Pulmonary embolism chest x ray: Difference between revisions
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| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br> | |||
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | |||
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{{Pulmonary embolism}} | {{Pulmonary embolism}} | ||
{{ | '''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{Rim}} | ||
==Overview== | ==Overview== | ||
The majority of chest X-rays ([[CXR]]) of patients with pulmonary embolism (PE) are abnormal; however, [[CXR]] findings are of limited value to establish a diagnosis of a pulmonary embolus (PE).<ref>{{cite journal | author = Worsley D, Alavi A, Aronchick J, Chen J, Greenspan R, Ravin C | title = Chest [[radiographic]] findings in patients with [[acute]] pulmonary embolism: observations from the PIOPED Study. | journal = Radiology | volume = 189 | issue = 1 | pages = 133-6 | year = 1993 | id = PMID 8372182}}</ref> The importance of a [[CXR]] obtained in patients with [[shortness of breath]] or [[chest pain]] suspected to have a PE is to rule out alternative diagnoses such as [[pneumonia]], [[congestive heart failure]], and [[rib fracture]].<ref>{{cite journal | author = Worsley D, Alavi A, Aronchick J, Chen J, Greenspan R, Ravin C | title = Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. | journal = Radiology | volume = 189 | issue = 1 | pages = 133-6 | year = 1993 | id = PMID 8372182}}</ref> The most common findings reported among patients with PE include [[atelectasis]] and/or increased [[opacity]] in [[parenchymal]] areas<ref name="pmid8372182">{{cite journal| author=Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE| title=Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. | journal=Radiology | year= 1993 | volume= 189 | issue= 1 | pages= 133-6 | pmid=8372182 | doi=10.1148/radiology.189.1.8372182 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8372182 }} </ref> and [[cardiomegaly]].<ref name="pmid10893356">{{cite journal| author=Elliott CG, Goldhaber SZ, Visani L, DeRosa M| title=Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry. | journal=Chest | year= 2000 | volume= 118 | issue= 1 | pages= 33-8 |pmid=10893356 | 5doi= | pmc= | url= }} </ref> | |||
==Chest X | ==Chest X Ray== | ||
* | * According to a substudy of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study on 1063 patients suspected to have PE, the most common [[CXR]] finding among patients with PE was [[atelectasis]] and/or increased [[opacity]] in [[parenchymal]] areas.<ref name="pmid8372182">{{cite journal| author=Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE| title=Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. | journal=Radiology | year= 1993 | volume= 189 | issue= 1 | pages= 133-6 | pmid=8372182 | doi=10.1148/radiology.189.1.8372182 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8372182 }} </ref> There was no significant difference between the prevalence of [[atelectasis]] and/or increased [[opacity]] in [[parenchymal]] areas among patients with confirmed PE vs those without PE.<ref name="pmid8372182">{{cite journal| author=Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE| title=Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. | journal=Radiology | year= 1993 | volume= 189 | issue= 1 | pages= 133-6 | pmid=8372182 | doi=10.1148/radiology.189.1.8372182 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8372182 }} </ref> | ||
* In contrast, in the observational retrospective International Cooperative Pulmonary Embolism Registry (ICOPER) study conducted at 52 hospitals in seven countries and involving 2,454 patients with suspected PE, [[cardiomegaly]] was the most common chest [[radiographic]] abnormality associated with [[acute]] PE. [[Cardiomegaly]] was not associated with the [[echocardiographic]] findings of [[hypokinesia]].<ref name="pmid10893356">{{cite journal| author=Elliott CG, Goldhaber SZ, Visani L, DeRosa M| title=Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry. | journal=Chest | year= 2000 | volume= 118 | issue= 1 | pages= 33-8 |pmid=10893356 | 5doi= | pmc= | url= }} </ref> | |||
* Approximately 12%-24% of patients with PE have a normal [[CXR]].<ref name="pmid8372182">{{cite journal| author=Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE| title=Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. | journal=Radiology | year= 1993 | volume= 189 | issue= 1 | pages= 133-6 | pmid=8372182 | doi=10.1148/radiology.189.1.8372182 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8372182 }} </ref><ref name="pmid10893356">{{cite journal| author=Elliott CG, Goldhaber SZ, Visani L, DeRosa M| title=Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry. | journal=Chest | year= 2000 | volume= 118 | issue= 1 | pages= 33-8 | pmid=10893356 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10893356 }} </ref> | |||
* "Classic", yet less uncommon, findings of PE on [[CXR]] include: | |||
** [[Westermark sign]]: [[vasoconstriction]] [[distal]] to the [[pulmonary]] [[embolus]] | |||
** [[Hampton hump]]: peripheral wedge-shaped density above the [[diaphragm]] | |||
** [[Palla's sign]]: enlarged right descending [[pulmonary artery]] | |||
* PE-related [[CXR]] changes have been evaluated among subjects free of [[cardiac]] and [[pulmonary]] diseases who were suspected to have PE and were enrolled in the PIOPED study. The [[CXR]] findings were compared between 117 patients with confirmed PE vs 247 patients without PE. The most common [[CXR]] abnormality in PE was [[atelectasis]] and/or increased [[opacity]] in [[parenchymal]] areas. Shown below are the percentage of [[CXR]] findings among patients with PE vs those without PE:<ref name="pmid1909617">{{cite journal| author=Stein PD, Terrin ML, Hales CA, Palevsky HI, Saltzman HA, Thompson BT et al.| title=Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. | journal=Chest | year= 1991 | volume= 100 | issue= 3 | pages= 598-603 | pmid=1909617 | doi= | pmc= | url= }} </ref> | |||
** [[Atelectasis]] and/or increased [[opacity]] in [[parenchymal]] areas: 68% vs 48% ( p <0.001) | |||
** [[Pleural effusion]]: 48% vs 31% (p <0.01) | |||
** Elevated [[diaphragm]]: 24% vs 19% ([[p-value]] is non-significant) | |||
** Prominent central [[pulmonary artery]] (or [[Fleischner sign]]): 15% vs 11% ([[p-value]] is non-significant) | |||
** [[Cardiomegaly]]: 12% vs 11% ([[p-value]] is non-significant) | |||
** [[Westermark's sign]]: 7% vs 2% ([[p-value]] is non-significant) | |||
** [[Pulmonary edema]]: 4% vs 13% (p <0.05) | |||
==References== | ==References== | ||
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[[Category:Hematology]] | [[Category:Hematology]] | ||
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[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Intensive care medicine]] | |||
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
The majority of chest X-rays (CXR) of patients with pulmonary embolism (PE) are abnormal; however, CXR findings are of limited value to establish a diagnosis of a pulmonary embolus (PE).[1] The importance of a CXR obtained in patients with shortness of breath or chest pain suspected to have a PE is to rule out alternative diagnoses such as pneumonia, congestive heart failure, and rib fracture.[2] The most common findings reported among patients with PE include atelectasis and/or increased opacity in parenchymal areas[3] and cardiomegaly.[4]
Chest X Ray
- According to a substudy of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study on 1063 patients suspected to have PE, the most common CXR finding among patients with PE was atelectasis and/or increased opacity in parenchymal areas.[3] There was no significant difference between the prevalence of atelectasis and/or increased opacity in parenchymal areas among patients with confirmed PE vs those without PE.[3]
- In contrast, in the observational retrospective International Cooperative Pulmonary Embolism Registry (ICOPER) study conducted at 52 hospitals in seven countries and involving 2,454 patients with suspected PE, cardiomegaly was the most common chest radiographic abnormality associated with acute PE. Cardiomegaly was not associated with the echocardiographic findings of hypokinesia.[4]
- "Classic", yet less uncommon, findings of PE on CXR include:
- Westermark sign: vasoconstriction distal to the pulmonary embolus
- Hampton hump: peripheral wedge-shaped density above the diaphragm
- Palla's sign: enlarged right descending pulmonary artery
- PE-related CXR changes have been evaluated among subjects free of cardiac and pulmonary diseases who were suspected to have PE and were enrolled in the PIOPED study. The CXR findings were compared between 117 patients with confirmed PE vs 247 patients without PE. The most common CXR abnormality in PE was atelectasis and/or increased opacity in parenchymal areas. Shown below are the percentage of CXR findings among patients with PE vs those without PE:[5]
- Atelectasis and/or increased opacity in parenchymal areas: 68% vs 48% ( p <0.001)
- Pleural effusion: 48% vs 31% (p <0.01)
- Elevated diaphragm: 24% vs 19% (p-value is non-significant)
- Prominent central pulmonary artery (or Fleischner sign): 15% vs 11% (p-value is non-significant)
- Cardiomegaly: 12% vs 11% (p-value is non-significant)
- Westermark's sign: 7% vs 2% (p-value is non-significant)
- Pulmonary edema: 4% vs 13% (p <0.05)
References
- ↑ Worsley D, Alavi A, Aronchick J, Chen J, Greenspan R, Ravin C (1993). "Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study". Radiology. 189 (1): 133–6. PMID 8372182.
- ↑ Worsley D, Alavi A, Aronchick J, Chen J, Greenspan R, Ravin C (1993). "Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study". Radiology. 189 (1): 133–6. PMID 8372182.
- ↑ 3.0 3.1 3.2 3.3 Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE (1993). "Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study". Radiology. 189 (1): 133–6. doi:10.1148/radiology.189.1.8372182. PMID 8372182.
- ↑ 4.0 4.1 4.2 Elliott CG, Goldhaber SZ, Visani L, DeRosa M (2000). "Chest radiographs in acute pulmonary embolism. Results from the International Cooperative Pulmonary Embolism Registry". Chest. 118 (1): 33–8. PMID 10893356.
- ↑ Stein PD, Terrin ML, Hales CA, Palevsky HI, Saltzman HA, Thompson BT; et al. (1991). "Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease". Chest. 100 (3): 598–603. PMID 1909617.