Pulm Edema Nav

7/29/2019 Pulm Edema Nav

1/20

CASE PRESENTATION

35 years old male from CCU

c/c chest pain and SOB for 3 daysClinically having ACS with anterior

wall MI with CCF

CXR PA view done.


2/20

B/L symmetrical alveolar opacities present in perihilar region

giving bat wing appearance with sparing of periphery.


3/20

IMPRESSION

ACS with anterior wall MI with CCF(clinically)

with pulmonary edema(on CXR).


4/20

Pulmonary oedema

Pulmonary oedema is a broad descriptive

term and is usually defined as an abnormal

accumulation of fluid in the extra-vascular

compartments of the lung.


5/20

Pathophysiology One method of classifying pulmonary oedema is as four

main categories on the basis of pathophysiology which

include increased hydrostatic pressure oedema

two pathophysiological and radiological phases are recognizedin the development of pressure oedema

interstitial oedema

alveolar flooding or oedema these phases are virtually identical for left-sided heart

failure and fluid overload

permeability oedema with diffuse alveolar damage (DAD)

permeability oedema without diffuse alveolar damage

mixed edema due to simultaneous increased hydrostaticpressure and permeability changes
http://radiopaedia.org/articles/missing?article[title]=left-sided+heart+failurehttp://radiopaedia.org/articles/missing?article[title]=fluid+overloadhttp://radiopaedia.org/articles/missing?article[title]=left-sided+heart+failurehttp://radiopaedia.org/articles/missing?article[title]=left-sided+heart+failurehttp://radiopaedia.org/articles/missing?article[title]=fluid+overloadhttp://radiopaedia.org/articles/missing?article[title]=fluid+overloadhttp://radiopaedia.org/articles/missing?article[title]=left-sided+heart+failurehttp://radiopaedia.org/articles/missing?article[title]=left-sided+heart+failurehttp://radiopaedia.org/articles/missing?article[title]=left-sided+heart+failurehttp://radiopaedia.org/articles/missing?article[title]=left-sided+heart+failure


6/20

CausesCardiogenic pulmonary edema.

Heart failure

Coronary artery disease with left ventricular failure.

Cardiac arrhythmias Fluid overload -- for example, kidney failure.

Cardiomyopathy

Obstructing valvular lesions -- for example, mitral stenosis

Myocarditis and infectious endocarditis

Non-cardiogenic pulmonary edema -- due to changes in capillary permeability

Smoke inhalation.

Head trauma

Overwhelming sepsis.

Hypovolemia shock

Re-expansion

By drainage of a large pleural effusion with thoracentesis Of the lung collapsed by a large pneumothorax

High altitude pulmonary edema

Disseminated intravascular coagulopathy (DIC)

Near-drowning

Overwhelming aspiration

Adult (acute) respiratory distress (deficiency) syndrome (ARDS)
http://www.learningradiology.com/archives03/COW%20072-Mitral%20stenosis/mscorrect.htmhttp://www.learningradiology.com/archives/COW%20019-Re-expansion%20pulm%20edema/reexpulmedemacorrect.htmhttp://www.learningradiology.com/archives06/COW%20211-Aspiration%20pneumonia/aspirationcorrect.htmhttp://www.learningradiology.com/lectures/chestlectures/ardrsppt_files/frame.htmhttp://www.learningradiology.com/lectures/chestlectures/ardrsppt_files/frame.htmhttp://www.learningradiology.com/archives06/COW%20211-Aspiration%20pneumonia/aspirationcorrect.htmhttp://www.learningradiology.com/archives/COW%20019-Re-expansion%20pulm%20edema/reexpulmedemacorrect.htmhttp://www.learningradiology.com/archives/COW%20019-Re-expansion%20pulm%20edema/reexpulmedemacorrect.htmhttp://www.learningradiology.com/archives/COW%20019-Re-expansion%20pulm%20edema/reexpulmedemacorrect.htmhttp://www.learningradiology.com/archives03/COW%20072-Mitral%20stenosis/mscorrect.htmhttp://www.learningradiology.com/archives03/COW%20072-Mitral%20stenosis/mscorrect.htm


7/20

Pulmonary oedema grading One grading system ofpulmonary oedema based

on chest radiograph appearances and pulmonarycapillary wedge pressure (PCWP) is as.

grade 0 : normal chest radiograph - PCWP 8 -12mmHg

grade 1: shows evidence of upper lobe diversionon a chest radiograph - PCWP 13- 18 mmHg

grade 2 : shows interstitial oedema on a chest

radiograph : PCWP 19 - 25 mmHg grade 3 : shows alveolar oedema on a chest

radiograph : PCWP > 25 mmHg
http://radiopaedia.org/articles/pulmonary-oedemahttp://radiopaedia.org/articles/pulmonary-oedemahttp://radiopaedia.org/articles/pulmonary-oedema


8/20

Imaging Findings

The key findings ofpulmonary interstitial edema: Kerley B lines (septal lines) Seen at the lung bases, usually no more than 1 mm thick and 1 cm

long, perpendicular to the pleural surface.

Pleural effusions Usually bilateral, frequently the right side being larger than the left

If unilateral, more often on the right.

Fluid in the fissures Thickening of the major or minor fissure.

Peribronchial cuffing

Visualization of small doughnut-shaped rings representing fluid inthickened bronchial walls.

Collectively, the above four findings comprisepulmonaryinterstitial edema.


9/20

Increased hydrostatic pressure edema in a 33-year-old man with acute

myelocytic leukemia who was admitted for fluid overload with renal and

cardiac failure.chest radiograph demonstrate progressive lobar vessel

enlargement, peribronchial cuffing (arrows).


10/20

Fluid in the major or minor fissure(shown here) produces thickening of thefissure beyond the pencil-point

thickness it can normally attain.

Cephalization meanspulmonary venoushypertension,


11/20

Kerley B Lines are short, white linesperpendicular to the pleural surfaceat the lung base.

Peribronchial cuffing results whenfluid-thickened bronchial wallsbecome visible producing doughnut-like densities in the lung parenchyma


12/20

Pulmonary alveolar edema(Bat Wing

Edema) refers to a central, nongravitational distribution

of alveolar edema.

It is seen in less than 10% of cases of pulmonary

edema and generally occurs with rapidlydeveloping severe cardiac failure as seen in acutemitral insufficiency (associated with papillarymuscle rupture, massive myocardial infarct, and

valve leaflet destruction due to septicendocarditis) or renal failure. In bat wing edema,the lung cortex is free of alveolar or interstitialfluid.


13/20

Bat wing edema in a 71-year-old woman with fluid overload and

cardiac failure. Chest radiograph (a) and high-resolution CT

scan(b) demonstrate bat wing alveolar edema with a central

distribution and sparing of the lung cortex.


14/20

Differential diagnosis

General imaging differential considerationsinclude

diffuse pulmonary haemorrhage : has no

dependent gradient and usually no pleural

effusion.

diffuse pulmonary infection : usually there is

no dependent gradient.can involve any part of

lung.
http://radiopaedia.org/articles/diffuse-pulmonary-haemorrhagehttp://radiopaedia.org/articles/missing?article[title]=diffuse+pulmonary+infectionhttp://radiopaedia.org/articles/missing?article[title]=diffuse+pulmonary+infectionhttp://radiopaedia.org/articles/missing?article[title]=diffuse+pulmonary+infectionhttp://radiopaedia.org/articles/diffuse-pulmonary-haemorrhage


15/20

SPOTTER


16/20

Intraosseous lipomaseen in fouth decade

a clump of dystrophic calcification may be seen within the osteolytic lesion

on plain radiographs and CT scans target or doughnut shaped sequestrum.

The calcification represents infarcted fat.

D/D on X RAY: Simple bone cyst :3-14 years of age

Chondroblastoma

well marginated, round to oval,osteolytic lesion.The tumor matrix often containscalcification, which is better appreciated on CT scans.Occasionally, the tumor may have multiloculatedappearance.

Enchondroma.- children and young adults. one orseveral, round or oval areas of decreased radiopacityare seen in the calcaneum. The lesions have well-defined margins. The tumor matrix is often calcified.


17/20

THANK YOU

REFERENCES:

http://radiographics.rsna.org/content/19/6/1

507.full.

http://www.learningradiology.com/
http://radiographics.rsna.org/content/19/6/1507.fullhttp://radiographics.rsna.org/content/19/6/1507.fullhttp://radiographics.rsna.org/content/19/6/1507.fullhttp://radiographics.rsna.org/content/19/6/1507.fullhttp://radiographics.rsna.org/content/19/6/1507.fullhttp://radiographics.rsna.org/content/19/6/1507.fullhttp://radiographics.rsna.org/content/19/6/1507.full


18/20


19/20

Cardiogenic and non cardiogenic

pumonary edema In NCPE, the initial site of fluid accumulation is the pulmonary

interstitium including peribronchial cuffs and septal lines. This typeof edema appears predominantly as alveolar filling, since thealtered (disrupted) alveolar-capillary membrane allows for thedirect accumulation in the air spaces of fluid that is tooproteinaceous to be cleared via the interstitium. In contrast, incardiogenic pulmonary edema filling of air spaces (alveolarflooding) occurs when the interstitial space is finally overwhelmed.

2. Kerley lines are never seen in increased permeability edemawhereas they are a common finding in cardiogenic. The appearanceof Kerley lines in NCPE, indicates the coexistence of cardiogenic

pulmonary edema. 3. Patchy or peripheral pattern of edema is relatively specific for

NCPE. Air bronchograms are frequently seen in patients with NCPE.


20/20

In cardiogenic pulmonary edema thedistribution of edema is central and pleuraleffusion usually coexists.

5. In NCPE, cardiac size, vascular pedicle widthand pulmonary blood volume are usuallynormal. On the contrary, in cardiogenicpulmonary edema cardiac size is increased,vascular pedicle width is enlarged and there isinverted distribution of blood flow.

Documents

Pulm Edema Nav