Pulmonary edema chest x ray
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Editor-In-Chief: C. Michael Gibson, M.S., M.D.  Associate Editor(s)-in-Chief: Farnaz Khalighinejad, MD 
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:
- Kerley B lines or thickening of the interlobular septa
- 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
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.
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
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.
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.
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 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|
- ↑ 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.
- ↑ Murray JF (February 2011). "Pulmonary edema: pathophysiology and diagnosis". Int. J. Tuberc. Lung Dis. 15 (2): 155–60, i. PMID 21219673.
- ↑ <"//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"
- ↑ Radiopaedia.org. From the case <"https://radiopaedia.org/cases/12334">rID: 12334
- ↑ <"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">
- ↑ Radiopaedia.org From the case <"https://radiopaedia.org/cases/6463">rID: 6463