signs of congestive heart failure on the chest radiograph

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Signs of Congestive Signs of Congestive Heart Failure on the Heart Failure on the Chest Radiograph Chest Radiograph Molly Lalor MS4 Molly Lalor MS4 OHSU Radiology Rotation November 2006 OHSU Radiology Rotation November 2006

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Signs of Congestive Heart Failure on the Chest Radiograph. Molly Lalor MS4 OHSU Radiology Rotation November 2006. When should you use the Chest x-ray in CHF?. - PowerPoint PPT Presentation

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Page 1: Signs of Congestive Heart Failure on the Chest Radiograph

Signs of Congestive Signs of Congestive Heart Failure on the Heart Failure on the Chest RadiographChest Radiograph

Molly Lalor MS4Molly Lalor MS4

OHSU Radiology Rotation November 2006OHSU Radiology Rotation November 2006

Page 2: Signs of Congestive Heart Failure on the Chest Radiograph
Page 3: Signs of Congestive Heart Failure on the Chest Radiograph

When should you use the Chest x-ray in When should you use the Chest x-ray in CHF?CHF?

► The Chest Radiograph is a valuable tool for The Chest Radiograph is a valuable tool for confirming signs of congestive heart failure confirming signs of congestive heart failure and should be considered in patients with and should be considered in patients with new or newly exacerbated new or newly exacerbated clinicalclinical signs and signs and symptoms of CHFsymptoms of CHF1.1.

► Can you name signs and symptoms of CHF?Can you name signs and symptoms of CHF?

Page 4: Signs of Congestive Heart Failure on the Chest Radiograph

CHF clinical symptoms and CHF clinical symptoms and signssigns

►Symptoms: Symptoms: dyspnea on exertion, orthopnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, paroxysmal nocturnal dyspnea, peripheral edema, fatigue. (Palpitations, chest pain, diaphoresis etc. fatigue. (Palpitations, chest pain, diaphoresis etc. may occur depending on etiology).may occur depending on etiology).

►SignsSigns: : Left: bibasilar rales (crackles), S3 or S4, signs of Left: bibasilar rales (crackles), S3 or S4, signs of

peripheral hypoperfusion.peripheral hypoperfusion. Right: jugular venous distention, large pulsatile Right: jugular venous distention, large pulsatile

liver, abdominojugular reflex, peripheral liver, abdominojugular reflex, peripheral edema.edema.

Page 5: Signs of Congestive Heart Failure on the Chest Radiograph

CXR in CHF: what can it show CXR in CHF: what can it show me?me?

There are four main pieces of information to be gleaned from a There are four main pieces of information to be gleaned from a chest radiograph regarding heart failure.chest radiograph regarding heart failure.

► Is there Pulmonary Edema?Is there Pulmonary Edema?► Is there evidence of Is there evidence of long termlong term pulmonary pulmonary

venous hypertension?venous hypertension?► What is my patient’s intravascular volume What is my patient’s intravascular volume

status?status?► Is there heart chamber enlargement?Is there heart chamber enlargement?

depends on etiology of CHF. This presentation depends on etiology of CHF. This presentation will not cover this topic.will not cover this topic.

Page 6: Signs of Congestive Heart Failure on the Chest Radiograph

CXR: What can it show me?CXR: What can it show me?

► So first let’s consider pulmonary edema. So first let’s consider pulmonary edema. ► Pulmonary edema is abnormal accumulation of Pulmonary edema is abnormal accumulation of

extravascular lung waterextravascular lung water2,32,3..

► There are two major types/ mechanisms: There are two major types/ mechanisms: hydrostatic edema and alveolar damage edema. hydrostatic edema and alveolar damage edema.

► There are other more rare mechanisms like There are other more rare mechanisms like endothelial damage edema, but we’ll consider the endothelial damage edema, but we’ll consider the two most common.two most common.

► Mixed types can occur but we’ll keep them separate Mixed types can occur but we’ll keep them separate for simplicity.for simplicity.

Page 7: Signs of Congestive Heart Failure on the Chest Radiograph

Pulmonary Edema = Abnormal Pulmonary Edema = Abnormal Extravascular Lung Water*Extravascular Lung Water*

► Again, because this is important: pulmonary Again, because this is important: pulmonary edema can be caused by elevated edema can be caused by elevated hydrostatichydrostatic pressure (CHF is in this pressure (CHF is in this category).category).

►Or, it can be caused by Or, it can be caused by alveolar damagealveolar damage like like in Adult Respiratory Distress Syndrome.in Adult Respiratory Distress Syndrome.

► On the following slide, look at the cartoon showing On the following slide, look at the cartoon showing physiologic barriers against edema formation.physiologic barriers against edema formation.

Page 8: Signs of Congestive Heart Failure on the Chest Radiograph

Pulmonary Edema BarriersPulmonary Edema Barriers

Alveolar Alveolar air spaceair space

alveolar epithelium with tight junctions

Interstitiumlymphatics

capillary endothemium with “loose” junctions

RBC RBC

Capillary

lumen

Page 9: Signs of Congestive Heart Failure on the Chest Radiograph

HydrostaticHydrostatic Pulmonary Edema Pulmonary Edemahigh capillary pressure forces water molecules across high capillary pressure forces water molecules across

endothelium (through loose junctions) into the interstitium and endothelium (through loose junctions) into the interstitium and sometimes into the air space.sometimes into the air space.

Alveolar Alveolar air spaceair space

alveolar epithelium with intact tight junctions

Interstitiumlymphatics

capillary endothemium with “loose” junctions

RBC RBC

Increased

capillary Pressure

H2O

Page 10: Signs of Congestive Heart Failure on the Chest Radiograph

Hydrostatic Pulmonary edema: In this section of lung, septal capillaries are Hydrostatic Pulmonary edema: In this section of lung, septal capillaries are congested and the alveoli are filled with pink-staining proteinaceous edema fluid. congested and the alveoli are filled with pink-staining proteinaceous edema fluid.

Within the edema fluid there are macrophages, many of which contain Within the edema fluid there are macrophages, many of which contain hemosiderin pigment. These changes result from increased hydrostatic pressure hemosiderin pigment. These changes result from increased hydrostatic pressure

in the pulmonary circulation, as is seen in left-sided heart failure or mitral in the pulmonary circulation, as is seen in left-sided heart failure or mitral

stenosis.stenosis.

From From www.pathology.vcu.edu/.../cardio/lab2.c.html

Page 11: Signs of Congestive Heart Failure on the Chest Radiograph

Pulmonary EdemaPulmonary Edema

faculty.southwest.tn.edu/wray/images/

Page 12: Signs of Congestive Heart Failure on the Chest Radiograph

HydrostaticHydrostatic Pulmonary Edema: Pulmonary Edema: Can you think of the causes of increased capillary Can you think of the causes of increased capillary

hydrostatic pressure?hydrostatic pressure?

Increased Arterial Pressure: more blood to push through the tube:

*Left to right shunts

*Renal Failure

*etc

Increased Venous Pressure:

•Left Heart (pump) failure with pressure backup

•Hypertension (systemic)

•Veno-occlusive disease

•Etc.

Capillary pressure

Page 13: Signs of Congestive Heart Failure on the Chest Radiograph

Alveolar DamageAlveolar Damage Pulmonary Pulmonary Edema:Edema:

NotNot from CHF from CHF Alveolar Alveolar air spaceair space

alveolar epithelium with BROKEN

tight junctions

Interstitiumlymphatics

RBCRBC

Broken tight junctions

Water in the air space

Page 14: Signs of Congestive Heart Failure on the Chest Radiograph

Pulmonary Edema continuedPulmonary Edema continued

► So in considering your patient who may So in considering your patient who may have CHF, evaluate his/her chest film for the have CHF, evaluate his/her chest film for the mechanism of pulmonary edema: is it mechanism of pulmonary edema: is it cardiogenic (hydrostatic) or is it from diffuse cardiogenic (hydrostatic) or is it from diffuse alveolar damage (ie there’s another process alveolar damage (ie there’s another process besides CHF going on.)besides CHF going on.)

► Let’s look at some examples.Let’s look at some examples.

Page 15: Signs of Congestive Heart Failure on the Chest Radiograph

Hydrostatic vs Alveolar Damage: you Hydrostatic vs Alveolar Damage: you can usually tell them apart on chest can usually tell them apart on chest

radiograph!radiograph!

CHF: More whiteness (water) in lower lung areas due to higher capillary pressures lower down.

Diffuse Alveolar Damage: all over whiteness from all over alveolar damage.

Page 16: Signs of Congestive Heart Failure on the Chest Radiograph

►Now that we’re clear that Now that we’re clear that CHFCHF manifests as manifests as hydrostatichydrostatic pulmonary pulmonary edema, what does that look like?edema, what does that look like?

*Vascular Indistinctness*Vascular Indistinctness

*Interlobular Fissure Thickening*Interlobular Fissure Thickening

* Peri-bronchial Cuffing* Peri-bronchial Cuffing

*Septal Lines (Kerleys)*Septal Lines (Kerleys)

Page 17: Signs of Congestive Heart Failure on the Chest Radiograph

Pulmonary edema= abnormal Pulmonary edema= abnormal extravascular lung waterextravascular lung water

No edema

Interstitial Edema

Note: peri-bronchovascular fluid cuff (imagine how this would blur the vessel margins on radiograph!)

Page 18: Signs of Congestive Heart Failure on the Chest Radiograph

Vascular IndistinctnessVascular IndistinctnessWater is the same density as vessels, and so as it Water is the same density as vessels, and so as it

leaves vasculature for interstitium the margins leaves vasculature for interstitium the margins become fuzzy.become fuzzy.

EdemaCrisp vessel margins, no edema

Page 19: Signs of Congestive Heart Failure on the Chest Radiograph

Vascular IndistinctnessVascular Indistinctness

Crisp margins, no edema Edema

Page 20: Signs of Congestive Heart Failure on the Chest Radiograph

Interlobular Fissure ThickeningInterlobular Fissure ThickeningEdema in the lung along the fissureEdema in the lung along the fissure

Page 21: Signs of Congestive Heart Failure on the Chest Radiograph

Peri-Bronchial CuffingPeri-Bronchial CuffingPeribronchial cuffing represents extravasated water surrounding the bronchus.

Pre-diuresis: note the cuffing (large arrow)

Post diuresis

Page 22: Signs of Congestive Heart Failure on the Chest Radiograph

Septal LinesSeptal LinesThickened interlobular septaeThickened interlobular septae

Page 23: Signs of Congestive Heart Failure on the Chest Radiograph

What about Cephalization?What about Cephalization?

►Cephalization means that the upper Cephalization means that the upper lung zone vessels look bigger than the lung zone vessels look bigger than the lower lung zone vessels because more lower lung zone vessels because more blood is flowing through the higher blood is flowing through the higher vessels. This is also called flow vessels. This is also called flow inversion. inversion.

►This phenomenon is the opposite of the This phenomenon is the opposite of the normal gravity-dependent regional normal gravity-dependent regional pulmonary blood flow.pulmonary blood flow.

Page 24: Signs of Congestive Heart Failure on the Chest Radiograph

CephalizationCephalizationThe upper lobe vascular caliber is greater than lower The upper lobe vascular caliber is greater than lower

vessels.vessels.

Page 25: Signs of Congestive Heart Failure on the Chest Radiograph

CephalizationCephalization

► Many sources teach that cephalization (flow Many sources teach that cephalization (flow inversion) is an early and sensitive sign of inversion) is an early and sensitive sign of acute pulmonary edema or acute CHFacute pulmonary edema or acute CHF4-74-7. This . This teaching is likely based on studies of chronic teaching is likely based on studies of chronic mitral stenosis patients.mitral stenosis patients.

► However, studies have shown that However, studies have shown that cephalization is not well correlated with acute cephalization is not well correlated with acute pulmonary hypertension in acute MIpulmonary hypertension in acute MI3,9,103,9,10, and , and that flow inversion remains after diuresisthat flow inversion remains after diuresis88..

► Ketai and Godwin in a review conclude that Ketai and Godwin in a review conclude that cephalization is almost never seen unless cephalization is almost never seen unless there is there is chronicchronic pulmonary venous pulmonary venous hypertensionhypertension3 3 ..

Page 26: Signs of Congestive Heart Failure on the Chest Radiograph

► Pistolesi et al (1988) found that flow Pistolesi et al (1988) found that flow inversion correlated positively with inversion correlated positively with pulmonary vascular resistance and not with pulmonary vascular resistance and not with wedge pressure, edema, or arterial oxygen wedge pressure, edema, or arterial oxygen tensiontension88..

► Therefore, cephalization likely reflects Therefore, cephalization likely reflects chronic structural changes in the dependent chronic structural changes in the dependent lung vasculature (like reduction of cross lung vasculature (like reduction of cross sectional area)sectional area)3,83,8..

CephalizationCephalization

Page 27: Signs of Congestive Heart Failure on the Chest Radiograph

CephalizationCephalization

►So what does that all mean?So what does that all mean?

► If you see cephalization it means your patient likely has a If you see cephalization it means your patient likely has a chronicchronic process causing pulmonary venous hypertension. process causing pulmonary venous hypertension.

► Cephalization is not a sign of pulmonary edema.Cephalization is not a sign of pulmonary edema.

Page 28: Signs of Congestive Heart Failure on the Chest Radiograph

Intravascular Volume StatusIntravascular Volume Status

The vascular pedicle (mediastinal width above top of aortic arch) represents the superior vena cava on the patient’s right and the left subclavian artery on the left.

If it is wide, that indicates greater intravascular volume.

Look at the example on the following slide.

Page 29: Signs of Congestive Heart Failure on the Chest Radiograph

Intravascular Volume StatusIntravascular Volume Status

Pre-dialysis Post-dialysis

Page 30: Signs of Congestive Heart Failure on the Chest Radiograph

Quiz Time!Quiz Time!

►For the following chest xrays, practice For the following chest xrays, practice deciding if you think there is deciding if you think there is pulmonary edema-hydrostatic or pulmonary edema-hydrostatic or alveolar damage.alveolar damage.

►Answers at the end.Answers at the end.

Page 31: Signs of Congestive Heart Failure on the Chest Radiograph

#1#1

Page 32: Signs of Congestive Heart Failure on the Chest Radiograph

#2#2

Page 33: Signs of Congestive Heart Failure on the Chest Radiograph

#3#3

Page 34: Signs of Congestive Heart Failure on the Chest Radiograph

#4#4

Page 35: Signs of Congestive Heart Failure on the Chest Radiograph

#5#5

Page 36: Signs of Congestive Heart Failure on the Chest Radiograph

#6#6

Page 37: Signs of Congestive Heart Failure on the Chest Radiograph

#7#7

Page 38: Signs of Congestive Heart Failure on the Chest Radiograph

Quiz AnswersQuiz Answers

►#3 and #5 show hydrostatic #3 and #5 show hydrostatic pulmonary edema.pulmonary edema.

►#6 shows alveolar damage pulmonary #6 shows alveolar damage pulmonary edema.edema.

►Bonus: #7 demonstrates Bonus: #7 demonstrates cephalization. cephalization.

Page 39: Signs of Congestive Heart Failure on the Chest Radiograph

ReferencesReferences

► 1. American College of Radiology Committee on Appropriateness Criteria for Congestive Heart Failure, 2006.1. American College of Radiology Committee on Appropriateness Criteria for Congestive Heart Failure, 2006.► 2. 2. Reading the Chest Radiograph; A Physiologic ApproachReading the Chest Radiograph; A Physiologic Approach. Milne and Pistolesi, 1993.. Milne and Pistolesi, 1993.► 3. Ketai and Godwin, A New View of Pulmonary Edema and Acute Respiratory Distress Syndrome. Journal of Thoracic Imaging 3. Ketai and Godwin, A New View of Pulmonary Edema and Acute Respiratory Distress Syndrome. Journal of Thoracic Imaging

13: 147-171. 1998. 13: 147-171. 1998. ► 4. UpToDate. Acute Decompensated Heart Failure (Cardiogenic Pulmonary Edema). Accessed 11/02/06. 4. UpToDate. Acute Decompensated Heart Failure (Cardiogenic Pulmonary Edema). Accessed 11/02/06. ► 5. EMedicine “Congestive Heart Failure and Pulmonary Edema”5. EMedicine “Congestive Heart Failure and Pulmonary Edema”► 6. Loyola University teaching website: 6. Loyola University teaching website:

www.meddean.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/CXR/atlas/pulmonaryedema.htm www.meddean.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/CXR/atlas/pulmonaryedema.htm ► 7. Sumer’s Radiology website:http://www.sumerdoc.blogspot.com/7. Sumer’s Radiology website:http://www.sumerdoc.blogspot.com/► 8. Pistolesi M et al. Factors Affecting Regional Pulmonary Blood Flow in Chronic Ischemic Heart Disease. Journal of Thoracic 8. Pistolesi M et al. Factors Affecting Regional Pulmonary Blood Flow in Chronic Ischemic Heart Disease. Journal of Thoracic

Imaging 3(3): 65-72. 1988.Imaging 3(3): 65-72. 1988.► 9. Kostuk WJ. Circulation 1973 48: 624.9. Kostuk WJ. Circulation 1973 48: 624.► 10. Goodman and Morgan. Pulmonary Edema and adult respiratory distress syndrome. Radiologic Clinics of North America 10. Goodman and Morgan. Pulmonary Edema and adult respiratory distress syndrome. Radiologic Clinics of North America

1991; 29: 943-963.1991; 29: 943-963.

Page 40: Signs of Congestive Heart Failure on the Chest Radiograph