Chest X-ray and Heart Failure, CXR and CHF

Mission

    • CHF and the Chest X-ray
    • Practical Approach
    • Anatomical considerations
    • Histological Considerations
    • Physiology/Pathophysiology


Principles

    • Key anatomical issues

–Size of the LA

–Ratio  branch pulmonary arteries to bronchus

–Relative size of the upper vessels to lower vessels

    • Key Histological issues

–Secondary lobule

    • Key Physiology and Pathophysiological

–LVEDP

–Wedge pressures

CXR and CHF
Ashley Davidoff MD

2 Major Questions

  1.  Is the LA Enlarged?
  2.  Is it an LA with a 10 mmHg, 20 mmHg or 30 mmHg pressure
And then 3 other questions
    1. Is the PA>Bronchus in the middle or upper lobe vessels
    2. Is there fuzziness to the vessels?
    3. Is there alveolar edema?
1) Is the LA Enlarged?
CXR and CHF
Ashley Davidoff MD
CXR and CHF
Ashley Davidoff MD
Is it an LA with a 10 mmHg, 20 mmHg or 30 mmHg pressure
CXR and CHF
 Ashley Davidoff MD
 2.1
Is the PA>Bronchus?
Then it is at least 10 mmHg
CXR and CHF
Ashley Davidoff MD

2.2
Is there fuzziness of the vessels?
ie Is there interstitial edema?
Then it is at least 20 mmHg

 

CXR and CHF
 Ashley Davidoff MD
 Kerley B Line and Peribronchial Cuffing
CHF INTERSTITIAL DISEASE with KERLEY B LINES (black oval) and PERIBRONCHIAL CUFFING (red circle)
Ashley Davidoff MD
 2.3
Are there perihilar batwing infiltrates?
ie Is there alveolar edema?
Then LA pressure is at least 30 mmHg
CXR and CHF
Ashley Davidoff MD

 

TOP left image is of normal alveoli
Top Rt is PA slightly greater than bronchus = LVEDP 10-20 mmHg
Bottom left = 20-30 interstitial edema – peribronchial cuffing and Kerley B
Bottom Rt >30 = Alveolar Edema

PHASES OF HEART FAILURE
The top left image is the a histological section of normal alveoli and normal wall and interstitium. Heart failure occurs when the left ventricular end diastolic pressure rises. There are 3 basic phases of heart failure. in the first phase (top right) the LVEDP rises above 12 mmHg and on an upright CXR there is equalization of the size of the vessels going to the upper lobes and lower lobes. As the LVEDP goes above about 15-18 mm Hg there is cephalization of the vessels and the upper lobe vessels are larger than the lower lobe vessels.
The second phase of interstitial edema (bottom left) occurs when the intravascular hydrostatic pressure exceeds the intravascular oncotic pressure and this occurs when the LVEDP goes above 25 mm Hg. Fluid accumulates in the alveolar walls and interstitium and the wall becomes thicker with fluid, and the lymphatics and interlobular septa are distended.
The last phase of alveolar edema (lower right) occurs when the pressure exceeds 35 mmHg and the fluid leaks into the alveoli .
Ashley Davidoff MD

 

The Carina

NORMAL FRONTAL CXR NORMAL ASYMMETRIC BRANCHING OF MAINSTEM BRONCHI
The normal CXR shows the characteristic asymmetric branching of the main stem bronchi. The right is short and stout and slightly more vertical while the left is long and thin and slightly more obtuse.
The normal carinal angle is between 40-80 degrees.
Ashley Davidoff MD 30397c02L.8

LEFT ATRIUM AND THE CARINA
Ashley Davidoff MD
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UPPER LOBE PA TO BRONCHUS RATIO – NORMAL
NORMAL RATIO OF UPPER LOBE BRONCHUS AND ARTERY
In this normal CXR a RUL segmental bronchus and artery are side by side with the lucent air filled bronchus in teal and the artery in royal blue. Note that at this stage they are the same size and they will be for many divisions until they reach the terminal bronchiole.
Courtesy of: Ashley Davidoff, M.D.

 

Cephalisation
Cephalization
44659.800 chest lung CXR cephalisation cephalization pulmonary arteries pulmonary artery fx distended distension fx pulmonary congestion dx CHF dx congestive heart failure cardiac imaging radiology Courtesy Ashley Davidoff MD

 

Interstitial edema

INTERSTITIAL EDEMA

 

CXR with Improving Alveolar Edema
Ashley Davidoff

41F 1 year ago

Presents with SOB Left Sided BE

References and Links