pressure in the initial stages, it decreases.

In children, the indicated symptoms are also observed, which are most clearly manifested in newborns with primary atelectasis. These are accompanied by easily observed retractions of the intercostal spaces when inhaling from the side of the affected lung, as well as retractions of the sternum when air enters the lungs.

Diagnostics

During medical diagnosis, in addition to the symptoms noticeable to the patient, the following signs of atelectasis can be identified:

The sound when tapping the chest (percussion) in the area of atelectasis becomes shorter and less sonorous (dullness), in contrast to the more “boxy” sound in the surrounding areas.
Weakening or complete absence of breathing during auscultation in the projection of atelectasis, asymmetry in the movements of the diseased and healthy half of the chest.
With atelectasis, which covers all or almost all of the lung, the heart shifts towards the collapsed organ. This can be detected by percussion of the borders of the heart, by changes in the localization of the apex beat zone, and by auscultation of the heart.

You should also remember:

Signs of atelectasis occur against the background of an existing underlying disease, sometimes aggravating the already critical general condition of the patient.
The collapse of a segment (in some cases even a lobe) of the lung may go unnoticed for the patient. However, it is these small collapsed areas that can become the first foci of pneumonia, which is severe in such patients.

An X-ray examination of the chest organs helps to clarify the presence of atelectasis, its location and extent in order to determine treatment tactics. It is carried out in at least two projections. In more difficult cases, tomography is used to diagnose cases.

X-ray signs that suggest the presence of atelectasis:

Change in density (darkening) of the shadow of a compressed area of the lungs in comparison with the surrounding tissues, often following the contours of a segment or lobe;
Change in the shape of the dome of the diaphragm, displacement of the mediastinal organs, as well as the roots of the lungs towards atelectasis;
The presence of functional signs of bronchoconstriction (not necessary if the mechanism of atelectasis is not obstructive);
Approximation of the shadows of the ribs on the affected side;
Scoliosis of the spine with the direction of the convexity towards atelectasis;
Stripe-like shadows against the background of unchanged areas (disc-shaped atelectasis) of the lungs.

Atelectasis of the middle lobe of the right lung on x-ray

Prognosis for pulmonary atelectasis

Sudden simultaneous total (subtotal) atelectasis one or two lungs, developed as a result of trauma (air entering the chest) or during complex surgical interventions in almost all cases ends in death immediately or in the early postoperative period.

Obstructive atelectasis, developed due to sudden blockage by foreign bodies at the level of the main (right, left) bronchi - also have a serious prognosis in the absence of emergency help.

Compression and distension atelectasis, developed during hydrothorax, with the removal of the cause that caused them, do not leave any residual changes and do not change the volume of the vital capacity of the lungs in the future.

The prognosis for the restoration of the functions of a compressed lung can be significantly changed by the attached lung, which in these cases leaves scar tissue replacing the collapsed alveoli.

Treatment

1. Elimination of the mechanism of atelectasis with restoration of ventilation in these areas

For obstructive atelectasis:

For compression atelectasis:

Pleural puncture with removal of effusion and air from the cavities, eliminating the causes of effusion and communication with the environment;
Surgical treatment of tumors of the lungs and lymph nodes, elimination of cavitary formations (cysts, abscesses, some forms of tuberculosis).

For distensional atelectasis:

Breathing exercises with the creation of high intrabronchial pressure (inflating balloons);
Inhalation with a mixture of air and 5% carbon dioxide to stimulate the respiratory center.

2. Artificial ventilation with the addition of oxygen

It is carried out when severe symptoms develop.

3. Correction of acid-base balance disorders in the blood

It is carried out by prescribing intravenous infusion therapy based on the patient’s biochemical blood data.

4. Antibiotic therapy

Aimed at preventing purulent complications.

5. Syndromic therapy

Includes elimination of the pain factor if present, correction of cardiovascular activity (normalization of pulse, blood pressure).

6. Physiotherapy

Chest massage is one of the methods of treating pulmonary atelectasis

It is carried out to prevent the formation of scars in the lungs and improve blood circulation in the area of atelectasis. For this purpose, UHF irradiation is used in the acute phase, and during the recovery period, electrophoresis with drugs (platifillin, aminophylline, etc.) is used.

7. Therapeutic and preventive physical education and chest massage

Aimed at improving the functioning of the respiratory muscles. A light vibration massage promotes the removal of sputum and mucus from the bronchoalveolar tree.

Video: pulmonary atelectasis in the program “Live Healthy!”

Pulmonary atelectasis is a disease associated with loss of airiness in the lung tissue. Formed due to the influence of internal factors. It may involve the entire respiratory organ or be limited to part of it. In this case, alveolar ventilation is disrupted, the respiratory surface decreases, and signs of oxygen starvation appear. In the collapsed part of the lung, conditions are created for the development of inflammatory processes, fibrosis, and bronchiectasis. Complications that arise may require surgical intervention when the atelectatic area has to be removed.

Collapse of the respiratory organ is also caused by external causes. This happens, for example, due to mechanical compression. In this case, the disease is called lung collapse.

Classification

There are several types of atelectasis syndrome. Based on its origin, it is divided into primary and secondary. The first is diagnosed at the birth of a child, when the lung does not expand completely during the first breath. The secondary form occurs as a complication after inflammatory diseases.

According to the mechanism of occurrence, there are several types of atelectasis:

Obstructive. It is formed when the lumen of the bronchus decreases due to an obstacle in the form of a foreign body, a clot of mucus, or a tumor. The main symptoms are shortness of breath, dry cough, difficulty breathing. There are both complete and partial collapse of the lung. Emergency action is needed to restore air patency in the bronchi. With each passing hour, the likelihood that the respiratory organ will be able to expand completely decreases. After 3 days, restoration of ventilation becomes impossible. The development of pneumonia in such conditions is a common occurrence with atelectasis of this type.

Compression. It has a more favorable prognosis. Even after a long period of compression of the lung tissue, ventilation can be completely restored. This type of disease occurs with the appearance of a pathological volume of inflammatory fluid in the pleural cavity, which leads to compression of the lung tissue. Symptoms increase gradually. They manifest themselves in the form of mixed shortness of breath, when both inhalation and exhalation are difficult.
Distensional (functional). Formed in the lower lobes. The type of disease is associated with a violation of the breathing mechanism. Patients who are on prolonged bed rest are most susceptible to it. Pathology occurs when there is an attempt to limit respiratory movements due to painful sensations associated with rib fractures or pleurisy. Pulmonary atelectasis caused by a stroke is called contractile.
Contraction. It is formed as a result of the proliferation of connective tissue, leading to compression of the pleural cavity and adjacent sections.

Separately, it is worth highlighting atelectasis of the middle lobe of the right lung. The middle lobe bronchus, being the longest, is most susceptible to blockage. The disease is characterized by a cough with sputum, accompanied by fever and wheezing. The disease is especially acute when the upper lobe of the right lung is affected.

The replacement of collapsed connective tissue is called fibroatelectasis.

Some medical sources identify a contractile type of this disease, when the size of the alveoli decreases, and surface tension is formed during bronchial spasms or injury.

Based on the level of bronchial blockage, which is detected by x-ray, the following types of atelectasis are distinguished:

Disc-shaped, when several lobes are compressed.
Subsegmental atelectasis. May lead to complete obstruction in the left or right lung.
Linear.

According to the International Classification of Diseases, atelectasis is assigned the code J98.1.

Causes of the disease

Congenital atelectasis is associated with penetration of amniotic fluid, mucus, and meconium into the respiratory organs. Its development is facilitated by intracranial trauma received during childbirth.

Among the common causes of acquired atelectasis or collapse, it is worth highlighting:

Prolonged compression of the respiratory organ from the outside.
Allergic reactions.
Obstruction of the lumens of one or more bronchi.
The presence of neoplasms of various nature, leading to compression of the lung tissue.
Blockage of the bronchus by a foreign object.
The accumulation of mucus in large volumes can lead to atelectasis.
Among the causes of fibroatelectasis are pleuropneumonia and tuberculosis.

In addition, pulmonary atelectasis is often provoked by various factors, including:

Respiratory diseases - pneumothorax, pleurisy in exudative form, hemothorax, chylothorax, pyothorax.
Long-term bed rest.
Fractured ribs.
Uncontrolled use of medications.
Overweight.
Smoking.

The risk of atelectasis is increased in people over 60 years of age, as well as in children under 3 years of age.

Symptoms

Vivid symptoms manifest themselves depending on the volume of the lungs to which the pathological process extends. When one segment is affected, pulmonary pathology can be practically asymptomatic. Only an x-ray can help detect it at this stage. The most pronounced manifestation of the disease is observed with atelectasis of the upper lobe of the right lung. When the middle lobe is affected, examination reveals elevation of the diaphragm.

The main symptoms of the disease, when several parts collapse:

Shortness of breath that occurs both during physical activity and at rest.
Painful sensations. If the right lung is affected - on the right side, and vice versa.
Increased heart rate.
Decreased blood tone.
Dry cough.
Cyanosis.

The listed symptoms are equally characteristic of adult patients and children.

Video

Video - What to do with pulmonary atelectasis

Diagnostics

Primary diagnosis includes taking a medical history, physical examination, assessing the condition of the skin, measuring pulse and blood pressure.

The main method for diagnosing what pulmonary atelectasis syndrome is is x-ray. An x-ray shows signs of collapse of the lung tissue.

These include:

An eclipse of a homogeneous nature in the affected area. Its size and shape can be different and depend on the type of disease. An extensive eclipse detected by X-ray indicates lobar atelectasis of the lung, a sign of subsegmental eclipse is an eclipse resembling a triangle or wedge in shape. Distension is located in the lower part of the respiratory organ, closer to the diaphragm.
Displacement of organs. Due to the pressure exerted by the affected side, with compression atelectasis, the mediastinal organs located between the lungs are shifted to the healthy side. For obstructive lung, on the contrary, when the right lung is affected, it is characterized by a displacement to the right, and the left - to the left.

X-rays help detect where organs are displaced during breathing and coughing. This is another factor that determines the type of disease.

Sometimes X-rays have to be supplemented with computed tomography and bronchoscopy. The extent to which the lungs are affected, the degree of deformation of the bronchi, and the condition of the blood vessels are determined by bronchography and angiopulmonography.

Treatment methods

If atelectasis is detected in newborns, the airways are cleared by suctioning out the contents with a catheter. Sometimes artificial ventilation is required.

The treatment regimen for secondary pulmonary atelectasis is compiled for each patient individually, taking into account the etiological factor.

Conservative methods include:

Therapeutic bronchoscopy to eliminate bronchial obstruction when the cause of the disease is the presence of a foreign object or a lump of mucus.

Washing with antibacterial agents.
Bronchoalveolar lavage – sanitation of the bronchi using the endoscopic method. It is performed when a large amount of blood or pus accumulates.
Tracheal aspiration.
Postural drainage. When atelectasis is localized in the upper parts, the patient is given an elevated position, if in the lower parts - on the side with the side lowered in the opposite direction from the affected lung. This can be either the right or left side.

Regardless of the nature of the disease, the patient is prescribed anti-inflammatory drugs, breathing exercises, percussion massage, a light complex of exercise therapy, and physiotherapeutic procedures.

You cannot self-medicate by trying to eliminate atelectasis using traditional medicine. Late seeking of medical help complicates and prolongs the treatment process. If conservative methods do not give a positive result, you have to resort to surgery, which removes the affected part of the lung.

Prevention

You can prevent the occurrence of atelectasis of any kind if you follow the following rules:

Adhere to a healthy lifestyle.
During the recovery period after bronchopulmonary diseases, follow all doctor’s recommendations.
Control your weight.
Do not take medications without a doctor's prescription.
Be regularly examined for preventive purposes.

The success of treatment depends on the cause of atelectasis and timely measures taken. A mild form of the disease can be cured quickly.

In severe cases of the disease, as well as in its fulminant form, complications often arise, sometimes leading to death.