PULMONARY EDEMA VS

PNEUMONIA
 WHAT SHOULD WE KNOW?
Pulmonary edema refers to the accumulation of excessive fluid in the alveolar walls and alveolar
spaces of the lungs. It can be a life-threatening condition in some patients.
Pulmonary edema can be:
• Cardiogenic (disturbed starling forces involving the pulmonary vasculature and interstitium)
• Non-Cardiogenic (direct injury/damage to lung parenchyma/vasculature)
Powell J, Graham D, O'Reilly S, Punton G. Acute pulmonary oedema. Nurs Stand. 2016 Feb 03;30(23):51-9; quiz 60

Pneumonia is a form of acute respiratory tract infection (ARTI) that affects the lungs. When an
individual has pneumonia, the alveoli in the lungs are filled with pus and fluid, which makes
breathing painful and limits oxygen intake. Pneumonia has many possible causes, but the most
common are bacteria and viruses.
Pneumonia and diarrhoea: Tackling the deadliest diseases for the world’s poorest children. New York, UNICEF, 2012.
Normal Chest X Ray
Pulmonary Edema Chest X Ray

Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
• Cardiomegaly:
• The heart is considered enlarged if the transverse diameter of the
heart is larger than diameter of the hemi thorax.
• Cardiac width is larger than half trans thoracic diameter.
Cardiothoracic ratio >0.5.
• You can encounter normal size heart in acute myocardial infarction or
in volume overload

Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
Vascular Phase
Vascular Phase :
• This is the first phase of congestive heart failure.
• It represents pulmonary venous hypertension.
• Cephalization: Vessels in upper chest is more prominent as a
manifestation of pulmonary venous hypertension.
• Note the blood vessels are more prominent in the upper lung fields
compared to the lung base, just the opposite of normal.
• In supine film the vessels are same size in upper and lower lung fields.
• You see increased (>1) artery to bronchus ratio at hilar level.
Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
 Jain S, Modi T, Aswani Y, Farma R. Chest radiography in adult critical care unit: A pictorial
review. Indian Journal of Radiology and Imaging [Internet]. 2019 [cited 18 December
2020];29(4):418-425. Available from: https://dx.doi.org/10.4103%2Fijri.IJRI_329_19

• Cardiomegaly with
cephalization of pulmonary
vessels (black arrow) and
patchy right-sided air space
opacities (white arrows) -
Right-sided unilateral
pulmonary edema.
Unilaterality can be mistaken
for pneumonia, pulmonary
hemorrhage, aspiration
Interstitial Phase:
• Kerley lines are 2-3 cm long horizontal lines in the base of lungs close
to chest wall.
• They are the result of interstitial edema and increased lymphatic
drainage.
• This is the second phase of congestive heart failure.

Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
• Kerley B lines. Interlobular septae are not visible on a normal chest
radiograph but can become visible if they accumulate excessive fluid.
First described by neurologist/radiologist Peter James Kerley, they are
very short (1 to 2 cm long), very thin (about 1 mm) horizontal lines
perpendicular to and abutting the pleural surface (oval)

Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
• Kerley A lines. The A lines (circle) appear when connective tissue near
the bronchovascular bundle distends with fluid. They extend from the
hila for several centimeters in the midlung and do not reach the
periphery of the lung like Kerley B lines do. A network of Kerley lines
is produced in the lungs in patients with congestive heart failure
producing the “prominence of the pulmonary interstitial markings”
seen in that disease.

Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
• Peribronchial cuffing. Normally the bronchus is invisible when seen
on-end in the periphery of the lung. When fluid accumulates in the
interstitial tissue around and in the wall a bronchus as it does in CHF,
the bronchial wall becomes thicker and can appear as ringlike 
densities when seen on-end (white arrows). Peribronchial cuffing may
not always produce perfectly round circles.

Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
 Alveolar Phase:

This x-ray shows normal size heart with bilateral

diffuse soft fluffy alveolar infiltrates coalescing
with each other in a butterfly distribution typical
of pulmonary edema.
The heart can be normal and develop failure, as is
in this case, due to acute MI.

Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier
 Summary Phase
(A) Earliest changes of pulmonary edema (CVP 10-25 mmHg):
redistribution of pulmonary veins- “cephalization” (curved
white arrows).
(B) (B) With increasing pressure (CVP 20–25 mmHg),
transudation of fluid around bronchi seen as peribronchial
cuffing (curved black arrows).
(C) (C) Interstitial edema within lymphatics - Kerley B lines
[thin, short lines 1–2 cm in length, at the periphery
perpendicular to pleural surface] (black arrows). Other
features seen are cardiomegaly, indistinctness of pulmonary
vessels (asterisks), and early changes of perihilar bat wing
opacities (white arrows).
(D) (D) At CVP 25- 30 mm Hg, fluid accumulates in alveoli
producing classic perihilar batwing or angel wing
consolidation (black arrow heads). Increased vascular
pedicle width (black arrows) points to a likely underlying
renal pathology (overhydration), leading to pulmonary
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958895/
Jain S, Modi T, Aswani Y, Farma R. Chest radiography in adult critical care unit: A pictorial review. Indian
Journal of Radiology and Imaging [Internet]. 2019 [cited 18 December 2020];29(4):418-425. Available
from: https://dx.doi.org/10.4103%2Fijri.IJRI_329_19
Pneumonia Chest X Ray
Infiltrates (white arrows) is the result of replacement of air in the alveoli by transudate, pus, blood, cells or other
substances.
Pneumonia is by far the most common cause of Infiltrates.
The disease usually starts within the alveoli and spreads from one alveolus to another.
When it reaches a fissure the spread stops there.

The key-findings on the X-ray are:

•ill-defined homogeneous opacity obscuring vessels
•Silhouette sign: loss of lung/soft tissue interface
•Air-bronchogram
•Extention to the pleura or fissure, but not crossing it
•No volume loss
Lobar Pneumonia

- Homogeneous consolidation of all or a substantial percentage

of a single lobe
- Sharply marginated by one or more fissures (6.3)
- Air bronchograms (red and white arrow)
- Silhouette sign when the consolidation is adjacent to the
heart, aorta, or hemidiaphragm (6.4) R. L. Eisenberg, What Radiology Residents Need to Know: Chest
Radiology, https://doi.org/10.1007/978-3-030-16826-1_6
Lobular Pneumonia

- Patchy, poorly defined, heterogeneous air-space consolidation that tends to

involve the peripheral portions of the lungs
- Frequently multifocal, involving several areas at the same time
- Tends to have indistinct margins (unless touching a pleural fissure)
- Associated with exudate filling the bronchi, leading to associated atelectasis and
absence of air bronchograms
- Patchy areas may coalesce to mimic lobar pneumonia

R. L. Eisenberg, What Radiology Residents Need to Know: Chest

Radiology, https://doi.org/10.1007/978-3-030-16826-1_6
Intertitial Pneumonia

- Involvement of the walls of the alveoli and airways producing a fine, reticular pattern
- Diffuse or patchy ground-glass opacification on CT
- Caused by viral pneumonias, mycoplasma, and chlamydia
- In immunosuppressed patients (CD4 counts under 200/mm2 ), likely to be Pneumocystis, with the
classic pattern of bilateral prominence of reticular markings radiating outward from the hila (may
mimic pulmonary edema)

R. L. Eisenberg, What Radiology Residents Need to Know: Chest

Radiology, https://doi.org/10.1007/978-3-030-16826-1_6
Round Pneumonia

- Infectious mass-like opacity, usually seen in children who have a history of infectious symptoms
and recent normal chest radiograph (making a neoplasm unlikely)
- Imaging appearance is due to underdeveloped pores of Kohn and the absence of canals of
Lambert, which limit the centrifugal spread of early bacterial infection
- Most commonly due to Streptococcus pneumoniae or Haemophilus influenzae

R. L. Eisenberg, What Radiology Residents Need to Know: Chest Radiology,

https://doi.org/10.1007/978-3-030-16826-1_6
 The Different

Herring, William. Learning Radiology : Recognizing the basics ; 3 rd edition. 2016 : Elsevier