Chest X-ray Findings in Chest X-ray Findings in Heart FailureHeart Failure

Stefan Da SilvaStefan Da SilvaJan 18Jan 18thth 2007 2007

Progression of findingsProgression of findings Related to increasing pulmonary capillary Related to increasing pulmonary capillary

pressures.pressures. Common Chest Xray FindingsCommon Chest Xray Findings

– Increased Heart SizeIncreased Heart Size– Cephalization of flow/Vascular RedistributionCephalization of flow/Vascular Redistribution– Interstitial EdemaInterstitial Edema– Pleural EffusionsPleural Effusions– Aveolar EdemaAveolar Edema

Case #1Case #1– 75 yr old male presenting with swelling 75 yr old male presenting with swelling

in legs.in legs.– Vitals 37.6, 70 HR, 150/80, 18RR sats Vitals 37.6, 70 HR, 150/80, 18RR sats

94% RA94% RA

Increased Heart Size– Usually a cardiothoracic ratio of >0.50– Sensitivity 54% - 79% (Knudsen et al.,

Fonseca et al)– Specificity 78% - 80% (Knudsen et al.,

Fonseca et al)

Dr. W. RoentgenDr. W. Roentgen– 18951895– 7 weeks of 7 weeks of

experiments after experiments after he discovered the he discovered the “x” ray to produce “x” ray to produce the first image.the first image.

Case #2Case #2– 75 yr old male with leg swelling and 75 yr old male with leg swelling and

increasing SOB on exertionincreasing SOB on exertion– Vitals 37.6, 70 HR, 150/80, RR 18 sats Vitals 37.6, 70 HR, 150/80, RR 18 sats

94% RA94% RA

Vascular Redistribution– Usually lung bases better perfused than

apices and vessels supplying lower lobes are larger than upper lobes.

– Perivascular edema develops in lower lobes compresses vessels causes equalization of size of vessels between lower lobes and apices.

– Upper vessel size > 3mm diameter

Vascular Redistribution con’t– Increasing pulmonary capillary pressure

causes “cephalization of flow” due to shunting to upper lobe vessels.

– Flip xray upside down– Poorly sensitive: 41% (as low as 17% in

one study)– Specificity: 94 - 96% (Knudsen et al.,

Fonseca et al)

Case #3Case #3– 75 yr old male with leg swelling and 75 yr old male with leg swelling and

progressive SOB while at restprogressive SOB while at rest– Vitals 37.6, 90 HR, 170/90, RR 25 sats Vitals 37.6, 90 HR, 170/90, RR 25 sats

89% RA89% RA

Interstitial Edema– (1) septal, producing Kerley lines (i.e.,

sharp, linear densities of interlobular interstitial edema);

– (2) perivascular, producing loss of sharpness of the central and peripheral vessels; and

– (3) subpleural, producing spindle-shaped accumulations of fluid between the lung and adjacent pleural surface.

– Accumulation of fluid leads toIndistinct hilar vesselsKerley “B” lines (Kerley “A” lines: same

significance but less common and seen more at inner lung fields towards hilum)

Fluid in the interlobar fissuresPeribronchial cuffing

– Sensitivity: 17 - 27% (Knudsen et al., Fonseca et al)

– Specificity: 95 - 98% (Knudsen et al., Fonseca et al)

Case #4Case #4– 75 yr old male with leg swelling and 75 yr old male with leg swelling and

increasing SOB at rest, diaphoretic.increasing SOB at rest, diaphoretic.– Vitals 37.6, 100 HR, 180/96, RR 30 sats Vitals 37.6, 100 HR, 180/96, RR 30 sats

85% RA85% RA

Pleural Effusions– Sensitivity: 1.2% - 25% (Knudsen et al.,

Fonseca et al)– Specificity: 92 - 99% (Knudsen et al.,

Fonseca et al)– Again seen with higher pulmonary

capillary pressures ( > 25 mg Hg)– Commonly seen with patients with

chronic heart failure

Case #5Case #5– 75 yr old male with leg swelling, 75 yr old male with leg swelling,

diaphoresis and marked SOB while at diaphoresis and marked SOB while at restrest

– Vitals 37.6, 110 HR, 190/100, RR >30 Vitals 37.6, 110 HR, 190/100, RR >30 sats 78% RAsats 78% RA

Alveolar Edema– Can lead to the “butterfly” or “batwing”

appearance commonly described– Sensitivity 1.9% - 6% (Knudsen et al.,

Fonseca et al)– Specificity: 97 – 99% (Knudsen et al.,

Fonseca et al)

Take home points– 1 in 5 pts with acute decompensated

heart failure with have no signs of congestion on chest xray (Collins et al.) (Collins et al.)

– Poorly sensitive– Those with chronic heart failure may

have subtle findings (Chakko et al.) (Chakko et al.)– Beware of portable chest xrays