Pulmonary edema chest x ray

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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 is confirmed on X-ray of the lungs, 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:

• Kerley B lines or thickening of the interlobular septa
• Cephalization
• Increased cardio-thoracic ratio
• Peribronchial cuffing
• 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

Kerley B Lines By Mikael Häggström, via Wikimedia.org

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 Dr Usman Bashir, via Radiopaedia.org

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, and dividing it by the diameter of the thoracic cage.

• 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

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

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

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