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{{CMG}}
{{Pulmonary edema}}
{{CMG}} {{AE}} {{FKH}}
 
==Overview==
==Overview==
The chest x-ray is the diagnostic modality of choice in the evaluation of the patient with suspected pulmonary edema.
The diagnosis of pulmonary edema usually confirmed on [[X-ray]], which shows increased fluid in the alveolar walls. [[Kerley B lines]], increased vascular filling, [[pleural effusion]]s, upper lobe diversion (increased blood flow to the higher parts of the lung) may be indicative of cardiogenic pulmonary edema, while patchy alveolar infiltrates with air bronchograms are more indicative of noncardiogenic edema.
Chest x-ray findings include:
 
#[[Kerley B lines]] or thickening of the interlobular septa
==Chest X Ray==
#[[Peribronchial cuffing]]
An x-ray may be helpful in the diagnosis of pulmonary edema. Findings on an x-ray suggestive of pulmonary edema include:<ref name="pmid3907943">{{cite journal |vauthors=Pistolesi M, Miniati M, Milne EN, Giuntini C |title=The chest roentgenogram in pulmonary edema |journal=Clin. Chest Med. |volume=6 |issue=3 |pages=315–44 |date=September 1985 |pmid=3907943 |doi= |url=}}</ref><ref name="pmid21219673">{{cite journal |vauthors=Murray JF |title=Pulmonary edema: pathophysiology and diagnosis |journal=Int. J. Tuberc. Lung Dis. |volume=15 |issue=2 |pages=155–60, i |date=February 2011 |pmid=21219673 |doi= |url=}}</ref>
#Thickening of the fissures
* [[Kerley B lines]] or thickening of the interlobular septa
#Cephalization
* [[Cephalization]]
#Increased vascular markings
* Increased [[cardio-thoracic ratio]]
#[[Interstitial edema]]
* [[Peribronchial cuffing]]
#[[Pleural effusion]]s
*Thickening of the fissures
*Increased vascular markings
*[[Interstitial edema]]
*Bat wing opacities 
===Kerley B Lines===
[[Kerley B lines]] are short parallel lines located at the lung periphery.
* Represent distended interlobular septa
* Usually less than 1 cm in length and parallel to one another at right angles to the [[pleura]]
* May be seen in any zone but are most frequently located at the lung bases
[[image:InkedChest radiograph of a lung with Kerley B lines - annotated LI.jpg|center|thumb|300px|Kerley B Lines By Mikael Häggström, via Wikimedia.org<ref><"//commons.wikimedia.org/wiki/User:Mikael_H%C3%A4ggstr%C3%B6m" title="User:Mikael Häggström">Mikael Häggström</ - <span class="int-own-work" lang="en">Own work</span>, <"http://creativecommons.org/publicdomain/zero/1.0/deed.en" title="Creative Commons Zero, Public Domain Dedication">CC0</, <"https://commons.wikimedia.org/w/index.php?curid=61595288"</ref>]]


==Cardiogenic Versus Noncardiogenic Pulmonary Edema==
===Cephalization===
==Cardiogenic Pulmonary Edema==
[[Cephalization on chest x-ray|Cephalization]] refers to the redistribution of blood into the upper lobe vessels.
[[Image:Interstitial edema.png|thumb|left]] Cardiogenic pulmonary edema can be distinguished from noncardiogenic pulmonary edema by the presence of redistribution of blood flow to the upper lobes (increased blood flow to the higher parts of the lung) and interstitial edema.
* Pulmonary venous pressure exceeds 10 to 12 mmHg results in cephalization
{{clr}}
Shown below is a chest x ray with the yellow arrow which demonstrate cephalization of blood vessels.
[[image:Upper-lobe-venous-diversion.jpg|center|thumb|300px|Cephalization - Case courtesy of <nowiki><a href="https://radiopaedia.org/">Radiopaedia.org</a></nowiki>. From the case <nowiki><a href="https://radiopaedia.org/cases/11838">rID: 11838</ref></nowiki>]]
===Increased cardio-thoracic ratio===
[[Cardio-thoracic ratio]] is useful for assessing an underlying cardiogenic cause of pulmunary edema.
* The cardiothoracic ratio is calculated by measuring the [[transverse diameter]] of the [[heart]] on a posterior/anterior chest X Ray,<nowiki/> and dividing it by the diameter of the [[thoracic cage]]


===Noncardiogenic Pulmonary Edema===
* A value > 0.5 or one half is consistent with enlargement of the heart
[[Image:Pulmonary alveolar edema.png|left|thumb]] In contrast, patchy alveolar infiltrates with air bronchograms are more indicative of noncardiogenic edema.{{clr}}
[[image:Cardiomegaly-3.jpg|center|thumb|300px|Increased cardio-thoracic ratio - Case courtesy of A.Prof Frank Gaillard, via Radiopaedia.org<ref>Radiopaedia.org. From the case <"https://radiopaedia.org/cases/12334">rID: 12334</ref>]]


==Correlation of Chest X-Ray Findings with Pulmonary Capillary Wedge Pressure==
===Peribronchial Cuffing===


*'''Normal''':5-10 mm Hg
[[Peribronchial cuffing]] is a radiologic sign, also referred to as peribronchial thickening or [[bronchial]] wall thickening.
*'''Cephalization''': 10-15 mm Hg
* Occurs when excess fluid buildup in the small [[airway]]
*'''Kerley B Lines''': 15-20 mm Hg
* Causes the area around the [[bronchus]] to appear more prominent on an X-ray
*'''Pulmonary Interstitial Edema''': 20-25 mm Hg
* Thin bronchial walls are thickened and take on a doughnut-like appearance
* '''Pulmonary Alveolar Edema''': > 25 mm Hg
Shown below is a chest x ray with the red arrows which demonstrate thickened bronchial walls that have a doughnut-like appearance.
[[Image:Pulm edema.jpg|300px|center|thumb|Peribronchial cuffing - By C Michael Gibson, via Wikimedia.org<ref><"https://www.wikidoc.org/index.php/File:Peribronchial_cuffing.png">File:Peribronchial cuffing.png at <"https://en.wikipedia.org/wiki/List_of_medical_wikis#WikiDoc" class="extiw" title="en:List of medical wikis">WikiDoc, <"https://creativecommons.org/licenses/by-sa/3.0" title="Creative Commons Attribution-Share Alike 3.0">CC BY-SA 3.0, <"https://commons.wikimedia.org/w/index.php?curid=65077075"></ref>]]
===Bat wing opacities===
'''Bat's wing''' or '''butterfly''' '''pulmonary opacities''' a radiologic sign.
* Bilateral perihilar shadowing
* Classically described on a frontal chest radiograph
Shown below is a chest x ray with the yellow arrow which demonstrate bat's wing.[[image:Bats-wings-of-pulmonary-oedema.jpg|center|thumb|300px|Bat wing opacities - Case courtesy of Dr Jeremy Jones, via Radiopaedia.org<ref>Radiopaedia.org From the case <"https://radiopaedia.org/cases/6463">rID: 6463</ref>]]


==Kerley B Lines==
===Differentiating Cardiogenic Versus Noncardiogenic Pulmonary Edema===
[[Kerley B lines]] are short parallel lines at the lung periphery. These lines represent distended interlobular septa, which are usually less than 1 cm in length and parallel to one another at right angles to the [[pleura]]. They are located peripherally in contact with the pleura, but are generally absent along fissural surfaces.  They may be seen in any zone but are most frequently observed at the lung bases at the costophrenic angles on the PA radiograph, and in the substernal region on lateral radiographs.
Cardiogenic pulmonary edema can be distinguished from noncardiogenic pulmonary edema by radiographic features.  
<gallery>
Image:Kerley B 001.jpg|Plain film: [[Mitral stenosis]], Kerley B lines
Image:Kerley B 002.jpg|Plain film: [[Mitral stenosis]], Kerley B lines
Image:Kerley B 003.jpg|Plain film: [[Mitral stenosis]], Kerley B lines
</gallery>


==Peribronchial Cuffing==
==== Cardiogenic Pulmonary Edema ====
[[Image:Peribronchial cuffing.png|thumb|left|The red arrows point to thickened bronchial walls that have a doughnut-like appearance.]] [[Peribronchial cuffing]] is an abnormality on a chest x-ray whereby the usually thin bronchial walls are thickened and take on a doughnut-like appearance.{{clr}}
* Presence of redistribution of blood flow to the upper lobes (increased blood flow to the higher parts of the lung)
* Interstitial edema
* Septal lines
* Peribronchial cuffing
* Pleural effusions


==Cephalization==
==== Noncardiogenic Pulmonary Edema ====
[[Image:Cephalization.png|left|thumb]]Cephalization refers to the redistribution of blood into the upper lobe vessels. It has been hypothesized that once the hydrostatic pressure exceeds 10 mm Hg, then fluid begins to leak into the interstitium of the lung. This excess fluid initially compresses the lower lobe vessels, perhaps as a result of gravity. After this, the upper lobe vessels are recruited to distribute a greater volume of blood. In order to carry a greater volume of blood, the upper lobe vessels increase in size.{{clr}}
* Patchy alveolar infiltrates 
* Air bronchograms 
<div class="center">
{| border="3"
|+  Radiographic Features That May Help to Differentiate Cardiogenic from Noncardiogenic Pulmonary Edema
! Radiographic Feature !! Cardiogenic Edema  !! Noncardiogenic Edema
|-
! Heart size
| Normal or greater than normal  || Usually normal
|-
! Septal lines
|Present
|Not usually present
|-
!Air bronchograms
|Not usually present  ||Usually present
|-
!Peribronchial cuffing
|Present  ||Not usually present
|-
!Pleural effusions
|Presens ||Not usually present
|-
!Distribution of edema
|Even or central ||Patchy or peripheral
|-
!Vascular distribution
|Balanced or inverted ||Normal or balanced
|}
</div>


==References==
==References==
{{Reflist|2}}
{{reflist|2}}


[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Physical examination]]
 
[[Category:Signs and symptoms]]
 
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Latest revision as of 14:45, 19 March 2018

Pulmonary edema Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Farnaz Khalighinejad, MD [2]

Overview

The diagnosis of pulmonary edema usually confirmed on X-ray, which shows increased fluid in the alveolar walls. Kerley B lines, increased vascular filling, pleural effusions, upper lobe diversion (increased blood flow to the higher parts of the lung) may be indicative of cardiogenic pulmonary edema, while patchy alveolar infiltrates with air bronchograms are more indicative of noncardiogenic edema.

Chest X Ray

An x-ray may be helpful in the diagnosis of pulmonary edema. Findings on an x-ray suggestive of pulmonary edema include:[1][2]

Kerley B Lines

Kerley B lines are short parallel lines located at the lung periphery.

  • Represent distended interlobular septa
  • Usually less than 1 cm in length and parallel to one another at right angles to the pleura
  • May be seen in any zone but are most frequently located at the lung bases
Kerley B Lines By Mikael Häggström, via Wikimedia.org[3]

Cephalization

Cephalization refers to the redistribution of blood into the upper lobe vessels.

  • Pulmonary venous pressure exceeds 10 to 12 mmHg results in cephalization

Shown below is a chest x ray with the yellow arrow which demonstrate cephalization of blood vessels.

Cephalization - Case courtesy of <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/11838">rID: 11838</ref>

Increased cardio-thoracic ratio

Cardio-thoracic ratio is useful for assessing an underlying cardiogenic cause of pulmunary edema.

  • A value > 0.5 or one half is consistent with enlargement of the heart
Increased cardio-thoracic ratio - Case courtesy of A.Prof Frank Gaillard, via Radiopaedia.org[4]

Peribronchial Cuffing

Peribronchial cuffing is a radiologic sign, also referred to as peribronchial thickening or bronchial wall thickening.

  • Occurs when excess fluid buildup in the small airway
  • Causes the area around the bronchus to appear more prominent on an X-ray
  • Thin bronchial walls are thickened and take on a doughnut-like appearance

Shown below is a chest x ray with the red arrows which demonstrate thickened bronchial walls that have a doughnut-like appearance.

Peribronchial cuffing - By C Michael Gibson, via Wikimedia.org[5]

Bat wing opacities

Bat's wing or butterfly pulmonary opacities a radiologic sign.

  • Bilateral perihilar shadowing
  • Classically described on a frontal chest radiograph

Shown below is a chest x ray with the yellow arrow which demonstrate bat's wing.

Bat wing opacities - Case courtesy of Dr Jeremy Jones, via Radiopaedia.org[6]

Differentiating Cardiogenic Versus Noncardiogenic Pulmonary Edema

Cardiogenic pulmonary edema can be distinguished from noncardiogenic pulmonary edema by radiographic features.

Cardiogenic Pulmonary Edema

  • Presence of redistribution of blood flow to the upper lobes (increased blood flow to the higher parts of the lung)
  • Interstitial edema
  • Septal lines
  • Peribronchial cuffing
  • Pleural effusions

Noncardiogenic Pulmonary Edema

  • Patchy alveolar infiltrates
  • Air bronchograms
Radiographic Features That May Help to Differentiate Cardiogenic from Noncardiogenic Pulmonary Edema
Radiographic Feature Cardiogenic Edema Noncardiogenic Edema
Heart size Normal or greater than normal Usually normal
Septal lines Present Not usually present
Air bronchograms Not usually present Usually present
Peribronchial cuffing Present Not usually present
Pleural effusions Presens Not usually present
Distribution of edema Even or central Patchy or peripheral
Vascular distribution Balanced or inverted Normal or balanced

References

  1. ↑ Pistolesi M, Miniati M, Milne EN, Giuntini C (September 1985). "The chest roentgenogram in pulmonary edema". Clin. Chest Med. 6 (3): 315–44. PMID 3907943.
  2. ↑ Murray JF (February 2011). "Pulmonary edema: pathophysiology and diagnosis". Int. J. Tuberc. Lung Dis. 15 (2): 155–60, i. PMID 21219673.
  3. ↑ <"//commons.wikimedia.org/wiki/User:Mikael_H%C3%A4ggstr%C3%B6m" title="User:Mikael Häggström">Mikael Häggström</ - Own work, <"http://creativecommons.org/publicdomain/zero/1.0/deed.en" title="Creative Commons Zero, Public Domain Dedication">CC0</, <"https://commons.wikimedia.org/w/index.php?curid=61595288"
  4. ↑ Radiopaedia.org. From the case <"https://radiopaedia.org/cases/12334">rID: 12334
  5. ↑ <"https://www.wikidoc.org/index.php/File:Peribronchial_cuffing.png">File:Peribronchial cuffing.png at <"https://en.wikipedia.org/wiki/List_of_medical_wikis#WikiDoc" class="extiw" title="en:List of medical wikis">WikiDoc, <"https://creativecommons.org/licenses/by-sa/3.0" title="Creative Commons Attribution-Share Alike 3.0">CC BY-SA 3.0, <"https://commons.wikimedia.org/w/index.php?curid=65077075">
  6. ↑ Radiopaedia.org From the case <"https://radiopaedia.org/cases/6463">rID: 6463


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