Sepsis chest x ray
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American Roentgen Ray Society Images of Sepsis chest x ray |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2] Jason Le, B.S.[3]
Synonyms and keywords: sepsis syndrome; septic shock; septicemia
Sepsis chest X-ray
Chest radiography (CXR) is a rapid, portable first-line imaging study in patients with suspected sepsis, particularly when a pulmonary source is suspected or no alternative source is apparent. There is no chest radiographic finding specific for sepsis. CXR is used primarily to identify a pulmonary source of infection, detect sepsis-associated lung injury including acute respiratory distress syndrome (ARDS), and assess the position of support devices and complications such as pneumothorax.[1][2]
The IDSA/multidisciplinary emergency-sepsis consensus task force supports chest imaging, usually CXR, together with urinalysis as default source evaluation when sepsis is suspected and there is no clear alternative source. The 2024 American College of Radiology (ACR) Appropriateness Criteria rate CXR as an appropriate initial study both when respiratory symptoms are present and when no localizing symptoms are available.[2][1]
Diagnostic performance
- In emergency department patients admitted to the intensive care unit with severe sepsis or septic shock, initial CXR had a sensitivity of 58% (95% CI 46%-68%) and specificity of 91% (95% CI 81%-95%) for pneumonia. The high specificity but limited sensitivity means that a positive study supports a pulmonary source, whereas a normal study does not exclude one.[1]
- Against chest CT as the reference standard, CXR sensitivity for pulmonary opacities is approximately 43.5% with specificity approximately 93%.[3]
- In critically ill patients with respiratory symptoms, pooled CXR sensitivity is only 49% (95% CI 40%-58%) with specificity 92% (86%-95%) compared with CT.[4][5]
- Interobserver reliability for CXR interpretation is suboptimal, including recognition of bilateral opacities meeting the imaging criterion for ARDS, and is not reliably improved by structured training.[6]
- Early pulmonary infiltrates may be absent and can appear later in the course of infection. Dehydration, neutropenia, and very early infection can contribute to a falsely normal CXR.[7]
Common radiographic findings
- Airspace consolidation or infiltrates are the most common radiographic findings when a pulmonary source is present. Patterns include lobar or segmental consolidation, multifocal bronchopneumonia, and interstitial abnormalities. These findings are nonspecific and can also occur with atelectasis, pulmonary edema, or aspiration.[3][7]
- Pleural effusion may accompany pneumonia. Blunting of the costophrenic angle on an upright PA radiograph generally requires approximately 175-200 mL of fluid. Loculated parapneumonic effusion or empyema may require source control and can be missed on supine ICU radiographs; ultrasound or CT is useful when the radiograph is equivocal.[8][9]
- Bilateral pulmonary opacities may indicate sepsis-associated ARDS. The classic ARDS pattern is bilateral, often patchy or diffuse alveolar opacities without cardiomegaly or substantial pleural effusion.[10][11]
- Cavitation, lung abscess, or a mass-like appearance may suggest particular infectious etiologies or alternative diagnoses and should prompt further evaluation when clinically appropriate.[3]
- Support-device evaluation should include assessment of endotracheal tube depth, central venous catheter tip position, and iatrogenic pneumothorax on films obtained in acutely ill septic patients.[1]
Acute respiratory distress syndrome imaging
For ARDS, the imaging criterion is bilateral opacities not fully explained by pleural effusions, lobar or lung collapse, or nodules or masses, with hydrostatic pulmonary edema from cardiac failure or fluid overload excluded as the primary explanation.[12][13]
The 2024 New Global Definition retains bilateral pulmonary opacities as an imaging criterion and accepts lung ultrasound as an alternative imaging modality when appropriate expertise is available.[12] Recognition of qualifying ARDS opacities on CXR is imperfect and varies between observers; therefore, CXR findings should be interpreted with the clinical context rather than used as the sole determinant of ARDS diagnosis.[6]
Distinguishing cardiogenic from non-cardiogenic pulmonary edema
Left ventricular failure should be considered before bilateral pulmonary opacities are attributed to sepsis-associated lung injury. Radiographic features favoring cardiogenic pulmonary edema include cardiomegaly, vascular redistribution or pulmonary vascular congestion, peribronchovascular cuffing, Kerley B lines, central ("bat-wing") airspace opacity, and pleural effusions. Non-cardiogenic edema/ARDS more often produces patchy bilateral infiltrates with air bronchograms without cardiomegaly or vascular engorgement.[11][14]
These radiographic features are helpful but imperfect. Integrate CXR findings with the clinical context and, when needed, natriuretic peptides and echocardiography rather than relying on radiography alone to distinguish hydrostatic from non-cardiogenic edema.[14]
When to go beyond the chest radiograph
- CT chest should be considered when CXR is normal or equivocal but a pulmonary source remains suspected, when complications such as empyema, abscess, or cavitation are suspected, when an alternative diagnosis such as pulmonary embolism is being considered, or in selected immunocompromised patients. CT is more sensitive than CXR for pulmonary abnormalities and may identify pneumonias missed on radiography.[7][1]
- Lung ultrasound (LUS) can be used as an alternative or adjunct to CXR when appropriate expertise is available. Recent evidence supports high diagnostic sensitivity for pneumonia and pleural abnormalities, but performance is operator-dependent and a negative examination does not completely exclude pneumonia.[15][16]
Clinically actionable points
- Obtain an initial CXR in patients with suspected sepsis who have respiratory symptoms or when no source is apparent, as part of source evaluation. Imaging should not delay time-critical sepsis evaluation or antimicrobial therapy in an unstable patient.[1][2]
- Treat a normal CXR as non-exclusionary. If clinical suspicion for pneumonia or another pulmonary source remains high, consider CT or LUS according to clinical circumstances and local expertise.[7][4][16]
- Assess for pleural effusion, empyema, abscess, and other complications that may require source control; use ultrasound or CT when the radiograph is equivocal or obtained in the supine position.[8][9]
- For bilateral pulmonary opacities, evaluate for ARDS while considering and clinically excluding cardiogenic or other hydrostatic pulmonary edema.[12][14]
- Review support-device position and complications on every relevant film, including endotracheal tube and central venous catheter position and evidence of pneumothorax.[1]
High-yield clinical pearls
- CXR is more useful for supporting a pulmonary source than excluding one because sensitivity is limited despite relatively high specificity.[1]
- Bilateral opacities without cardiomegaly or substantial pleural effusion should raise suspicion for sepsis-associated ARDS, but radiographic findings alone do not establish the diagnosis.[12][11]
- Early pulmonary infiltrates may be absent, particularly with very early infection, dehydration, or neutropenia.[7]
- CXR interpretation has suboptimal interobserver reliability; correlate findings with the clinical presentation and obtain formal radiologic interpretation when appropriate.[6]
Common pitfalls
- Using a normal CXR to exclude pneumonia or another pulmonary source.[7][4]
- Missing small or loculated pleural effusions/empyema on supine ICU radiographs.[8][9]
- Attributing bilateral pulmonary opacities to ARDS without considering hydrostatic/cardiogenic edema.[14]
- Delaying time-critical sepsis evaluation or antimicrobial therapy in an unstable patient solely to obtain imaging.[2]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Brixey AG, Fung A, De Leon AD; et al. (2024). "ACR Appropriateness Criteria® Sepsis". Journal of the American College of Radiology. 21 (6S): S292–S309. doi:10.1016/j.jacr.2024.02.029.
- ↑ 2.0 2.1 2.2 2.3 Yealy DM, Mohr NM, Shapiro NI; et al. (2021). "Early Care of Adults With Suspected Sepsis in The Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report". Annals of Emergency Medicine. 78 (1): 1–19. doi:10.1016/j.annemergmed.2021.02.006.
- ↑ 3.0 3.1 3.2 Torres A, Cilloniz C, Niederman MS; et al. (2021). "Pneumonia". Nature Reviews Disease Primers. 7 (1): 25. doi:10.1038/s41572-021-00259-0.
- ↑ 4.0 4.1 4.2 Winkler MH, Touw HR, van de Ven PM, Twisk J, Tuinman PR. (2018). "Diagnostic Accuracy of Chest Radiograph, and When Concomitantly Studied Lung Ultrasound, in Critically Ill Patients With Respiratory Symptoms: A Systematic Review and Meta-Analysis". Critical Care Medicine. 46 (7): e707–e714. doi:10.1097/CCM.0000000000003129. PMID 29601314.
- ↑ Expert Panel on Thoracic Imaging, Laroia AT, Donnelly EF; et al. (2021). "ACR Appropriateness Criteria® Intensive Care Unit Patients". Journal of the American College of Radiology. 18 (5S): S62–S72. doi:10.1016/j.jacr.2021.01.017.
- ↑ 6.0 6.1 6.2 Fan E, Brodie D, Slutsky AS. (2018). "Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment". JAMA. 319 (7): 698–710. doi:10.1001/jama.2017.21907.
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Aliberti S, Dela Cruz CS, Amati F, Sotgiu G, Restrepo MI. (2021). "Community-Acquired Pneumonia". The Lancet. 398 (10303): 906–919. doi:10.1016/S0140-6736(21)00630-9. PMID 34481570 Check
|pmid=value (help). - ↑ 8.0 8.1 8.2 Brogi E, Gargani L, Bignami E; et al. (2017). "Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment". Critical Care. 21 (1): 325. doi:10.1186/s13054-017-1897-5.
- ↑ 9.0 9.1 9.2 Shen KR, Bribriesco A, Crabtree T; et al. (2017). "The American Association for Thoracic Surgery Consensus Guidelines for the Management of Empyema". The Journal of Thoracic and Cardiovascular Surgery. 153 (6): e129–e146. doi:10.1016/j.jtcvs.2017.01.030.
- ↑ Hotchkiss RS, Moldawer LL, Opal SM; et al. (2016). "Sepsis and septic shock". Nature Reviews Disease Primers. 2: 16045. doi:10.1038/nrdp.2016.45.
- ↑ 11.0 11.1 11.2 Angus DC, van der Poll T. (2013). "Severe Sepsis and Septic Shock". The New England Journal of Medicine. 369 (9): 840–851. doi:10.1056/NEJMra1208623.
- ↑ 12.0 12.1 12.2 12.3 Matthay MA, Arabi Y, Arroliga AC; et al. (2024). "A New Global Definition of Acute Respiratory Distress Syndrome". American Journal of Respiratory and Critical Care Medicine. 209 (1): 37–47. doi:10.1164/rccm.202303-0558WS. PMID 37487152 Check
|pmid=value (help). - ↑ Gorman EA, O'Kane CM, McAuley DF. (2022). "Acute Respiratory Distress Syndrome in Adults: Diagnosis, Outcomes, Long-Term Sequelae, and Management". The Lancet. 400 (10358): 1157–1170. doi:10.1016/S0140-6736(22)01439-8. PMID 36070788 Check
|pmid=value (help). - ↑ 14.0 14.1 14.2 14.3 Ware LB, Matthay MA. (2005). "Acute Pulmonary Edema". The New England Journal of Medicine. 353 (26): 2788–2796. doi:10.1056/NEJMcp052699.
- ↑ Padrao EMH, Caldeira Antonio B, Gardner TA; et al. (2025). "Lung Ultrasound Findings and Algorithms to Detect Pneumonia: A Systematic Review and Diagnostic Testing Meta-Analysis". Critical Care Medicine. doi:10.1097/CCM.0000000000006818. PMID 40810585 Check
|pmid=value (help). - ↑ 16.0 16.1 Reyes LF, Conway Morris A, Serrano-Mayorga C; et al. (2025). "Community-Acquired Pneumonia". The Lancet. 406 (10517): 2371–2388. doi:10.1016/S0140-6736(25)01493-X. PMID 41110447 Check
|pmid=value (help).