Lung Collapse

Relevant physical signs

• Collapse
  • Comfortable or in respiratory distress
  • Deviation of trachea towards the affected side
  • Reduced chest expansion on the affected side
  • Dull (but not stony dull) percussion note on the affected side)
  • Reduced air entry on the affected side
  • Reduced vocal resonance on the affected side
• Underlying malignancy
  • Cachectic
  • Clubbing
  • Tar staining of fingers
  • Wasting of dorsal interossei
  • Conjunctival pallor
  • Ipsilateral Horner’s syndrome
  • Voice hoarseness
  • Cervical lymphadenopathy
  • Signs of post-obstructive infection
  • Signs of superior vena obstruction
    • Facial plethora
    • Distended neck veins
    • Positive Pemberton’s sign
    • Stridor
• Tuberculosis
  • Cervical lymphadenopathy
  • Thoracoplasty scar
• Dynamic airways obstruction
  • Wheeze
  • Hyper-expanded chest

Differential diagnosis

• Fibrothorax
• Pleural effusion (trachea should be deviated away from effusion, stony dull percussion)
• Pleural plaques
• Space-occupying lesion within that anatomical space
• Raised hemidiaphragm
• Hiatus hernia

Causes of lung collapse

• Intra-luminal
  • Mucous plugging, e.g. secondary to asthma, bronchiectasis or infection
  • Foreign body
  • Incorrect placement of endotracheal tube
• Luminal
  • Dynamic airway obstruction (asthma / COPD)
  • Bronchial wall carcinoma
  • Endobronchial tuberculosis
• Extra-luminal
  • Compression from surrounding lymphadenopathy (lymphoma, sarcoidosis, TB)
  • Compression from mediastinal masses (retrosternal goitre, thymoma, teratoma)
  • Compression from primary or secondary tumour
• Non-obstructive atelectasis
  • Compression atelectasis (pleural effusion)
  • Adhesive (e.g. acute respiratory distress syndrome, radiation pneumonitis)
  • Passive atelectasis due to loss of contact between visceral and parietal pleura

Investigations

• If in respiratory distress: arterial blood gas
• Chest radiograph to delineate collapse, look for mass lesion
• Computed tomography scan of the thorax with adrenal cuts to stage lung malignancy
• Spirometry to assess fitness for surgery (FEV₁ > 1.5L, transfer factor > 50%)
• Bronchoscopy with biopsy to obtain tissue for definitive diagnosis

Management

• Multidisciplinary team approach with patient education on underlying disease
• If in respiratory distress:
  • Oxygen supplementation
  • Chest physiotherapy to remove mucus plug
• Pre-bronchoscopy evaluation for coagulopathy, oxygenation, infection
• Consider endobronchial stenting to relieve obstruction
• Consider bronchodilators for dynamic airway obstruction
• May require emergent radiotherapy to remove obstruction

Summary

Sir, this patient has tracheal deviation towards the left, accompanied by a dull percussion note over the left anterior chest wall and reduced breath sounds and vocal resonance over this area. In the absence of a lateral thoracotomy scar, the most likely diagnosis is a left upper lobe collapse. The patient is comfortable at rest, and does not require supplemental oxygen. There is no cervical lymphadenopathy, clubbing or tar staining of the fingers to suggest and underlying mitotic process, and the patient is no cachectic. Possible differentials for dullness to percussion with reduced air entry and tracheal deviation include a fibrothorax, pleural plaques, as well as a loculated pleural effusion.

In summary, this patient has a left upper lobe collapse, which is currently not causing respiratory distress. He requires urgent investigation for an underlying cause of the collapse, such as an endobronchial mitotic process or external compression by mediastinal structures.