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Pulmonary Pulmonary EdemaEdema
Pathophysiological ConsiderationsPathophysiological Considerations Manifestations on Chest Radiography Manifestations on Chest Radiography
Kathryn Glassberg MS4Kathryn Glassberg MS4
February 2006February 2006
Pulmonary Edema: Pulmonary Edema: OverviewOverview
Pathophysiology : Edema as an end Pathophysiology : Edema as an end result of a multitude of diverse insults result of a multitude of diverse insults (not just heart failure vs. ARDS!) (not just heart failure vs. ARDS!)
Physiologic approach for radiologic Physiologic approach for radiologic evaluation of edemaevaluation of edema Hydrostatic edemaHydrostatic edema Permeability edema +/- diffuse alveolar Permeability edema +/- diffuse alveolar
damagedamage Mixed permeability and hydrostatic edemaMixed permeability and hydrostatic edema
Pulmonary EdemaPulmonary Edema
Edema occurs when physiologic resorption Edema occurs when physiologic resorption of fluid via lymphatics is overwhelmed of fluid via lymphatics is overwhelmed
Causes usually divided into “hydrostatic” Causes usually divided into “hydrostatic” and “increased capillary permeability”, but and “increased capillary permeability”, but both mechanisms can occur in the same both mechanisms can occur in the same patient!patient!
Chest radiography, when combined with Chest radiography, when combined with clinical data, helps distinguish pathologic clinical data, helps distinguish pathologic cause in vast majority of casescause in vast majority of cases
Causes of Pulmonary Causes of Pulmonary EdemaEdema11
HydrostaticHydrostatic
Cardiac: Left heart failureCardiac: Left heart failure NoncardiacNoncardiacIncreased transmural
capillary pressureIncreased transmural
capillary pressureLymphatic block: lymphangitis, carcinomitosis, lymphangiectasia
Lymphatic block: lymphangitis, carcinomitosis, lymphangiectasia
Increased intracapillary pressure:neurogenic, hyperperfusion (high altitude,
postembolic, post transplant)
Increased intracapillary pressure:neurogenic, hyperperfusion (high altitude,
postembolic, post transplant)
Lowered extracapillary pressure: reexpansion edema,
postglottic spasm
Lowered extracapillary pressure: reexpansion edema,
postglottic spasm
Oncotic: nutritional, near-drowningOncotic: nutritional, near-drowning
Combined hemodynamic/oncotic: renal failure, overhydration
Combined hemodynamic/oncotic: renal failure, overhydration
Causes of Pulmonary Causes of Pulmonary EdemaEdema11
Increased capillary permeability
Increased capillary permeability
InjuryInjuryNoninjury:
Allergic, endocrineNoninjury:
Allergic, endocrine
Extracapillary (alveolar insult): Inhalation, aspiration, infection
Extracapillary (alveolar insult): Inhalation, aspiration, infection
IntracapillaryIntracapillary
“Trauma”: sepsis, hypotension,
Pancreatitis, DIC
“Trauma”: sepsis, hypotension,
Pancreatitis, DIC
Embolism: fat, air, amniotic fluid
Embolism: fat, air, amniotic fluid
Pathophysiology Pathophysiology overviewoverview22
Normally, excess Normally, excess hydrostatic hydrostatic transudate from transudate from pulmonary pulmonary capillaries is capillaries is filtered into filtered into peribronchovasculperibronchovascular lymphatics and ar lymphatics and removedremoved
Pathophysiology Pathophysiology overviewoverview22
In hydrostatic edema, In hydrostatic edema, transudatetransudate accumulates in the accumulates in the interstitum initially, interstitum initially, only entering alveoli in only entering alveoli in severe cases severe cases
In permeability edema In permeability edema associated with diffuse associated with diffuse alveolar damage alveolar damage (DAD), (DAD), exudateexudate fills fills the interstitum and the interstitum and the alveolithe alveoli
Hydrostatic EdemaHydrostatic Edema33
The lungs can accommodate The lungs can accommodate increases in fluid: the lymphatic increases in fluid: the lymphatic flow can increase 3-10x before flow can increase 3-10x before edema developsedema develops
Higher hydrostatic pressures Higher hydrostatic pressures force fluid through endothelial force fluid through endothelial cell pores, but the tighter cell pores, but the tighter junctions of epithelial cells junctions of epithelial cells prevent fluid from entering prevent fluid from entering alveoli until pulmonary capillary alveoli until pulmonary capillary pressures reach ~ 40 mm Hg, pressures reach ~ 40 mm Hg, causing stress failurecausing stress failure
Hydrostatic Edema: Hydrostatic Edema: radiologic manifestationsradiologic manifestations33
Earliest sign: vascular indistinctnessEarliest sign: vascular indistinctness Bronchial wall thickening/peribronchial Bronchial wall thickening/peribronchial
cuffingcuffing Septal lines: Kerley A, B, CSeptal lines: Kerley A, B, C Thickened fissuresThickened fissures Severe edema: dependent ground glass Severe edema: dependent ground glass
opacities reflecting alveolar involvementopacities reflecting alveolar involvement Often associated with bilateral Often associated with bilateral
transudative pleural effusionstransudative pleural effusions
Hydrostatic Edema: Hydrostatic Edema: radiologic manifestationsradiologic manifestations33
““Cephalization” or “inversion” not Cephalization” or “inversion” not specific for edemaspecific for edema Reflects chronic pulmonary venous changes Reflects chronic pulmonary venous changes
in patients with left-sided heart failurein patients with left-sided heart failure Vascular pedicle widthVascular pedicle width
patients with volume overload often have patients with volume overload often have widened vascular pedicles when compared widened vascular pedicles when compared to previous studiesto previous studies
However, patients can certainly have However, patients can certainly have hydrostatic edema despite a narrow hydrostatic edema despite a narrow pedicle, thus this sign can be misleadingpedicle, thus this sign can be misleading
Vascular indistinctnessVascular indistinctnessNormal
Edema
Images courtesy of Dr. Marc Gosselin
Vascular IndistinctnessVascular IndistinctnessNormal
Edema
Images courtesy of Dr. Marc Gosselin
Peribronchial cuffingPeribronchial cuffing
Images shown Images shown are pre- and are pre- and post-treatment post-treatment for hydrostatic for hydrostatic edemaedema
Arrowheads Arrowheads point to Kerley A point to Kerley A lineslines
Septal LinesSeptal Lines33
The presence of septal lines reflects fluid The presence of septal lines reflects fluid accumulation between the lung lobulesaccumulation between the lung lobules
Kerley linesKerley lines A: long, diagonal, centralA: long, diagonal, central B: short, horizontal, extend to lateral pleural B: short, horizontal, extend to lateral pleural
surfacessurfaces C: reticular pattern of ~ 1 cm polygons C: reticular pattern of ~ 1 cm polygons
representing septal lines viewed on end representing septal lines viewed on end (I’ve heard Dr. Kerley is the only one who (I’ve heard Dr. Kerley is the only one who has ever really seen these…)has ever really seen these…)
Septal LinesSeptal Lines
Septal lines Septal lines in a patient in a patient with cardiac with cardiac failurefailure
Septal LinesSeptal Lines
Lateral view of Lateral view of same patient– same patient– note fluid in note fluid in both fissuresboth fissures
Septal LinesSeptal Lines
All three All three Kerleys Kerleys claim to be claim to be present; present; can you can you find them?find them?
Septal LinesSeptal Lines
Even in you Even in you can’t name can’t name the lines, you the lines, you can see that can see that this patient this patient has severe has severe hydrostatic hydrostatic edema in edema in need of need of treatment!treatment!
A
B
C?
Evolving hydrostatic Evolving hydrostatic edemaedema44
33 year-old 33 year-old with AML with AML admitted for admitted for renal failure renal failure and fluid and fluid overloadoverload
Evolving hydrostatic Evolving hydrostatic edemaedema44
Arrows indicate Arrows indicate peri-bronchial peri-bronchial cuffingcuffing
Note increasing Note increasing size of azygous size of azygous veinvein
Evolving hydrostatic Evolving hydrostatic edemaedema44
Arrowheads Arrowheads indicate septal indicate septal lineslines
Note ground-Note ground-glass, glass, indicating indicating alveolar edemaalveolar edema
Permeability EdemaPermeability Edema
multiple insults can cause increased multiple insults can cause increased pulmonary vessel permeability pulmonary vessel permeability resulting in leakage of fluid AND resulting in leakage of fluid AND proteinprotein
In its most severe form, the disease In its most severe form, the disease is a combination of vessel is a combination of vessel permeability and DAD, leading to the permeability and DAD, leading to the acute respiratory distress syndrome acute respiratory distress syndrome (ARDS)(ARDS)
ARDS pathologyARDS pathology33
Acutely, exudative Acutely, exudative edema in the edema in the alveoli causes alveoli causes hyaline membrane hyaline membrane formationformation
Type II epithelial Type II epithelial cells then cells then proliferate and, proliferate and, usually, fibrosis usually, fibrosis occursoccurs
ARDS: Radiologic ARDS: Radiologic manifestationsmanifestations33
Patchy, diffuse ground glass opacitiesPatchy, diffuse ground glass opacities Pattern of opacification does not change Pattern of opacification does not change
with position change, as the exudates are with position change, as the exudates are trapped in alveolitrapped in alveoli
Septal lines, peribronchial cuffing, and Septal lines, peribronchial cuffing, and thick fissures are usually ABSENTthick fissures are usually ABSENT
In severe cases, air bronchograms can be In severe cases, air bronchograms can be seenseen
Good rule of thumb: presence of ET tube!Good rule of thumb: presence of ET tube!
ARDS: Radiologic ARDS: Radiologic manifestationsmanifestations33
Caution: While a normal sized heart Caution: While a normal sized heart and narrow vascular pedicle are and narrow vascular pedicle are helpful signs, neither is specific for helpful signs, neither is specific for injury edemainjury edema
ARDS ARDS
Patchy Patchy diffuse diffuse ground glassground glass
Air Air bronchogrambronchogramss
ET tubeET tube
Permeability Edema Permeability Edema without DADwithout DAD33
Seen in IL-2 therapy for metastatic Seen in IL-2 therapy for metastatic disease, hantavirus pulmonary disease, hantavirus pulmonary syndromesyndrome
Severe capillary permeability Severe capillary permeability without alveolar involvementwithout alveolar involvement
Radiographically, resembles Radiographically, resembles hydrostatic edema (septal lines, hydrostatic edema (septal lines, peribronchial cuffing) because peribronchial cuffing) because alveolar epithelium remains intactalveolar epithelium remains intact
Mixed hydrostatic and Mixed hydrostatic and permeability edemapermeability edema
High-altitude pulmonary edemaHigh-altitude pulmonary edema Neurogenic edemaNeurogenic edema Reexpansion and post-obstructiveReexpansion and post-obstructive
High-altitude pulmonary High-altitude pulmonary edema (HAPE)edema (HAPE)33
Hypoxia causes non-uniform Hypoxia causes non-uniform pulmonary vasoconstriction, leaving pulmonary vasoconstriction, leaving other lung units over-perfused and other lung units over-perfused and predisposed to edemapredisposed to edema
Higher pressures can result in some Higher pressures can result in some capillary damage and stress failurecapillary damage and stress failure
High-altitude pulmonary High-altitude pulmonary edemaedema33
Radiographs show Radiographs show patchy ground patchy ground glass with a glass with a central distribution central distribution favoring favoring peribronchial peribronchial cuffing and cuffing and vascular vascular indistinctness over indistinctness over septal linesseptal lines
Neurogenic EdemaNeurogenic Edema33
Pathophysiology similar to HAPE– Pathophysiology similar to HAPE– neural mechanisms result in non-neural mechanisms result in non-uniform vasoconstrictionuniform vasoconstriction
High protein content of fluid High protein content of fluid indicates capillary leakage involved indicates capillary leakage involved as wellas well
Neurogenic EdemaNeurogenic Edema33
Classically, neurogenic edema has Classically, neurogenic edema has an upper lobe predominance; an upper lobe predominance; however, it can present with any however, it can present with any patternpattern
Often clears rapidly, arguing for Often clears rapidly, arguing for intact alveoliintact alveoli
Neurogenic EdemaNeurogenic Edema44
54 year-old 54 year-old woman with woman with intracranial intracranial hemorrhagehemorrhage
Note upper Note upper lobe lobe predominancepredominance
Reexpansion and Reexpansion and Postobstructive EdemaPostobstructive Edema33
Both occur in setting of high negative Both occur in setting of high negative pleural pressurepleural pressure
Reexpansion: usually seen as localized Reexpansion: usually seen as localized lung injury, with alveolar filling and lung injury, with alveolar filling and exudative fluid, arguing for increased exudative fluid, arguing for increased permeability as a causepermeability as a cause
Postobstructive: pattern usually Postobstructive: pattern usually hydrostatic, secondary to increased hydrostatic, secondary to increased central blood volume caused by the relief central blood volume caused by the relief of obstructionof obstruction
Reexpansion EdemaReexpansion Edema44
Right pneumothorax One-hour post chest-tube placement
Postobstructive EdemaPostobstructive Edema44
Postextubation Laryngospasm: note Postextubation Laryngospasm: note central distribution and central distribution and peribronchial cuffing.peribronchial cuffing.
ConclusionsConclusions Hydrostatic Edema is characterized by Hydrostatic Edema is characterized by
Vascular indistinctnessVascular indistinctness Peribronchial cuffingPeribronchial cuffing Septal lines/fissure thickeningSeptal lines/fissure thickening
Permeability Edema with DAD (ARDS) is Permeability Edema with DAD (ARDS) is characterized bycharacterized by Diffuse, patchy ground glass opacitiesDiffuse, patchy ground glass opacities Air bronchogramsAir bronchograms
Overlap is seen in pathophysiology, thus Overlap is seen in pathophysiology, thus can be reflected in the radiographcan be reflected in the radiograph
Summary TableSummary Table11
HydrostaticHydrostatic Permeability Permeability with DADwith DAD
Heart sizeHeart size Often enlargedOften enlarged Usually not Usually not enlarged enlarged
Septal LinesSeptal Lines CommonCommon AbsentAbsent
Peribronchial Peribronchial cuffscuffs
CommonCommon Not commonNot common
Air Air bronchogramsbronchograms
Not commonNot common Very commonVery common
Regional Regional distributiondistribution
Even or centralEven or central Patchy or Patchy or peripheralperipheral
Hydrostatic and Hydrostatic and Permeability EdemaPermeability Edema
Images courtesy of Dr. Marc Gosselin
““The condition of the capillary The condition of the capillary endothelium and that of the endothelium and that of the
alveolar epithelium are the main alveolar epithelium are the main determinants”determinants”33
ReferencesReferences11Milne ENC and Massimo P. Milne ENC and Massimo P. Reading the Chest Reading the Chest
Radiograph: A Physiologic Approach.Radiograph: A Physiologic Approach. Mosby, Mosby, 1993.1993.
22Ware LB and Matthay MA. Acute pulmonary Ware LB and Matthay MA. Acute pulmonary edema. edema. The New England Journal of Medicine. The New England Journal of Medicine. 2005; 353: 2788-96. 2005; 353: 2788-96.
33Ketai LH and Godwin JD. A new view of pulmonary Ketai LH and Godwin JD. A new view of pulmonary edema and acute respiratory distress syndrome. edema and acute respiratory distress syndrome. Journal of Thoracic ImagingJournal of Thoracic Imaging. 1998; 13: 147-171.. 1998; 13: 147-171.
44Gluecker T. Capasso P. Schnyder P. Gudinchet F. Gluecker T. Capasso P. Schnyder P. Gudinchet F. Schaller MD. Revelly JP. Chiolero R. Vock P. Schaller MD. Revelly JP. Chiolero R. Vock P. Wicky S. Wicky S. Clinical and radiologic features of pulmonary edema. Radiographics. Radiographics. 19(6):1507-31; 19(6):1507-31; discussion 1532-3, 1999 Nov-Dec. discussion 1532-3, 1999 Nov-Dec.
ReferencesReferences
Images taken from: Images taken from: myweb.lsbu.ac.ukmyweb.lsbu.ac.uk/ ~/ ~dirt/museum/p6-71.htmldirt/museum/p6-71.html www.bcm.eduwww.bcm.edu/.../cases/ pediatric/text/7a-desc.htm/.../cases/ pediatric/text/7a-desc.htm http://www.hcoa.org/hcoacme/chf-cme/chf00030.htmhttp://www.hcoa.org/hcoacme/chf-cme/chf00030.htm http://www-medlib.med.utah.edu/WebPath/LUNGHTML/LUNG131.htmlhttp://www-medlib.med.utah.edu/WebPath/LUNGHTML/LUNG131.html http://www-medlib.med.utah.edu/WebPath/LUNGHTML/LUNG133.htmlhttp://www-medlib.med.utah.edu/WebPath/LUNGHTML/LUNG133.html http://www.lumen.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/CXR/atlas/http://www.lumen.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/CXR/atlas/
images/310a1.jpgimages/310a1.jpg www.high-altitude-medicine.com/ AMS-medical.html www.high-altitude-medicine.com/ AMS-medical.html Sherman SC. Reexpansion pulmonary edema: a case report and review of the Sherman SC. Reexpansion pulmonary edema: a case report and review of the
current literature. current literature. Journal of Emergency Medicine.Journal of Emergency Medicine. Jan 2003; 24(1): 23-7. Jan 2003; 24(1): 23-7.
Thanks to Dr. Marc Gosselin for Thanks to Dr. Marc Gosselin for images, insightsimages, insights