CARDIOMEGALY, CCF &

PULMONARY EDEMA
BY: RAJHMUNIRAN KANDASAMY
CRITERIA OF A GOOD CHEST
X-RAY

CRITERIA DESCRIPTION
1. Well centred ,not rotated Spinous process should be equidistant with both medial head of clavicles
2. Well collinated Ability to visualize from apex of lung till costophrenic angle
3. Adequate inspiration Diaphragm should intersect by 6-8th ribs ant, 8-10th ribs posteriorly.
4. Adequate Intervertebral spaces barely visible through the heart shadow
exposure/penetration
CARDIOMEGALY
CONGESTIVE HEART FAILURE
 High
Cardiac resistance Fluid
failure in the overload
circulation

CHF

Right ventricle
failure LVF

Pulmonary
edema/pleural effusion
 •However the common findings are ;
• Cardiomegaly
• Vascular phase (artery:bronchus)
• Hilar fullness with haziness
/dilated upper lobe vessels
• Interstitial phase (Kerley B lines)
• Alveolar edema (Bat wing sign)
• Pleural effusion
In daily clinical practice however
some of these features are not
seen in this sequence and
THEORICALLY …….. sometimes may not be present at
all.
(mitral valve dx, chronic hf, copd)
PATHOPHYSIOLOGY OF THE FINDINGS(
STAGES EXPECTED FINDINGS BRIEF)
Redistribution • Normal chest film in erect position , pulmonary vessels supplying the upper lung fields are
smaller and fewer in number than those supplying the lung bases
(applies to CXR
taken in full • Pulmonary bed has higher reserve capacity (open up/distension)
inspiration erect • Equalisation of the blood flow – distribute blood from lower zone to upper zone
position) • IMP finding : artery to bronchus ratio increased (best seen at perihilar region)
Interstitial • Fluid leakage into interlobular and peribronchial interstitium ( increased capillary pressure)
edema • Fluid in peripheral interlobular septa = seen as Kerley B (short,perpendicular line,CP angle)
• Fluid in peribronchovascular interstitium = seen as thickening of the bronchial walls
(peribronchial cuffing) and as loss of definition of these vessels (perihilar haze).
Alveolar edema • Continued fluid leakage into the interstitium, which cannot be compensated by lymphatic
drainage.
• This leads to fluid leakage in the alveoli (alveolar edema-Bat wing sign) and to leakage into
the pleural space (pleural effusion).
• The distribution of the alveolar edema can be influenced by:
- Gravity: supine or erect position and right or left decubitus position
- Obstructive lung disease, i.e. fluid leakage into the less severe diseased areas of the lung.
Increased artery to bronchus ratio
VASCULAR PEDICLE
WIDTH
1. Is the indicator of the intravascular
volume
2. Increase width of VP = increase width of
azygos vein
3. Normal < 60mm, >85 mm -pathology
Kerley B lines =interlobular septa thickening
Kerley B line
Perihilar haze
PULMONARY EDEMA
CARDIOGENIC
VS NON-
CARDIOGENIC
 QEUSTION???

How you differentiate acute

and chronic heart failure
 QEUSTION???

What did you understand by the

terms congestive heart failure and
pulmonary edema