PULMONARY

EDEMA
◦ Pulmonary edema is defined as an abnormal accumulation of
fluid in the extravascular compartments of the lung

◦ Pulmonary edema can be divided into four main categories

on the basis of pathophysiology:
a. Increased hydrostatic pressure edema: an imbalance between
intra-and extravascular hydrostatic and capillary oncotic
pressures, often the result of pulmonary venous hypertension
b. Permeability edema with diffuse alveolar damage (DAD):
ARDS
c. Permeability edema without DAD: Heroin-induces Pulmonary
Edema, pulmonary edema following administration of
Cytokines, high-altitude Pulmonary edema
d. Mix edema due to simultaneous increased hydrostatic
pressure and permeability changes: neurogenic pulmonary
edema,
Clinical Presentation
The clinical presentation of pulmonary edema includes:
◦ acute breathlessness
◦ orthopnea
◦ paroxysmal nocturnal dyspnea
◦ foaming at the mouth
◦ distress
Plain radiograph
Features useful for broadly assessing pulmonary edema on a plain chest
radiograph include:

◦ central pulmonary venous congestion

◦ upper lobe pulmonary venous diversion/pulmonary venous engorgement/
stag's antler sign
◦ increased cardiothoracic ratio/cardiac silhouette size: useful for assessing for
an underlying cardiogenic cause or association
◦ features of pulmonary interstitial edema:
peribronchial cuffing and perihilar haze
septal lines/Kerley lines
thickening of interlobar fissures
◦ features of pulmonary alveolar edema:
air space opacification classically in a batwing distribution
may have air bronchograms
◦ pleural effusions and fluid in interlobar fissures
INTERSTISIAL EDEMA
◦ Increase of 15-25 mmHg in mean transmural arterial pressure
and results in the early loss of definition of subsegmental and
segmental vessels, mild enlargement of the
peribronchovascular spaces, the appearance of Kerly lines, and
subpleural effusion
Bat Wing Edema
◦ Bat wing edema refers to a central, nongravitational
distribution of alveolar edema
Chest radiographic findings of interstitial (A-C) and alveolar (D) edema. A, Interlobular septal
thickening. B, Perihilar “haze.” C, Peribronchial cuffing (arrow). D, Consolidation (alveolar edema).
Pulmonary edema Grading
One grading system on pulmonary edema based on chest
radiograph appearances and pulmonary capillary wedge
pressure (PCWP) is as follows:

◦ grade 0: normal chest radiograph, PCWP 8-12 mmHg

◦ grade 1: shows evidence of upper lobe diversion on a chest
radiograph, PCWP 13-18 mmHg
◦ grade 2: shows interstitial edema on a chest radiograph, PCWP
19-25 mmHg
◦ grade 3: shows alveolar edema on a chest radiograph, PCWP
>25 mmHg