The Radiology of Acute Pulmonary Oedema

Abstract

The purpose of this paper is to describe some of the X-ray appearances of acute pulmonary cedema occurring in heart failure, and to distinguish them from other shadows in the lung commonly associated with heart disease. It is based on films of patients taken during attacks of breathlessness due to acute pulmonary cedema. The films were usually taken in the ward with a portable X-ray apparatus, a procedure causing little discomfort to the patient, though with the inherent disadvantages of a short tube-distance and a longer exposure time. Teleradiograms at six feet were taken at once in a few cases when the patient was admitted to hospital during an attack. Not every patient with paroxysmal dyspncea shows the radiological changes of acute pulmonary cedema, especially if the attack is mild; but such changes are frequently evanescent so that if examination is delayed even a few hours they may have vanished.Twenty cases are included in this series: 10 had hypertensive heart failure, comprising 2 with malignant hypertension, 4 with nephritis, and 4 without renal involvement; another without hypertension, had great enlargement of the left ventricle aid left bundle branch block; three patients had aortic incompetence, 1 due to bacterial endocarditis and 2 due to syphilis, but in one of these heart failure was due to cardiac infarction. There were 6 cases of mitral stenosis, all women, and all in normal rhythm except one with auricular fibrillation where acute pulmonary cedema was caused by a blood transfusion. GENERAL FEATURESAcute pulmonary cedema appears on the film as dense cloudy opacities covering both hilar regions, often obscuring all details of the lung roots and of the adjacent lung structures. The shadows spread outwards from the hila over the central portions of the lung fields and down into the lung bases; it is noteworthy, however, that the apices of the lungs above are usually unaffected, and so quite often are the costophrenic angles below (Fig. IA, llA, and -12B). Occasionally the opacities affect mainly the hilar region and do not extend far into the lung field ( Fig. 8A and 17A), or the main density is perihilar and softer clouds lie farther out towards the periphery (Fig. 9A and 16A).The cloudiness usually ends before it reaches the chest wall, so that the periphery of the lungs with the apices and the costophrenic angles form a continuous light outer zone (Fig. IA and 3). In very severe cases or with repeated attacks, the cloudy areas extend to the chest wall and only the apices escape ( Fig. 4A and 12A). Both lungs are always simultaneously affected, though sometimes one more than the other. In the anterior view there is no tendency towards a lobar or segmental distribution of the opacities which radiate from the hila without regard to the anatomical divisions of the lungs. Here acute pulmonary cedema differs from pulmonary infarction, which is frequently confined to one side and limited to a portion of a lobe.

The pathology of butterfly densities in uraemia

“…In this context some important information has been obtained from studies of pulmonary oedema and vascular changes associated with mitral stenosis. It is known that central pulmonary oedema may complicate mitral III R. T. Hughes stenosis (Jackson, 1951), especially in pregnancy, but rarely when long-standing heart failure is associated with gross left ventricular dilatation. In a pathological study Parker (1958) found that central pulmonary congestion occurs when arterial changes are minimal.…”

“…This was true in one of Doniach's cases, and similarly Bass and Singer (1950) found that extensive shadows might disappear when left ventricular failure was alleviated. NON-SPECIFICITY It has been made abundantly clear in the literature that the butterfly density is not specific to uraemia (Doniach, 1949;Jackson, 1951). It is recognized as the classical appearance of acute pulmonary oedema (Nessa and Rigler, 1941) and it occurs almost invariably in patients in whom an attack of severe dyspnoea complicates an illness in which strain is being thrown on the left side of the heart (Hodson, 1950).…”

Unilateral Pulmonary Edema Secondary to Left Heart Failure

“…Jackson [9] did not find any unilateral presentation in a re view of 20 cases. Gleason and Steiner [7] found 6 cases with an unilateral pattern in the same number of patients.…”