Original subtitles

hello everybody welcome today i'm going

to share with you the features of

congestive cardiac failure on a chest

x-ray

now we're going to start by having a

look at this normal chest x-ray and i

want you to imprint this image on your

mind

have a look at the costophrenic angles

look at the lung fields the pulmonary

vasculature the heart size

and then we look at images later on in

this talk you can think back to this

image

and notice the differences for yourself

now i want to stress before we get

started that congestive cardiac failure

is a clinical syndrome

it's something that we diagnose

clinically and we can use radiographic

features

to supplement that clinical information

but we're not going to make the

diagnosis on chest x-ray

or on ct scan we're going to use these

features to help us

supplement the clinical picture so

congestive cardiac failure is when

someone's heart

has either a structural or functional

anomaly that renders it unable to

pump blood out effectively and perfuse

end organs

and because it's a closed system it's

then

also unable to accommodate incoming

pulmonary

blood and leads to increased pulmonary

pressures and

actually increased promonty blood volume

now on a chest x-ray it's very difficult

to see that

decreased capacity to expel blood from

the heart

but what we can see very clearly on a

chest x-ray is features of

pulmonary congestion and ultimately

pulmonary edema

so that's what we're going to be doing

in this talk is looking at the features

of pulmonary edema and it actually

happens in a very logical and stepwise

fashion and it goes through these

three well-identified phases now these

happen in this order and it happens as

the

pulmonary capillary wage pressure

increases to certain levels

so first we'll get redistribution of

blood around the lungs then we'll get

seeping of fluid into the interstitium

out of the extravascular space and

eventually fluid filling the alveolar

spaces

filling the airways as well as fluid

going out into the pleural space and

giving us

plural effusions so let's have a look at

redistribution cast your eyes to this

image

and the more images you look at the more

you'll realize that these vessels here

in the superior portions of the lungs

are grossly dilated and these are not

normal so if we look here we've got

you can clearly see these vessels in the

upper portions of the lungs now normally

these vessels are kind of collapsed on

themselves

gravity will mean that the lung

vasculature at the

lower zones will be filled and it

doesn't really need to fill up the

vasculature here in the upper portions

of the lungs

now as the pressures and the volumes

increase from that inability to

of the heart to take up that blood

coming from the pulmonary circulation

we get increased pressures opening up

those pulmonary vessels

and this is an accommodation mechanism

for the lungs

and this is the first thing to happen as

our pulmonary capillary wedge pressures

increase

so whenever you're looking at an x-ray

that's the first place to look at if

you're suspecting congestive cardiac

failure

is look at those vessels can you see

them clearly are they dilated

now we're going to look at the same

image as those pressures now increase

further

we can have fluids seeping out into the

interlobular septa and actually cause

interlobular septal thickening with that

fluid now it's often quite difficult to

see and you need to look quite carefully

on the image but if you look at the

periphery of the lungs here

we can see these thin septal lines about

two to three centimeters

long and they are abutting the pleura at

a perpendicular angle

and this is what's known as curly b

lines so that's just an indication that

fluid has now seeped

out from our vessels into the

interstitial space causing interlobular

septal thickening and these are called

curly b

lines lines seen closer to this uh

the center of the image or by the aorta

those are known as curly a lines

and people will often name these lines

seen here as curly

c lines the way i remember this is that

b lines are by the border of the image

a lines are by the aorta or the center

of the image and then in between those

the central portion

is the curly c lines now we can see this

person has a

pacemaker and a large heart so this is

showing us that this pulmonary edema is

probably cardiogenic

cause and we can infer that maybe this

is congestive cardiac failure that's

causing this pulmonary edema

now as these pressures now increase

further we get fluids seeping out into

the alveolar spaces

spreading between the pores of con

causing fluid to fill these spaces

and we can see here that there's uh our

bronchi here a patent is giving us

air bronchograms here but the alveolar

spaces

next to it are completely filled with

fluid they're completely opacified

they're not the normal lucent lung that

we see

and so this can often look like

consolidation

but generally we will see fluid filling

these densely filling these alveolar

spaces causing denser pacification

of the lung fields here and what we've

got here is we're losing our costophonic

angles here we've lost it completely and

we've lost our left diagram

diaphragm we've probably got a large

pleural effusion on

that side which is a very common

occurrence in congestive cardiac failure

again this heart is large we can infer

that maybe this is a cardiogenic in

cause of this pulmonary edema

and when you see an image like this you

know that the severity or the grade of

pulmonary edema is very high

because we've got all the features of

congestive cardiac failure on this image

so let's have a look at an example case

again we've got all our features so if

we look here we've got dilated pulmonary

vasculature at the top here

accommodating that redistribution of

blood we've got

uh fluid in our horizontal fissure here

we've got small

we've got curly b lines there

interlobular septal thickening

we've got fluid within the alveolar

spaces here we've got a large

right-sided pleural effusion and we've

also lost our

left costophrenic angle and left

diaphragms we've got bilateral pleural

effusions here

and as i say congestive cardiac failure

is a

clinical diagnosis we don't can't always

tell from an x-ray what the underlying

etiology is

and we can't tell what the precipitating

factor that's caused this person to now

go into congestive cardiac failure but

when you see an image like this

you can see stenotomy wires that if that

have closed the previous stone to me we

can see surgical clips here and if you

look closely we can see

um evidence um might be difficult to see

here of

previous um stenting in the saucer most

likely this is uh cardiogenic in cause

and it's probably

ischemic and cause

those are the radiographic features on a

chest x-ray i just want to show you a ct

scan quickly before finishing off

because for me it just solidifies the

concepts a little bit clearer and it's a

bit easier to see on this axial

ct so here we've got a large heart and

this is someone who has congestive

cardiac failure

we've got a vessel that is larger than

its accompanying bronchi

which it shouldn't be the vessel should

normally be the same size or smaller and

this is showing us that that vessel has

that to accommodate some extra pressure

some extra volume

we've got fluid within our interlobular

scepter here

we've got fluid in our fissures we've

got

large bilateral pleural effusions here

this is the

fluid that's seeped to the back of the

patient as well as if you look closely

this is a subtle sign but something

that's quite

good to recognize on a ct is that our

lung is far more loosened here the

at the anterior portion of the patient

compared to posterior it kind of gets

more

pacified as we go posteriorly and that's

indicating that this is fluid

that by gravity is seeping towards the

posterior side of the patient who's

actually lying on their back here

and that's another way to differentiate

is this like a dense infective

consolidation

or is this fluid that can kind of flow

freely within the lungs

so that's all for pulmonary edema again

if you're the clinician who is looking

at these images and needs to now act

with this patient

it's very important to go and find the

underlying etiology

is there a valvular problem is there

hypertensive heart disease or

cardiomyopathy

and then you need to find out why this

patient has now

exacerbated that cardiac failure are

they anemic or is there sepsis on board

or are they thyrotoxic

and you need to address those issues

congestive cardiac failure has a very

poor prognosis and it's often

got worse mortality or five-year

mortality than

various cancers so this is something

that's serious and needs to be dealt

with and needs to be spoken about

with your patients who will then need to

make either drastic lifestyle changes or

really get on top

of the medical management and then you

can use serial imaging to see

how how are you managing the pulmonary

edema are you on a winning footing or do

you need to step up your management

so i hope that helped if it did please

hit the like button and subscribe to the

channel and i'll see you all in the next

video

goodbye everybody