Appraising Pulmonary Edema Using Supine Chest Roentgenograms in Ventilated Patients

Abstract

The role of portable, anteroposterior, supine chest X-rays (CXRs) in distinguishing hydrostatic pulmonary edema (HPE) from permeability pulmonary edema (PPE) in mechanically ventilated patients is controversial. We prospectively obtained and evaluated such CXRs in 33 supine, mechanically ventilated intensive-care-unit patients with pulmonary artery catheters. Three chest radiologists independently reviewed CXRs without clinical information and recorded the cardiothoracic (CT) ratio, vascular pedicle width (VPW), and other radiographic features commonly used to evaluate pulmonary edema. Hydrostatic pulmonary edema was associated with a larger CT ratio (p < 0.001), subjective impressions of cardiomegaly (p < 0.01), and increased VPW (p = 0.02). There was a significant correlation between the pulmonary artery occlusion pressure and the VPW (r = 0.45, p = 0.0076) and CT ratio (r = 0.52, p = 0.0016), as well as between the VPW and CT ratio (r = 0.49, p = 0.0032). Despite this detailed evaluation of the CXRs, the mean accuracy of the radiologists' clinical diagnosis of HPE versus PPE was 41%, and 15 of 19 (79%) of PPE patients showed one or more roentgenographic signs of volume overload. Receiver-operating-characteristic curves were constructed to determine optimum cut-off values of VPW and CT ratio associated with HPE. Hydrostatic pulmonary edema was found to correlate best using a VPW > 63 mm coupled to a CT ratio > 0.52 (p = 0.027). With this combination of objective criteria, radiologists' diagnostic accuracy could have been increased to 73%. We therefore conclude that measurements of CT ratio and VPW correlate with pulmonary artery occlusion pressure in supine, mechanically ventilated patients. Distinction of hydrostatic from permeability pulmonary edema is difficult using portable, supine CXRs, but readily assessed radiologic signs may contribute to the correct diagnosis.

Prediction of Cardiac Complications After Liver Transplantation

“…These included pulmonary edema (nϭ61; 74% of all complications, overt congestive heart failure, nϭ7). Pulmonary edema was diagnosed by chest X-ray according to previously published standardized criteria (24,25), whereas congestive heart failure was identified as clinically significant presence of dyspnea at rest, tachypnea, tachycardia, severe hypoxemia, and rales or wheezing (24).…”

“…Classically, pulmonary edema is classified as hydrostatic or permeability-type edema (25). The distinction is difficult and most cases are usually considered to be mixed-cause.…”

Clinical relevance of time of onset, duration, and type of pulmonary edema after liver transplantation

“…This distinction is unreliable if based solely on radiographic findings. 14 In this study, we differentiated between hydrostatic and permeability pulmonary edema on the basis of hemodynamic assessment using the cutoff criteria recommended by the American-European Consensus Conference. 11 This distinction is arbitrary, and in critically ill patients there is frequently no pure hydrostatic or permeability pulmonary edema.…”

Revisiting Clinical Utility of Chest Radiography and Electrocardiogram to Determine Ischemic Stroke Subtypes: Special Reference on Vascular Pedicle Width and Maximal P-Wave Duration

“…In 1984, Milne and co-workers [4] measured vascular pedicle width (VPW), which represents the mediastinal silhouette of the great vessels on chest X-rays (CXR), to evaluate the intravascular volume status, and similar studies [5,6,7] of VPW have been reported so far. According to these studies [4,5,6,7], VPW is correlated with intravascular volume status and is significantly larger in patients with volume overload.…”

“…According to these studies [4,5,6,7], VPW is correlated with intravascular volume status and is significantly larger in patients with volume overload. In addition, Ely et al [7] suggested that VPW also correlates with intravascular pressure indicated by pulmonary artery occlusion pressure and distinguishes cardiogenic from non-cardiogenic lung edema.…”