Interlobar fissure displacement

Introduction Atelectasis is a basic disease of the lungs. Because of various reasons, the gas in the alveoli is absorbed, and the lung volume is congested, causing interlobular displacement.

Cause

Causes:

According to the extent of involvement, atelectasis can be divided into segments, lobules, leaves or entire lungs. It can also be classified into obstructive (absorbent) and non-obstructive according to its mechanism. The latter includes adhesion, passive, Compression, scarring and hypostatic atelectasis. Most atelectasis is caused by endogenous or exogenous obstruction of the bronchus of the leaves or segments. Blocking the distal part of the lung segment or the absorption of gas in the lung lobe, causing the lung tissue to shrink, showing an opaque area on the chest radiograph, generally no bronchial air sign, also known as absent atelectasis. If there is multiple or peripheral blockage, bronchial air signs may occur. Non-obstructive atelectasis is usually caused by scars or adhesions, which is manifested by a decrease in lung capacity, a decrease in light transmission, and generally a bronchial air sign. Scarring (collapsed) atelectasis comes from chronic inflammation, often accompanied by varying degrees of fibrosis of the lung parenchyma. Such atelectasis is usually secondary to bronchiectasis, tuberculosis, fungal infections, or organizing pneumonia.

Adhesive atelectasis has peripheral airway and alveolar collapse, which can be diffuse (such as hyaline membrane disease), multifocal (such as micro-infertility and sub-segment atelectasis caused by postoperative and diaphragmatic dyskinesia) Or leaf, segmental atelectasis such as pulmonary embolism, the mechanism is not completely clear, may be related to the lack of surfactant.

Compressive atelectasis is caused by the pressure of adjacent dilated lesions, such as tumors, lung air sacs, and pulmonary bullae, while slack (passive) atelectasis is caused by gas accumulation and effusion in the thoracic cavity. Tolerance, often manifested as a round of atelectasis. Discoid atelectasis is relatively rare, and its occurrence is associated with decreased diaphragmatic movement (common in abdominal effusion) or decreased respiratory motility.

1. Bronchial obstruction: Partial or complete obstruction of the lobes of the leaves, segments can cause a variety of radiological changes, one of which is atelectasis. The consequences of obstruction are related to factors such as the degree of obstruction, the variability of the lesion, and the presence of collateral gas traffic. The lesion causing the obstruction can be inside, outside or inside the lumen (Table 1). When the airway is blocked, the vascular bed in the affected part of the lung tissue begins to absorb air, causing the alveoli to gradually collapse. In the past healthy lungs, the air will be completely absorbed 24 hours after the blockage. Because the rate of oxygen diffusion is much higher than that of nitrogen, patients who inhale 100% pure oxygen can develop atelectasis 1 hour after occlusion. Air absorption increases the negative pressure in the thoracic cavity, causing leakage of capillaries, and fluid retention in the interstitial and alveolar spaces of the incontinent lung. This situation is similar to "drowning the lungs." However, obstruction of the bronchi does not necessarily cause atelectasis. If there is good gas flow between the lungs or the lung segments, blocking the distal lung tissue can maintain normal ventilation and even excessive expansion. Clinically, bronchial obstruction caused by mucinous or mucopurulent sputum thrombus and subsequent lobes, segments or total atelectasis are more common. Most of the iliac sacs are located in the central airway, forming a uniform lobes, reducing the transmittance of the segments, with or without bronchial air. If there is a sputum plug in the surrounding airway, the gas-free lung parenchyma can reveal the bronchial air sign of the central airway. Atelectasis after surgery is the most common obstructive atelectasis, with an incidence of about 5% after major surgery. Such patients usually have a history of chronic bronchitis, severe smoking, or pre-operative respiratory infections. Other predisposing factors include excessive anesthesia, upper abdominal surgery, poor airway cleaning during and after surgery, and impaired mucociliary clearance. Most of these patients had fever, tachycardia and shortness of breath 24 to 48 hours after surgery. The cough has a snoring but the cough is weak, and the affected area is cloudy and the breathing sound is reduced. Fiberoptic bronchoscopy often shows scattered mucus plugs in the corresponding bronchi. Patients often have secondary infections. If infection occurs before the bronchus is completely blocked, complete lung atelectasis may not occur due to lung consolidation. Occasionally, in the case of neurological disorders, the atelectasis is caused by the formation of mucus plugs due to respiratory muscle weakness or coma. At this time, cough weakness is the main factor, and respiratory infections are often a risk factor. Patients with chronic suppurative bronchitis may develop atelectasis due to the formation of emboli due to thick secretions. Atelectasis caused by chest wall disease often occurs in the lower lung of the affected side. Multiple rib fractures can form a flail chest that can significantly affect the ability of the ipsilateral lung to clear secretions. However, if the single fracture is dislocated, it can also inhibit the respiratory atelectasis due to pain, especially in patients with chronic bronchitis with more secretions. . Other causes of atelectasis caused by chest trauma include blockage of blood clots or bronchial laceration in the bronchi.

In acute exacerbations of bronchial asthma, bronchioles can form a valve-like obstruction, resulting in extensive bilateral lung over-expansion, but occasionally sticky mucus plugs can also cause segmental or leaf atelectasis. This situation is more common in children. It usually works with anti-asthma treatment, but sometimes it may require an urgent bronchoscope to suck out the sputum. If atelectasis occurs in adult asthma patients, it is often suggested that there is a possibility of mucus caulking caused by allergic bronchopulmonary aspergillosis. Late stage of mucoid viscidity (pancreatic cystic fibrosis) can also cause atelectasis due to mucus plugs.

2. Aspiration of foreign bodies: foreign body inhalation is mainly found in infants and young children. Common inhalants are peanuts, melon seeds, candy, fish bones, caps, etc., occasionally seen in dentures or coma, dull elderly. It is customary to use small parts and gadgets in the mouth to inhale during work. Facial trauma, especially in car accidents, can also inhale broken teeth.

Children inhaled foreign bodies often have a clear history of inhalation. Inhalation has a sudden cough or a cough when speaking, followed by an asymptomatic period of several minutes to several months. After that, the child has a chronic cough, tight air, often can smell and wheezing or wheezing, can cough and purulent. Organic foreign bodies can quickly produce severe pharyngeal-tracheal-bronchitis with symptoms of fever and poisoning. Because doctors fail to think about the possibility of inhalation, or the problem is not appropriate, it is often impossible to collect a history of foreign body inhalation. If the asymptomatic gap is too long, it is more difficult to link the symptoms to the history of inhalation.

The physical examination is related to the degree of obstruction and also depends on whether the foreign body is fixed or active. When the foreign body forms part of the open flap, it can smell and wheezing, but few other abnormalities are found. Due to over-inflation of the affected side, the trachea and apex can be displaced to the healthy side, the affected area is unvoiced, the breath sound is reduced, and the inspiratory or expiratory wheezing can be heard. If there is atelectasis or obstructive pneumonia, the trachea and apical impulses can be displaced to the affected side. At this time, the ipsilateral thorax becomes smaller, the vocal fibrillation is reduced, the intercostal space is invaginated during inhalation, the percussion is voiced, the tactile tremor is reduced, and the breath sound is reduced or disappeared. The affected lungs may have inspiratory wet sounds. It is often difficult to distinguish between atelectasis, obstructive pneumonia or pleural effusion by physical examination.

The chest radiograph has considerable diagnostic value. If the foreign body is not transparent, the chest radiograph can be diagnosed and positioned. If the X-ray foreign body is transmitted, obstructive lesions or other radiological changes on the plain film may also indicate the foreign body. Obstructive pulmonary hyperinflation due to intrabronchial flap disease is the most common radiological change. Incompleteness of the whole leaf is generally caused by complete obstruction, but it is not common. If the obstruction is in the main bronchus, the entire lung can collapse. Depending on the degree of obstruction, it can be characterized by recurrent pneumonia, bronchiectasis or a rare lung abscess. CT examination is more important for the existence of foreign bodies and their nature and location.

If clinically considered as a foreign body in the bronchi, it should be confirmed by bronchoscopy that the purpose of treatment can often be achieved by bronchoscopy. Most foreign bodies can be seen under the microscope. Some plant foreign bodies can be hidden under the mucosa of the edema and are not easy to find because they cause obvious inflammatory reactions.

3. Neoplastic bronchiostenosis: Atelectasis and obstructive pneumonia are the most common radiological signs of central bronchogenic lung cancer. There is also a considerable amount of atelectasis caused by bronchial lung cancer. Complete bronchial obstruction is mainly seen in squamous cell carcinoma and large cell undifferentiated carcinoma, while adenocarcinoma and small cell carcinoma are rare. Typical patients are middle-aged men with a history of severe smoking for many years, often with respiratory symptoms such as cough, hemoptysis, cough, chest pain, and shortness of breath. Chest radiographs showed enlarged hilar and widened mediastinum. In some cases, the tumor volume is large, forming an "S" sign. Cytological examination or bronchial biopsy of bronchial aspirate or brush has a very high diagnostic value for defining tumor-induced atelectasis. However, it is not easy to see the inferior lobe due to the inconvenience of operation of the fiberoptic bronchoscope.

Percutaneous lung puncture or mediastinoscopy of bronchogenic carcinoma can also lead to positive results, especially when there is an enlarged hilar or supraclavicular lymphadenopathy, the latter can also be directly biopsy. Metastatic tumors in the lungs also invade the bronchial tubes to block them. Bronchoscopy often has a positive finding, and sputum cytology can detect tumor cells, but it is not easy to differentiate from bronchogenic lung cancer. Adrenal adenomas are a common cause of endobronchial metastases. At the time of tumor metastasis, the atelectasis can also be caused by the swelling of the bronchus by the enlarged lymph nodes.

The degree of malignancy of bronchial adenomas is relatively low, mainly from the bronchial mucosa. 90% of bronchial adenomas are carcinoid, and the source of cells appears to be argyrophilic cells rather than glands. Mucinous gland tumors include columnar tumors (adenocystic cystic carcinoma), mucoepidermoid adenomas, and mixed tumors. The growth of columnar tumors is slow, but it is the highest degree of malignancy in bronchial adenomas. It is easy to relapse after resection. The incidence of male and female patients with bronchial adenoma is similar, mainly seen in people under 50 years old, and 85% of cases have symptoms such as cough, hemoptysis, pain, repeated fever and wheezing. In 75% of cases, there was evidence of airway obstruction on the chest radiograph, usually atelectasis, obstructive emphysema and obstructive pneumonia. Most of the bronchial adenomas are located outside the bronchi, so a medium-sized opaque shadow adjacent to the hilar can be seen on the chest radiograph with distal atelectasis. There are signs of atelectasis when the lungs are extensively affected. Most adenomas originate from the larger main bronchus, so it is easy to see the tumor under the bronchoscope and take a biopsy.

Usually the bronchial mucosa on the surface of the adenoma remains intact, and a biopsy under the bronchoscope can cause massive bleeding. There are often no positive findings in cytology or bronchial washing. Lymphoma can also cause bronchial obstruction and atelectasis. Hodgkin's disease can cause atelectasis in the bronchial infiltrates, often accompanied by other parts of the lesion such as mediastinal lymphadenopathy, cavity formation, intrapulmonary nodules or rough diffuse reticular infiltration. A diagnosis can often be made by bronchoscopy biopsy, irrigation or sputum cytology. Abdominal atelectasis caused by enlarged lymph node compression is extremely rare. Some non-Hodgkin lymphomas can also cause atelectasis, which is generally seen in the advanced stages of the disease and can also be diagnosed by bronchoscopy. Benign bronchial tumors are relatively rare. About 10% of teratomas appear as isolated intrabronchial tumors, and unless there is obstructive atelectasis or obstructive pneumonia, there is generally no clinical symptoms. Other endobronchial tumors such as leiomyoma, fibroids, schwannomas, chondromas, hemangioma, lipoma, etc. can also cause obstructive atelectasis. Endobronchial papilloma is mainly found in children, often multiple, usually associated with recurrent pharyngeal papilloma, which can cause cough, hemoptysis, and wheezing. Alveolar cell carcinoma generally does not cause bronchial obstruction.

4. Non-neoplastic bronchiostenosis: bronchial tuberculosis is the most important cause of benign bronchial stenosis. In most cases, atelectasis occurs in fibrovascular tuberculosis, which is caused by tuberculous granulation tissue and ulceration, and fibrous stenosis can also occur during the healing period. In primary pulmonary tuberculosis, bronchial obstruction and atelectasis are mainly caused by enlarged lymph nodes outside the tube. X-ray signs of tuberculous bronchoconstriction are rapidly growing thin-walled cavities with atelectasis or bronchiectasis. Bronchoscopy and sputum culture can confirm the diagnosis. Sometimes it can be seen from the bronchoscope that the narrow nature is tuberculosis. Tuberculous atelectasis can also be caused by scarring of the lung parenchyma. Pulmonary mycosis, as well as bronchial stenosis, can also be caused when foreign bodies in the bronchi are not treated in time. Non-specific localized bronchitis is inflammation that is confined to the lobes of the lungs or segments of the lungs, and severe inflammation and granuloma formation can block the bronchi. This rare disease can only be diagnosed by excluding tumors, foreign bodies, and specific infections, sometimes requiring a thoracotomy. Most of the chronic inflammation-induced bronchoconstriction is unclear, and may be due to compression outside the lumen. Wegener granulomatosis can also cause bronchoconstriction and atelectasis. Bronchoscopy biopsy is usually not easy to diagnose. If surgical repair is not performed in time after trauma, large bronchospasm can cause bronchoconstriction and atelectasis. Atelectasis can occur in the acute injury period, but it is more common in 4 to 6 weeks after the acute phase, and its occurrence is often unpredictable. The acute phase usually manifests as single or multiple fractures of the first to third ribs, pneumothorax, mediastinal emphysema and subcutaneous emphysema. The most common cause is the contusion of traffic accidents. Intrabronchial sarcoidosis is less likely to cause atelectasis, but other radiological changes such as enlarged hilar, diffuse reticular plaque in the lung, and nodular shadow are often seen. Fiberoptic bronchoscopy can often make a diagnosis.

5. Broncholithiasis: Bronchial stones are rare. They are formed by bronchial lymph nodes around the bronchi. The common cause is tuberculosis and histoplasmosis. Clinical symptoms include cough, hemoptysis and chest pain. The history of coughing out sand or calcified substances is extremely diagnostic. If it is not completely blocked, it can smell and wheezing, while complete obstruction can cause obstructive pneumonia and atelectasis. The main cause of obstruction is the formation of large amounts of granulomatous tissue around the stones protruding from the lumen. A typical chest radiograph shows most of the calcifications of atelectasis and proximal end. Tomography and CT are of great value in determining the presence of stones and evaluating the relationship between stones and bronchial walls. Bronchoscopy can be clearly diagnosed in 75% of cases. If the granulation tissue is completely covered with stones, it is not easy to see stones. These cases can only be diagnosed by open chest biopsy.

6. Mucous impaction: The bronchial secretion concentrates to form a semi-solid or solid mucus plug. At this time, due to the side branch gas traffic, the distal alveolar is still filled with gas. The characteristic radiological signs of mucus caulking after atelectasis become insignificant, such as single or multiple nodule shadows, "finger-like", "grape bunches" or "toothpaste-like" changes. Clinical signs include eosinophilia in asthma, peripheral blood, and sputum, and evidence of allergic aspergillosis can often be found in laboratory tests. Mucus embolism also occurs in asthmatic patients without aspergillosis or in patients with cystic fibrosis and bronchiectasis. The above-mentioned X-ray signs can also occur in mucus caulking at the distal end of an obstructive bronchial lesion (such as a tumor). If there is gas passing through the obstruction or flank ventilation, there is no collapse of the distal lung.

7. Iatogenic atelectasis: catheter displacement with balloon in mechanical ventilation can quickly cause collapse of the entire lung, more common in the balloon catheter beyond the carina into the right main bronchus, so that the left lung is completely ventilated . Auscultation at the time of auscultation without lungs can immediately confirm the diagnosis, so the chest auscultation should be performed regularly after the catheter is replaced. Patients with coronary artery bypass grafting often have left lower atelectasis. The main reason is that the local use of ice during the operation is cold, which causes left phrenic nerve paralysis.

8. Bronchial obstruction due to extrinsic pressure: adjacent structures abnormally oppressed bronchus can also cause atelectasis, such as aneurysm, enlarged heart (especially left atrium), hilar lymphadenopathy , mediastinal tumor, fibrotic mediastinal inflammation, cysts and malignant tumors of the lungs. Exogenous compression is most commonly seen as a swollen lymph node around the bronchi, with the right middle lobe being the most commonly affected. The diseases that cause lymphadenopathy are mainly tuberculosis, followed by fungal infections, lymphomas, and metastatic tumors. Common chest radiographs can be seen at the same time as pulmonary atelectasis with enlarged hilar and vascular abnormalities, suggesting the possibility of exogenous compression. Thoracic tomography and CT can further confirm the diagnosis. A histological data of the primary disease can sometimes be obtained by mucosal biopsy at the obstruction site, but the aneurysm must be excluded prior to biopsy. There may be non-specific inflammation in the compressed bronchi. Carcinoid lymphadenopathy rarely compresses the bronchi, while lymphoma and metastatic tumors rarely cause hilar lymphadenopathy. Atelectasis in this case is usually caused by direct invasion within the bronchi rather than by exogenous compression. Exogenous masses have more children than adults across the wall.

9. Middle lobe syndrome: The right middle lobe is particularly prone to chronic or recurrent infections and atelectasis. Middle lobe syndrome originally refers to the atelectasis caused by swelling of the lymph nodes and compression of the bronchi. The middle bronchus is easily affected by its anatomical features, especially the middle bronchus is relatively slender and closer to the lymph nodes. Another reason is that the middle lobe is completely isolated from other lungs and lacks collateral ventilation. The current mid-lobe syndrome is more widely used to describe chronic or recurrent inflammation of the middle lobe caused by various causes, including bronchial lung cancer (20% to 40%), benign tumors, other types of bronchoconstriction (including bronchial stones), Exogenous compression, bronchiectasis, chronic infection, etc. The most common cause is non-specific infection, which is mostly non-obstructive.

10. Non-obstructive atelectasis: Occasionally, the leaf bronchus is not obstructed and there is a decrease in lung leaf volume. This type of atelectasis is secondary to obstruction caused by mucus plugs or inflammatory swelling in small peripheral bronchi and bronchioles. There is a bronchial air sign in the solid or collapsed lung lobe on the chest radiograph, indicating that the main bronchus is still unobstructed. This phenomenon can also be seen in bacterial pneumonia, viral pneumonia, bronchial asthma and mucoidosis. Bronchoscopy and bronchography showed invisible lobes in the middle lobe of the lobe, while the surrounding bronchioles and alveoli could not be filled with contrast agents. Strictly speaking, the above situation does not belong to "non-obstructive" atelectasis. In addition, it can be seen that the blocked bronchus expands. If the underlying disease is relieved, the lungs can be re-expanded and the dilated bronchus can return to normal size (recoverable bronchiectasis). If the mucus plug cannot be removed, it may cause permanent scarring atelectasis. Most scarring atelectasis is secondary to chronic inflammatory processes such as tuberculosis, fungal infections, silicosis, coal pneumoconiosis, asbestosis, bronchiectasis, mineral oil granuloma and chronic non-specific pneumonia (mechanized pneumonia), with chronic inflammation associated with Fibrosis can cause shrinkage and volume reduction of the affected lung lobe, in which case the reduction in lung capacity is more severe than other types of atelectasis. Scleroderma and other connective tissue diseases can also cause fibrosis and scarring atelectasis in the lungs.

Adhesive atelectasis is a decrease in lung capacity due to insufficient surfactant. Insufficient surfactant production or decreased activity is seen in hyaline disease, acute respiratory distress syndrome, uremia, too slow breathing, post-cardiac bypass surgery, radiation pneumonitis, severe smoking, and toxic pneumonia. This is also the mechanism of sub-segment (disc, disc-shaped) atelectasis when pulmonary embolism occurs. Incomplete embolization disappeared quickly on the chest radiograph, indicating no tissue necrosis. Complete or incomplete pulmonary embolism secondary to pulmonary thrombosis is similar to obstructive atelectasis: 1 lung volume is reduced, common ipsilateral diaphragm elevation; 2 opaque shadow is segment-leaf distribution, often Triangle, base toward the pleura, tip pointing to the hilar; 3 generally lack of bronchial air sign; 4 often found in other parts of the sub-segment (disc) atelectasis; 5 often occurs after surgery.

The imaging features suggesting pulmonary embolism rather than obstructive atelectasis are: 1 there is still some light transmission in the lesion; 2 there is Hampton hump; 3 pulmonary blood is reduced; 4 hilar vascular enlargement. The diagnosis of pulmonary embolism relies heavily on pulmonary angiography or pulmonary ventilation-perfusion scans.

11. Compressive atelectasis: intrathoracic space-occupying lesions can be squeezed to squeeze the lung tissue to make it atelect. Such arrhythmia is generally mild or incomplete, but may even be complete lung collapse. Intrathoracic lesions include pleural effusion, empyema, pneumothorax, thoracic or intrapulmonary tumors, pulmonary bullae, and pulmonary balloon swelling. Abdominal bulging can also cause the diaphragm to lift and squeeze the lungs, such as obesity, intra-abdominal tumors, liver and spleen growth, massive ascites, intestinal obstruction, and pregnancy.

12. Hypostatic atelectasis: There is a gravity-dependent part and a non-gravity-dependent part of the lung. The decrease in the gravity-dependent part suggests an increase in lung tissue perfusion and a decrease in alveolar ventilation. In the upright position, the alveolar volume of the end of the lung is about 4:1, and the ratio is about 2.5:1 when lying down. Gravity gradients can be involved in the formation of atelectasis in some cases, such as patients who are bedridden for a long time, breathing too shallow, impaired mucociliary delivery system, and diseases with increased lung weight such as pneumonia, pulmonary edema and pulmonary congestion.

13. Round atelectasis (platelike atelectasis): Round atelectasis (platelike atelectasis): a simple type of atelectasis, usually located at the base of the subpleural lung, in a circular or elliptical shape. Below the bronchus or vascular shadow extends to the hilum, which looks like a "star tail". It is often seen that the adjacent pleura and interlobular fissures are thickened. The imaging characteristic constant of the round atelectasis remains unchanged for a year. Circular atelectasis is generally considered to be associated with exposure to asbestos. The mechanism may be as follows: asbestos pleurisy has pleural thickening adhesion and pleural effusion, lung tissue floating in the pleural effusion and adhesion to the pleura, when the pleural effusion increases, the lung tissue can not fully re-expand. Disc or dish-shaped lungs are disc-shaped or dish-shaped shadows 2 to 6 cm above the diaphragm, moving up and down with the breath. It is common when the diaphragmatic movement is weakened in the ascites or obesity, or when the respiratory motility caused by various causes is weakened. Pulmonary embolism can also occur discoidally, the mechanism is as described above.

an examination

Related inspection

Chest CT examination

Interlobular shift check:

Symptoms and signs of atelectasis depend on the rate at which bronchial obstruction occurs, the extent of involvement, and whether the infection is concomitant.

1. Symptoms: Blockage formed in a short period of time with large area of lung collapse, especially in the case of co-infection, the affected side may have obvious pain, sudden breathing difficulties, cyanosis, and even blood pressure drop, tachycardia, fever, even Can cause shock. Slowly formed atelectasis can have no symptoms or only mild symptoms. Mid-leaf syndrome is mostly asymptomatic, but often has a severe irritating dry cough.

Some clinical conditions may suggest the possibility of bronchial obstruction and atelectasis. If some children with asthma continue to have wheezing, lung atelectasis may occur. If there is fever, it will prompt diagnosis. Allergic aspergillosis with mucus caulking is mainly seen in patients with asthma. Fever and tachycardia (postoperative pneumonia) 48 hours after surgery are often caused by atelectasis.

The left lower lobe is most likely to occur after cardiac surgery. Patients with chest wall disease cannot have an effective cough and are a predisposing factor for atelectasis. In patients with respiratory symptoms, the possibility of atelectasis should be considered. Atelectasis can occur in single or multiple rib fractures, especially in the presence of chronic bronchitis.

Children should be aware of the possibility of inhalation of foreign body when they have respiratory symptoms, especially if they have cough, suffocation or cough in their medical history. Patients often cannot provide such information on their own initiative and need to be excluded through a purposeful inquiry. It should be noted that there is an asymptomatic period of varying lengths after inhalation of foreign bodies. Adults often provide a clear history of foreign body inhalation, with the exception of those who are slow or unconscious.

Lung incontinence secondary to bronchial lung cancer is mainly seen in middle-aged or elderly men with a history of smoking, often with a history of chronic cough. This type of condition is often accompanied by infection, patients often have fever, chills, chest pain and cough and sputum, repeated small amount of hemoptysis is more characteristic. Significant symptoms can occur when the tumor is transferred to the chest. More women than men with bronchial adenoma, the age of onset is smaller than that of bronchial lung cancer. There are no specificities in respiratory symptoms, but there are many hemoptysis. Occasionally, the patient may present with a carcinoid syndrome, suggesting a broad metastasis of the tumor.

If there is tuberculosis, pulmonary fungal infection, foreign body inhalation or chronic asthma in the medical history, attention should be paid to the presence or absence of bronchoconstriction. Previous history of chest trauma should be noted to rule out the presence or absence of undetected bronchial laceration and bronchoconstriction. About 50% of patients with atelectasis secondary to bronchial stones have a history of coughing calcification, and patients often fail to pay attention and need a doctor's prompt. Some patients think that doctors do not believe that they will cough up "stones", so they intentionally miss this medical history. Other common symptoms of bronchial stones include chronic cough, wheezing, repeated hemoptysis, and repeated lung infections. In addition, patients in the intensive care unit are also prone to atelectasis.

2. Signs: The typical signs of obstructive atelectasis are evidence of decreased lung capacity (decreased tactile tremor, diaphragmatic uplift, mediastinal shift), turbidity, speech tremors, and decreased or absent breath sounds. If a small amount of gas enters the collapsed area, it can smell wet. There may be obvious cyanosis and difficulty in breathing. After the operation, the patient is characterized by repeated coughing and weakness. If the affected area is small, or the surrounding lung tissue is fully and effectively compensated for excessive expansion, the signs of atelectasis may be atypical or absent. Non-obstructive atelectasis and its main bronchus are still unobstructed, so speech tremor is often enhanced and respiratory sounds are present. The upper lobe is invisible due to its adjacent trachea, which can be heard in the lungs and bronchial breath sounds. The signs of inferior atelectasis are similar to those of pleural effusion and unilateral diaphragmatic elevation.

Signs related to underlying diseases are found during physical examination and can provide diagnostic clues. Mucus plugs, mucus caulking or atelectasis secondary to bronchoconstriction of asthma, auscultation can be characterized by characteristic expiratory wheezing. Bronchial lung cancer may have clubbing or other signs of metastasis. Lymphoma-induced atelectasis can be found in different parts of the lymph nodes. Atelectasis with jugular vein dilatation or engorgement and liver enlargement often suggest fibrotic mediastinal inflammation. Compressive atelectasis caused by cardiovascular disease can detect signs of heart murmur, galloping, cyanosis or heart failure. It is easier to find one or more rib fractures when palpation in chest trauma, and even sputum chest when inhaling. Elevation of atelectasis due to weakness of the chest wall often has evidence of underlying neuromuscular disease.

On the basis of clinical symptoms and signs, the following examination methods can determine whether there is atelectasis and provide clues for the diagnosis of the cause.

1. Radiological examination: Radiological examination is the most important means of diagnosing atelectasis. Conventional chest radiographs usually define the presence and location of the leaf or segmental atelectasis. The radiological manifestations of atelectasis vary widely and are often atypical. In the anterior or posterior position of the lack of projection conditions, due to the cover of the heart, the left lower lobe is often missed. Inferior lobe can be mistaken for mediastinal widening, and the effusion is similar to atelectasis, and a large amount of pleural effusion can cover the inferior lobe. Bronchial air sign can rule out complete bronchial obstruction, but can not eliminate lung lobe collapse.

The discovery of calcified lymph nodes in the atlantic segment or at the top of the lobes is important for the diagnosis of bronchial stones. Mediastinal calcification can be found in fibrotic mediastinal inflammation and various inflammatory lymph nodes.

Allergic aspergillosis, mucoidosis, lymphoma, X-ray-free foreign bodies and bronchial laceration have corresponding signs of radiological abnormalities. When the foreign body blocks the main bronchus, the conventional chest radiograph can be found that one side of the lung becomes smaller, the transmittance decreases, and the other side increases the volume of the lung, and the transmittance increases. This phenomenon may indicate that one side of the lung is over-expanded due to obstruction of the valve, and the contralateral lung is compressed to make it absent; 2 the absorptive atelectasis occurs on one side of the lung, and the compensatory hyper-expansion of the contralateral lung. Fluoroscopy and comparison of inspiratory and end-tidal chest radiographs can identify the above two conditions, because only the bronchial smooth lungs have significant changes in volume between inhalation and exhalation.

The tomographic imaging is helpful for the following situations: describing the location and shape of the collapsed lobes, the presence or absence of bronchial air signs, the presence or absence of calcification and its location, the occlusion of the disease, and the presence or absence of occlusion in the lumen. CT examination is more valuable for the diagnosis of such problems, especially for the following cases, which are better than tomography, including: identifying the location or even nature of obstructive lesions in the bronchial lumen, exploring the enlarged mediastinal lymph nodes, and identifying the mediastinal masses. The lungs around the mediastinum are atelect. Bronchography is mainly used to understand whether there is bronchiectasis in non-obstructive atelectasis, but it has been basically replaced by CT. If the pulmonary atelectasis is suspected to be caused by pulmonary thrombosis, pulmonary ventilation-perfusion imaging or pulmonary angiography may be considered, and the specificity of angiography is relatively high.

For patients with atelectasis caused by fibrotic mediastinal inflammation, superior vena cava angiography has a certain value. A variety of imaging techniques can be selected when cardiovascular disease causes compression atelectasis.

2. Laboratory examination: The routine diagnosis of blood has limited value in the differential diagnosis of atelectasis. Asthma and Pulmonary Aspergillosis with mucus impaction are infected with blood eosinophilia, occasionally in Hodgkin's disease, non-Hodgkin's lymphoma, bronchial lung cancer, and sarcoidosis. Blocking distal secondary infections has neutrophils and increased erythrocyte sedimentation rate. Chronic infections and lymphomas are mostly anemia. Sarcoidosis, amyloidosis, chronic infection, and lymphoma showed increased gamma globulin.

Serological tests for anti-Aspergillus antibodies have a high sensitivity and specificity for the diagnosis of pulmonary allergic Aspergillus infection. The specific complement fixation test can be positive when histoplasmosis and coccidioidomycosis cause bronchoconstriction. The detection of serotonin in blood and urine has diagnostic value for carcinoid syndrome caused by bronchial lung cancer.

3. sputum and bronchial aspirate examination: Because the cough secretion is mainly from the lungs that do not occur, can not reflect the pathological process that causes bronchial obstruction, so the sputum examination has little significance in the diagnosis of atelectasis. Smear examination and culture of bacteria, fungi and Mycobacterium tuberculosis should be performed, and cytological examination should be routinely performed. Allergic Aspergillus infection can sometimes produce Aspergillus, but it is necessary to pay attention to the contamination of Aspergillus in the laboratory. If you cough up the sputum and find a large number of hyphae under the microscope, you can establish a diagnosis.

Cytological examination of bronchial lung cancer can have a positive finding, while most adenocarcinoma and benign tumors are negative for cytology. Occasionally, tumor cells can be found in patients with lymphoma.

4. Skin test: The skin test has little effect on the diagnosis of atelectasis. The tuberculin, coccidiostat or histoplasmin skin test can be positive for atelectasis caused by bronchial stones and provide clues for diagnosis. If the atelectasis is caused by the enlargement of the hilar lymphadenopathy, the tuberculin skin test turns positive in the near future, especially in children or adolescents, and has certain diagnostic value. Skin tests in allergic Aspergillus infections are typically immediate skin reactions, and some patients exhibit biphasic responses.

5. Bronchoscopy: Bronchoscopy is one of the most valuable diagnostic methods for atelectasis and can be used in most cases. In most cases, obstructive lesions can be seen directly under the microscope and biopsies taken. If a rigid bronchoscope is used, the stenosis can be dilated and exogenous or endogenous stones removed. If foreign bodies or bronchial stones are surrounded by granulation tissue, it is not easy to confirm the diagnosis under the microscope.

The surface of bronchial adenocarcinoma is usually covered with a normal epithelial tissue. If the tumor is pedunculated, it is easily mistaken for the pressure lesion in the cavity. But most adenocarcinomas have pedicles that help determine the origin of their bronchi. Bronchial carcinoid blood vessels are abundant, and it is easy to bleed during biopsy. At this time, it should be left for thoracotomy, and should not be blind biopsy. Sometimes the surface of bronchogenic lung cancer can also be covered with a layer of granulation tissue. Only microscopic examination can take inflammatory tissue. At this time, if there are still small gaps in the obstructed bronchus, oncology evidence can be obtained by deep brushing. For extra-bronchial compression lesions, biopsy of the bronchial mucosa occasionally reveals histological abnormalities associated with the underlying lesion. However, the pulsatile mass outside the tube should not be biopsied. For obstructive atelectasis caused by mucus plugs, bronchoscopic aspiration is both diagnostic and therapeutic. Biopsy and brushing under fiberoptic bronchoscopy also have diagnostic value for benign and malignant tumors, sarcoidosis and specific inflammation that cause obstruction.

6. Lymph node biopsy and extrathoracic biopsy: If the atelectasis is caused by bronchial lung cancer or lymphoma, the biopsy of the scalene and mediastinal lymph nodes is helpful for diagnosis, and the fiberoptic biopsy is often negative. If there is a clear hilar or mediastinal growth, lymph node biopsy often has a positive finding, and if the radiological changes only the distal lung tissue collapses, it is difficult to obtain a positive result. When sarcoidosis, tuberculosis, and fungal infections cause atelectasis, there are occasional positive findings in the subcutaneous and mediastinal lymph node biopsy. Extrathoracic biopsies (liver, bone, bone marrow, peripheral lymph nodes) can sometimes provide diagnostic assistance for certain diseases such as sarcoidosis, infectious granuloma, lymphoma, and metastatic bronchogenic lung cancer.

7. Pleural effusion examination and pleural biopsy: There are many reasons for the formation of pleural effusion during atelectasis. Pleural effusion may mask the radiological signs of atelectasis. Pleural effusion and pleural biopsy have diagnostic value for malignant lesions and certain inflammatory lesions. The blood chest is seen in a chest trauma or an aneurysm rupture, while a bloody pleural effusion suggests a tumor, pulmonary embolism, tuberculosis or trauma.

Differential diagnosis

Symptoms that are easily confused by interlobular displacement:

Interlobular fissure often has a curved drop: Klebsiella infection X-ray manifestations, can have large leaf consolidation, lobular infiltration and abscess performance, large leaf consolidation is mostly located in the upper lobe, thick due to inflammation and exudate Therefore, the interlobular crack often falls in a curved shape. Inflammatory infiltration is also denser than other pneumonia, with sharp borders, and 16% to 50% of patients have lung abscess formation.

Hepatic lobe atrophy: refers to B-ultrasound or CT detection, the size of the liver lobe is reduced, if the whole liver shrinks, it belongs to the "bulging" of traditional medicine, modern medicine is characterized as "cirrhosis", and there is no such thing as liver transplantation at home and abroad. Other effective treatments. However, liver transplantation is to find the right source of liver, second, strong rejection after surgery, and third, it will cause pain and permanent scars to the donors and patients. Fourth, the cost is high, and the general civilian patients are weak. Tolerance has caused countless patients to die because of the lack of money to change the liver, so it is imperative to seek a simple, scientific and economical method for treating liver atrophy that is acceptable to many civilian patients.

Segmental or large-leaf blurred shadows around the lower lobe of the lung: examination often found that segmental or large-leaf blurred shadows around the lower lobe of the lung are x-ray findings of lobar pneumonia.

1. The disease occurs in young men and winter and spring and spring.

2. There are many incentives before the onset of illness. About half of the cases have pre-existing manifestations such as upper respiratory virus infection.

3. Sudden onset of chills and high fever.

4. Cough, chest pain, shortness of breath, rust and rust. Severe patients can be accompanied by shock.

5. Physical signs of the lungs. In severe cases, blood pressure often drops below 10.5/6.5KPa (80/50mmHg).

6. The total number of white blood cells increased, neutrophils reached 0.80 or more, and the nucleus moved to the left, with poisonous particles.

7. A large number of Gram-positive cocci are visible in the smear.

8. , blood culture has pneumococcal growth.

9. Serological test positive (cooperative agglutination test, convective immunoelectrophoresis detection of pneumococcal capsular polysaccharide antigen).

10. Chest X-ray examination showed a large patchy density with uniform segment or leafiness.

11. Blood gas analysis showed a decrease in PaO2 and PaCO2, and PaCO2 in patients with chronic obstructive pulmonary disease increased.

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