Volume 36 • Number 25

December 15, 2013

Imaging of Atelectasis
Larson Hsu, MD, Daniel Green, MD, Jesse Chusid, MD, Arunabh Talwar, MD,
and Rakesh Shah, MD
After participating in this activity, the diagnostic radiologist should be better able to diagnose the various radiographic
manifestations of atelectasis and to identify their potential etiologies and clinical significance.

CME Category: General Radiology

Subcategory: Chest
Modality: Radiography
The chest radiograph is the most frequently requested
radiologic study in the United States and often provides the
earliest sign of chest disease. Likewise, atelectasis is one of
the most common abnormalities encountered in chest radi-
ography. The term “atelectasis” (ateles ektasis, Greek for
“incomplete expansion”) describes the collapsed lung as a
result of decreased aeration.1 Atelectasis usually manifests
radiographically as radiopaque density on a background of
aerated lucent lung parenchyma. Four main mechanisms of
atelectasis (i.e., obstructive, passive, adhesive, and cicatric-
ial) have been described, each associated with a wide range
of processes, both benign and malignant. Detection and accu-
rate interpretation of findings associated with atelectasis is,
therefore, essential in any patient work-up.
Types of Atelectasis
Obstructive (or Resorptive) Atelectasis. Obstructive atel-
ectasis occurs when airway obstruction prevents aeration and
ventilation of downstream alveoli, while the retained gas is
Dr. Hsu is Resident, Dr. Green is Resident, Dr. Chusid is Assistant Professor
of Radiology, Dr. Talwar is Associate Professor of Medicine, and Dr. Shah
is Associate Professor of Radiology, Department of Radiology, North Shore
University Hospital, 300 Community Drive, Manhasset, NY 11030; E-mail:
larsonhsu@gmail.com.
All authors and staff in a position to control the content of this CME activity and
their spouses/life partners (if any) have disclosed that they have no relationships
with, or financial interests in, any commercial organizations pertaining to this
educational activity.
resorbed into the bloodstream. Obstruction can occur at any
level of the tracheobronchial tree. Endobronchial obstruction
is typically the result of a benign or malignant neoplasm, a
mucous plug, or an aspirated foreign body. Broncholiths are
a less common cause.2 A similar concept exists with endotra-
cheal tube malpositioning.
Obstruction of a bronchus results in atelectasis of the
affected lung or lobe; however, significant volume loss may
not always be present. After gas resorption, pulmonary secre-
tions and transudate can fill the airways and maintain lung
volume.1 This phenomenon, known as “drowned lung,” has
a characteristic CT appearance of consolidated lung with a
central mass and fluid attenuation present in the airways.
Obstruction of bronchioles may or may not result in atel-
ectasis. Mucoid-impacted small airways without associated
atelectasis are a common finding on high-resolution chest CT
(HRCT), as adjacent lung segments provide collateral aeration
via pores of Kohn. Although adjacent lung segments are able
to communicate with one another, these communicating pores
of Kohn do not cross fissures.
Passive (or Relaxation) Atelectasis. Passive atelectasis
refers to lung collapse secondary to adjacent mass effect or
the loss of negative intrapleural pressure. Mass effect may be
exerted by pleural effusion, intrathoracic tumors, or diaphrag-
matic hernia. The loss of negative intrapleural pressure results
in the setting of pneumothorax or diaphragm paralysis, with
subsequent decreased lung volume.1
Adhesive Atelectasis. Surfactant is required for alveoli to
maintain expansion by reducing surface tension. Premature
newborns lacking adequate surfactant experience incomplete
expansion of alveoli, resulting in adhesive atelectasis.3 Other
conditions associated with either decreased surfactant or

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education activity expires on February 3, 2014.
1
destruction of the type II pneumocytes that produce surfactant
are smoke inhalation, adult respiratory distress syndrome,
radiation pneumonitis, and the postoperative period.
Cicatricial Atelectasis. Pulmonary fibrosis of all causes
results in decreased pulmonary compliance and incomplete
expansion of the affected lung parenchyma.1 Cicatricial atel-
ectasis affects the lungs diffusely in diffuse interstitial lung
disease or focally in conditions such as radiation fibrosis and
chronic pulmonary infection.
Signs of Atelectasis
The radiographic findings of atelectasis can be separated
into direct and indirect signs. Direct signs are due to volume
loss and include displacement of interlobar fissures and crowd-
ing of pulmonary vessels.1 A displaced interlobar fissure is the
most specific sign indicating volume loss. If a fissure cannot
be identified, crowding of pulmonary vessels or airways is a Figure 1. This axial CT image demonstrates an enhancing
atelectatic right lower lobe and nonenhancing left lower lobe
useful but uncommon direct finding. Indirect signs of atelecta- pneumonia exudate.
sis also are secondary to volume loss. Indirect signs typically
include ipsilateral hemidiaphragm elevation, mediastinal shift, the initial presentation. A collapsed lobe typically assumes a
and compensatory hyperinflation of the nonatelectatic lung. triangular shape. The apex of the triangle is at the hilum,
More subtle indirect signs include hilar displacement, increased where the parietal and visceral layers of pleura are continu-
lung opacity, approximation of the ribs, and shifting of a pre- ous, forming an anchor. The base is peripheral, as the lobe
existing lung abnormality, such as a granuloma. usually maintains contact at its costal pleural surface. At least
one other border of the triangle is formed by a fissure, which
Direct radiographic signs of atelectasis are due to is demarcated by the opaque lung and bows toward the col-
volume loss and include displacement of interlobar lapsed lobe. Homogeneous parenchymal opacity delineating
fissures and crowding of pulmonary vessels. a fissure should raise the suspicion of lobar atelectasis. The
orientation of each fissure contributes to a characteristic
radiographic appearance of atelectasis of each individual lobe.
In addition to the signs listed previously, the presence of
intravenous contrast enhancement may be useful in differen-
tiating atelectasis from pneumonia on CT. When otherwise The orientation of each fissure contributes to
indistinguishable, atelectatic lung parenchyma enhances, a characteristic radiographic appearance of
whereas cellular exudate in pneumonia does not enhance atelectasis of each individual lobe.
(Figure 1).
In right upper lobe atelectasis, the right upper lobe collapses
On contrast-enhanced chest CT, atelectatic superiorly and medially (Figure 2). Superior displacement of
lung parenchyma enhances, whereas cellular the minor fissure is readily identifiable on the frontal chest
exudate in pneumonia does not enhance. radiograph (Figure 3). Anterior bowing of the upper aspect
of the major fissure and superior bowing of the minor fissure
also are seen on the lateral chest radiograph. Opaque lung
Lobar Atelectasis silhouettes the upper mediastinal border and possibly the right
Lobar atelectasis is most commonly the result of airway upper lobe pulmonary artery. If right upper lobe collapse is
obstruction and subsequent resorptive atelectasis. A malignancy the result of an obstructing lesion, the frontal chest radio-
is commonly the obstructing mass, and atelectasis is often graph may show a characteristic appearance known as the
The continuing education activity in Contemporary Diagnostic Radiology is intended for radiologists. EDITOR: Robert E. Campbell, M.D., Clinical Professor of Radiology,
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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2

Figure 2. Illustration of right upper lobe (RUL) atelectasis. Normal
RUL in the frontal and lateral views (left column) and various
degrees of RUL atelectasis (middle and right columns). RLL, right
lower lobe; RML, right middle lobe.
“Golden S” sign.4 In the Golden S sign, in addition to superior
displacement and bowing of the lateral aspect of the minor
fissure, there is downward bulging of the medial aspect of the
minor fissure because of the obstructing mass (Figure 4). The
“juxtaphrenic peak” sign is an additional sign that is seen
occasionally in upper lobe collapse of either lung. The frontal
chest radiograph depicts tenting of the ipsilateral hemidia-
phragm secondary to volume loss and retraction by an inferior
accessory fissure or inferior pulmonary ligament.
The “Golden S” sign on the frontal chest radiograph
is the result of obstruction right hilar lesion with
associated right upper lobe atelectasis.
Figure 3. Right upper lobe atelectasis. Triangular opacity with the
apex at the hilum, elevation of the minor fissure with superior
bowing (arrow), and elevated right hemidiaphragm are shown.
Figure 4. “Golden S” sign. Right hilar mass (asterisk) and subse-
quent right upper lobe collapse are shown. The tracheal shift to
the right and elevation of the right hemidiaphragm are the result
of volume loss in the right lung.
Although the minor fissure usually is identifiable on a nor-
mal frontal chest radiograph, in right middle lobe atelectasis
it is displaced inferiorly and no longer visualized. Instead,
right middle lobe atelectasis can be recognized on a frontal
chest radiograph by obscuration of the right heart border as
the lobe becomes airless (Figure 5). Because of the relatively
small size of the right middle lobe, complete lobar atelectasis
of it usually does not result in appreciable volume loss of the
right lung. The lateral chest radiograph depicts inferior dis-
placement of the minor fissure and superior displacement
and bowing of the anteroinferior aspect of the major fissure
(Figure 6). The opaque lung between the 2 closely approxi-
mated fissures accounts for increased wedge-shaped attenu-
ation projecting over the heart (Figure 7).5
Figure 5. Right middle lobe atelectasis. Obscuration of the right
heart border is present.
3

Figure 6. Right middle lobe atelectasis. Approximation of the minor
and major fissures and opacification of the collapsed lobe are seen.
Right middle lobe atelectasis can be recognized
on a frontal chest radiograph by obscuration of
the right heart border, but is best seen as a
wedge-shaped opacity overlying the heart on
the lateral view.
Figure 7. Illustration of right middle lobe (RML) atelectasis. Normal
RML in the frontal and lateral views (left column) and various
degrees of RML atelectasis (middle and right columns). RLL, right
lower lobe; RUL, right upper lobe.
4
Figure 8. Illustration of right lower lobe (RLL) atelectasis. Normal
RLL in the frontal and lateral views (left column) and various
degrees of RLL atelectasis (middle and right columns). RML, right
middle lobe; RUL, right upper lobe.
The right major fissure is not seen normally on the frontal
chest radiograph; however, in the setting of right lower lobe
atelectasis, it rotates posteriorly into the plane of the x-ray
beam and becomes visible as the superior border of the
triangular opacity (Figure 8). The right hemidiaphragm and
lower right paraspinal interfaces are obscured. The right heart
border remains visible because it remains in contact with the
aerated right middle lobe (Figure 9). The minor fissure also
remains visible and is displaced inferiorly. On the lateral
view, inferior displacement of the upper portion of the major
fissure and posterior displacement of its lower portion result
Figure 9. Right lower lobe atelectasis. Obscuration of the right hemi-
diaphragm medially is present. The right heart border remains visible.

Figure 10. Right middle and lower lobe atelectasis. Obscuration of
both the right heart border and the right hemidiaphragm is evident.
in a posterior triangular opacity overlying the spine and sil-
houetting the posterior hemidiaphragm.
In right lower lobe atelectasis, the right heart
border remains visible because it remains in
contact with the aerated right middle lobe.
A single obstructing lesion in the bronchus intermedius
can account for both right middle and lower lobe atelectasis.
The frontal chest radiograph is similar to that of right lower
Figure 11. Illustration of left lower lobe (LLL) atelectasis. Normal
LLL in the frontal and lateral views (left column) and various
degrees of LLL atelectasis (middle and right columns). LUL, left
upper lobe.
lobe atelectasis except that the right heart border and minor
fissure are not visible (Figure 10). The lateral chest radio-
graph shows combined findings of both right middle and
lower lobe atelectasis, with the opaque lung both anterior and
posterior to the lower aspect of the major fissure.
The finding of left lower lobe atelectasis is similar to that
of the right lower lobe (Figure 11). The oblique fissure is
displaced and bowed posteriorly (Figure 12). On the frontal
chest radiograph, the retrocardiac diaphragm, descending
aorta, and paraspinal interface become silhouetted, whereas
the left heart border remains visible (Figure 13). An additional
sign associated with left lower lobe atelectasis is known as
the “flat waist” sign, in which leftward rotation of the heart
results in straightening of the left heart border.
With left lower lobe atelectasis on the frontal
chest radiograph, the retrocardiac diaphragm,
descending aorta, and paraspinal interface
become silhouetted; whereas the left heart
border remains visible.
In left upper lobe atelectasis, a homogeneous ill-defined
opacity is present in the upper left hemithorax. It obscures
the left heart and upper mediastinal borders on the frontal
chest radiograph (Figure 14). The left upper lobe pulmo-
nary artery also may be silhouetted. On the lateral view, the
left upper lobe collapses anteriorly with anterior displace-
ment and bowing of the interlobar fissure. The superior
Figure 12. Left lower lobe atelectasis. Posterior displacement of
the interlobar fissure is seen.
5

Figure 13. Left lower lobe atelectasis. Obscuration of the left
hemidiaphragm and left paraspinal interface is shown. The left
heart border remains visible and appears straightened in contour,
also known as the “flat waist” sign. The left tracheal shift is due
to volume loss in the left lung.
segment of the left lower lobe compensates by hyperexpand-
ing to occupy the upper left hemithorax, manifesting on the
frontal view as left apical lucency. When this lucency inter-
poses between the collapsed left upper lobe and the aorta
(Figure 15), it forms a crescent shape6 that has been termed
Figure 14. Illustration of left upper lobe (LUL) atelectasis. Normal
LUL in the frontal and lateral views (left column) and various degrees
of LUL atelectasis (middle and right columns). LLL, left lower lobe.
6
Figure 15. Left upper lobe atelectasis. Obscuration of the upper
left heart border is present. There is compensatory hyperexpan-
sion of the superior segment of the left lower lobe, which accounts
for the left apical lucency, and becomes insinuated between the
upper mediastinum and the upper portion of the collapsed lobe
(arrow). CT axial image (inset) demonstrates corresponding find-
ings (arrow). Note the juxtaphrenic peak sign (arrowhead) on the
frontal chest radiograph.
the “luftsichel” sign (German for “air crescent”). Left upper
lobe atelectasis also may be associated with a juxtaphrenic
peak sign.
In left upper lobe atelectasis, the left upper lobe
collapses anteriorly and obscures the left heart
and upper mediastinal borders.
Figure 16. Round atelectasis. Lung window illustrates the “comet-
tail” sign with curvilinear vasculature (arrow).

Figure 17. See quiz question 4 on page 8.
In some cases of left upper lobe bronchus obstruction, lin-
gular branches may not be affected; and, therefore, the left
heart border is not obscured. Likewise, if only the lingular
branches are obstructed, radiographic findings will be similar
to those of right middle lobe atelectasis, and a luftsichel sign
will not be present.
Round Atelectasis
An additional variation of airspace collapse manifests as a
focal round opacity, thus termed round or helical atelectasis.
This process is associated frequently with chronic pleural
abnormalities and has an association with asbestos exposure.
Round atelectasis occurs when a segment of the diseased
visceral pleural surface invaginates into the thoracic cavity
and a portion of the lung periphery folds inward onto itself.
Adhesions in the folded pleural cleft and parenchymal fibro-
sis prevent the affected lung from unfolding. As such, clas-
sification of round atelectasis is probably a combination of
passive, adhesive, and cicatricial atelectasis. On plain chest
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radiographs, round atelectasis is difficult to distinguish from
a lung tumor. Frontal and lateral views may be useful because
the atelectatic mass usually appears as an ill-defined opacity
on one view and a well-defined peripheral opacity on the
other depending on its location. CT is sufficient to differenti-
ate this entity from a lung neoplasm based on 4 diagnostic
criteria. The opacity must be as follows:
1. Round in shape
2. Adjacent to an area of pleural abnormality such as effusion
or thickening
3. Associated with whirling of the adjacent lung parenchyma,
vasculature, and airways, forming a comet-tail sign7
(Figure 16)
4. Associated with volume loss
Round atelectasis is difficult to distinguish from
a lung tumor on chest radiographs, but CT can
differentiate the 2 entities.
Conclusion
Atelectasis is encountered on a daily basis in most radiology
practices. This CME activity emphasizes that atelectasis is
associated with a wide range of processes and occasionally can
be the earliest detectable sign of lung malignancy. Therefore,
knowledge of the basic radiographic appearances of atelectasis
and their significance is important for all radiologists.
References
1. Woodring J, Reed J. Types and mechanisms of pulmonary atelectasis.
J Thorac Imaging. 1996;11:92-108.
2. Seo J, Song K, Lee J, et al. Broncholithiasis: review of the causes with radiologic-
pathologic correlation. Radiographics. 2002;22:S199-S213.
3. Agrons G, Courtney S, Stocker J, et al. lung disease in premature neonates:
radiologic-pathologic correlation. Radiographics. 2005;25:1047-1073.
4. Woodring J, Reed J. Radiographic manifestations of lobar atelectasis. J Thorac
Imaging. 1996;11:109-144.
5. Raasch B, Heitzman E, Carsky E, et al. A computed tomographic study of
bronchopulmonary collapse. Radiographics. 1984;2:195-232.
6. Ashizawa K, Hayashi K, Aso N, et al. Lobar atelectasis: diagnostic pitfalls on
chest radiography. Br J Radiol. 2001;74(877):89-97.
7. Partap V. The comet tail sign. Radiology. 1999;213:553-554.
7
 CME QUIZ: VOLUME 36, NUMBER 25
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1. On the frontal chest radiograph, all of the following are silhou- 6. The “juxtaphrenic peak” sign on a frontal chest radiograph is
etted in left lower lobe atelectasis, except caused by
A. left heart border A. asbestosis
B. retrocardiac diaphragm B. atelectasis of either upper lobe
C. descending aorta C. pleural mesothelioma
D. paraspinal interface D. empyema
E. basal pneumothorax
2. A patient with a normal baseline chest radiograph is intubated.
An hour later, a follow-up chest radiograph shows complete 7. The frontal chest radiograph of a 57-year-old smoker with hemop-
left lung collapse. The most likely diagnosis is tysis reveals the “Golden S” sign. The most likely diagnosis is
A. mucous plug A. lobar pneumonia
B. foreign body aspiration B. pulmonary fibrosis
C. lung neoplasm C. right middle lobe atelectasis
D. endotracheal tube malposition D. a broncholith in the bronchus intermedius
E. a malignant hilar mass with right upper lobe atelectasis
3. Which one of the following statements regarding round atelecta-
sis is false? 8. Which one of the following is the most common cause of lobar
A. It appears as a focal round opacity on chest radiographs. atelectasis?
B. It frequently is associated with chronic pleural disease. A. Large pleural effusion
C. It is difficult to distinguish from a lung tumor on chest B. Tension pneumothorax
radiographs. C. Inadequate surfactant
D. On CT, the “comet-tail” sign is often present. D. Airway obstruction
E. It is not associated with lung volume loss. E. Radiation pneumonitis
4. Figure 17 on page 7 is a frontal chest radiograph in a symp- 9. All of the following are radiographic features of combined atel-
tomatic patient. The most likely diagnosis is ectasis of the right middle and lower lobes, except
A. left tension pneumothorax A. silhouetting of the right heart border
B. left upper lobe atelectasis B. obscuration of the right hemidiaphragm
C. Klebsiella pneumonia C. “luftsichel” sign
D. left lower lobe atelectasis D. triangular opacities with the apex at the hilum
E. pericardial effusion E. volume loss in the right lung
5. All of the following are associated with cicatricial atelectasis, 10. Which one of the following is a direct radiographic sign of
except atelectasis?
A. radiation pneumonitis A. Compensatory hyperinflation of the nonatelectatic lung
B. sarcoidosis B. Displacement of an interlobar fissure
C. chronic pulmonary infection C. Mediastinal shift
D. adult respiratory distress syndrome D. Elevation of the hemidiaphragm
E. idiopathic pulmonary fibrosis E. Change in position of a previously noted granuloma