Reading chest radiographs in the critically ill (Part II): Radiography of lung pathologies common in the ICU patient

Ali Nawaz Khan, Hamdan Al-Jahdali, Sarah AL-Ghanem, and Alaa Gouda King Fahad Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia Address for correspondence: Dr. Ali Nawaz Khan King Abdulaziz Medical Ci !, King "ahad Na ional Guard Ho#$i al, %.&. 'o( ))*+,, -i!adh ..*)/, Saudi Arabia. 0-mail1 dr2han.+//3m#n.com -ecei4ed December .5, ),,67 Acce$ ed Januar! )+, ),,+. Co$!righ 8 Annal# o9 :horacic Medicine :hi# i# an o$en-acce## ar icle di# ribu ed under he erm# o9 he Crea i4e Common# A ribu ion Licen#e, which $ermi # unre# ric ed u#e, di# ribu ion, and re$roduc ion in an! medium, $ro4ided he original wor2 i# $ro$erl! ci ed.

Abstract
:hi# i# $ar ;; o9 wo #erie# re4iew o9 reading che# radiogra$h# in he cri icall! ill. Con4en ional che# radiogra$h! remain# he corner# one o9 da! o da! managemen o9 he cri icall! ill occa#ionall! #u$$lemen ed b! com$u ed omogra$h! or ul ra#ound 9or #$eci9ic indica ion#. ;n hi# #econd re4iew we di#cu## radiogra$hic 9inding# o9 cardio$ulmonar! di#order# common in he in en#i4e care $a ien and #ugge# guideline# 9or in er$re a ion ba#ed no onl! on imaging bu al#o on he $a ho$h!#iolog! and clinical ground#. Keywords: Che# (-ra!, in en#i4e care uni , cardio$ulmonar! di#order# ;n er$re ing che# radiogra$h# in he cri icall! ill $a ien # in in en#i4e care uni # <;C=> $o#e# a challenge no onl! 9or he in en#i4e care $h!#ician# bu al#o 9or he radiologi# . :he#e challenge# ari#e becau#e o9 #e4eral 9ac or#1?.@ ;C= $a ien # are $rone o #e4eral cardio$ulmonar! di#order# which when #u$erim$o#ed on he underl!ing $a holog! ha $rom$ ed admi##ion crea e# a com$le( radiological a$$earance, which ma! be di99icul o in er$re on imaging 9inding# alone. ?)@ :he # andard $o# ero-an erior <%A> radiogra$h i# re$laced b! he #ubo$ imal A% radiogra$h in he ;C= $a ien .?A@ ;n# rumen a ion, mechanical 4en ila ion, eBui$men 9or moni oring o9 cardiac and o her 4i al #ign#, 9eeding ube#, e c., di# rac 9rom o her 9inding# on he ;C= che# radiogra$h.?*@ -adiologi# #C;n en#i4e care $h!#ician# are under $re##ure 9or ra$id in er$re a ion o9 che# (-ra!# when rea ing cri icall! ill $a ien #, o9 en wi h inadeBua e clinical in9orma ion $ar l! due o he 9ac ha hing# can change ra$idl! in he cri icall! ill.?5@ -adiological in er$re a ion i# ham$ered b! he bewildering arra! o9 line $lacemen # in he ;C= $a ien , where incorrec $lacemen i# no uncommon, which ma! no be ob4iou# o he ob#er4er wi hou clinical in$u .?/@ Air #$ace #hadowing in he ;C= $a ien ma! ha4e iden ical a$$earance# in a 4arie ! o9 cardio$ulmonar! $a hologie#. Al hough he imaging modali ! o9 choice in he ;C= $a ien remain# ha o9 che# radiogra$h!, com$u ed omogra$h! i# o9 en $er9ormed a# com$u erized omogra$h! $ulmonar! ar er! <C:%A> wi h #u#$ec ed $ulmonar! emboli#m. =l ra#ound i# u#ed o con9irm $leural and $ericardial e99u#ion# and when $leural in er4en ion i# $lanned.

:he aim o9 hi# $a$er i#?.@ o di#cu## he radiogra$hic 9inding# o9 cardio$ulmonar! di#order# common in he ;C= $a ien and #ugge# guideline# 9or in er$re a ion ba#ed no onl! on he che# radiogra$h bu al#o on he $a ho$h!#iolog! and clinical ground#7?)@ o de#cribe he normal $o#i ion o9 moni oring de4ice# and correc $lacemen o9 o her line#, and $rom$ recogni ion when he! are mi#$laced or when o her com$lica ion# occur. De di#cu## correc $lacemen o9, a# well a# common com$lica ion# due o, moni oring line#. :hi# i# a wo-$ar #erie#1?.@ %ar ;1 Normal che# radiogra$hic a$$earance# in he ;C= $a ien , correc and incorrec $lacemen o9 4ariou# in ra horacic ube# and line# and com$lica ion# 9rom in# rumen a ion. %ar ;;1 -adiogra$h! o9 lung $a hologie# common in he ;C= $a ien .

Pulmonary dema
%ulmonar! edema i# #econdar! o accumula ion o9 9luid in he lung in er# i ium or al4eolar #$ace. %ulmonar! edema i# 9reBuen l! #een and i# a common cau#e o9 o(!gen de#a ura ion in he ;C= $a ien . Se4eral mechani#m# are im$lica ed in he gene#i# o9 $ulmonar! edema, including increa#ed h!dro# a ic gradien , increa#ed onco ic $re##ure or increa#ed ca$illar! $ermeabili !. &ne or a combina ion o9 he#e mechani#m# ma! be in4ol4ed. %ulmonar! edema i# broadl! #ubdi4ided in o cardiac and noncardiac. Cardiac edema i# u#uall! #econdar! o $oor cardiac 9unc ion, whil# noncardiogenic $ulmonar! edema can re#ul 9rom 4olume o4erload, dimini#hed onco ic $re##ure or 9rom endo helial inEur! a# in he $a ien wi h adul re#$ira or! di# re## #!ndrome <A-DS>. ;n er# i ial edema re#ul # 9rom 9luid collec ion in he lung in er# i ial #$ace and u#uall! de4elo$# when he $ulmonar! 4enou# $re##ure ri#e# o )5-A,mm Hg. ;n er# i ial $ulmonar! edema i# one condi ion which ma! be #een on a che# radiogra$h be9ore #!m$ om# de4elo$. -adiogra$hic #ign# ha #ugge# in er# i ial $ulmonar! edema include lo## o9 de9ini ion o9 large $ulmonar! 4e##el#, he a$$earance# o9 #e$ al line#, in erlobar #e$ al hic2ening, di99u#e re icular $a ern re#embling in er# i ial 9ibro#i# and $eribronchial cu99ing #een a# bronchial wall hic2ening a# a re#ul o9 9luid re en ion in he lung in er# i ium. Se$ al line# re$re#en 9luid in he dee$ #e$ ae and l!m$ha ic# and a$$ear a#?.@ Kerle!F# A line#, which range 9rom 5 o .,cm in leng h and e( end 9rom he hilum o9 he lung oward he $eri$her! in a # raigh or #ligh l! cur4ed cour#e7 and?)@ Kerle!F# ' line#, a$$ro(ima el! )cm long, #een in he $eri$her! o9 he lower lung, e( ending o he $leura ?"igure .@. Al4eolar $ulmonar! edema generall! de4elo$# when he $ulmonar! 4enou# $re##ure e(ceed# A, mm Hg and i# u#uall! $receded b! in er# i ial $ulmonar! edema ?"igure )@. Che# radiogra$hic 9inding# include bila eral o$aci ie# ha e( end in a 9an #ha$e ou ward 9rom he hilum in a Gba wingH $a ern ?"igure A@. Di h wor#ening al4eolar edema, he lung o$aci9ica ion become increa#ingl! homogenou#. Normall! he bronchi in he lung $eri$her! are no #een becau#e o9 air den#i ! wi hin he bronchi and he #urrounding lung $arench!ma. Howe4er, along wi h 9luid9illed al4eoli 9rom $ulmonar! edema or in9ec ion <$neumonia>, he air-9illed bronchi can be ea#il! #een, an a$$earance 2nown a# Gair bronchogramH ?"igure *@. Air bronchogram# a##ocia ed wi h conge# i4e hear 9ailure are u#uall! 4i#ible in he righ u$$er lobe. ;n $ulmonar! edema due o hear 9ailure, he hear #ize i# o9 en enlarged.

Diagno#i# o9 $ulmonar! edema i# no alwa!# # raigh 9orward, and a !$ical $a ern# can $re#en diagno# ic di99icul ie# on radiogra$hic 9inding# alone. A !$ical radiogra$hic $a ern# o9 $ulmonar! edema include unila eral, lobar, miliar! or lower-zone# edema7 and o her a#!mme ric or unu#ual di# ribu ion $a ern# ?"igure 5@. Miliar! edema ma! $recede 9ull-blown lung edema. Lower-zone# edema and lobar $ulmonar! edema generall! occur in $a ien # wi h chronic ob# ruc i4e $ulmonar! di#ea#e and $ulmonar! em$h!#ema. Conge# i4e cardiac 9ailure cau#ing cardiogenic $ulmonar! edema i# u#uall! he re#ul o9 le9 4en ricular 9ailure, which i# in urn due o $oor cardiac ou $u and increa#ed $ulmonar! 4enou# h!dro# a ic $re##ure#. Generall! i i# a combina ion o9 a 9ailing cardiac $um$ and 9luid o4erload ha i$# $a ien # in o conge# i4e hear 9ailure. :he che# radiogra$h i# an im$or an diagno# ic ool in di# ingui#hing 9luid o4erload or conge# i4e 9ailure. :hi# diagno#i# o9 a le9 -#ided cardiac 9ailure due o an acu e i#chemic cardiac in#ul i# #ugge# ed on he che# radiogra$h# in )5I o *,I o9 $a ien # be9ore he on#e o9 #!m$ om#. ;deall! he be# echniBue in hi# #e ing i# a # andard %A che# radiogra$h becau#e he accurac! o9 de ec ing cardiomegal! and redi# ribu ion o9 $ulmonar! blood 9low on #u$ine A% 9ilm# i# $oor. &b aining an erec %A radiogra$h ma! no be alwa!# $o##ible in an ;C= $a ien 7 and here9ore a# a com$romi#e, #emi-erec and decubi u# 9ilm# are recommended. Cardiomegal!, increa#ed $ulmonar! 4a#cula ure, and $leural e99u#ion# are e4iden in he $a ien #u99ering 9rom conge# i4e hear 9ailure. A che# radiogra$h ma! di99eren ia e be ween cardiac and noncardiac $ulmonar! edema. :he radiogra$hic 9ea ure# o9 cardiac edema include cardiomegal!, $leural e99u#ion#, u$$er lobe blood di4er#ion, #e$ al line#, $eribronchial cu99ing and ba#al edema. :he onl! e(ce$ ion where he a9oremen ioned change# ha4e no had ime o de4elo$ i# acu e m!ocardial in9arc ion. :here are a mul i ude o9 cau#e# o9 noncardiogenic $ulmonar! edema, which include inhaled irri an # cau#ing a more mo led a$$earance and more $eri$heral di# ribu ion o9 lung $arench!mal change#. & her cau#e# o9 noncardiogenic $ulmonar! edema include near-drowning, al i ude #ic2ne##, o(!gen hera$!, ran#9u#ion reac ion#, 9a emboli#m, cen ral ner4ou# #!# em di#order, A-DS or a#$ira ion, renal di#order orCand drug reac ion#, o name Eu# a 9ew.?.J.5@.

Adult Respiratory !istress "yndrome

Adul re#$ira or! di# re## #!ndrome <A-DS> i# a erm a$$lied o a #!ndrome where #ign# and #!m$ om# o9 $ulmonar! edema occur in he ab#ence o9 ele4a ed $ulmonar! 4enou# $re##ure#. A-DS i# a##ocia ed wi h high mor ali !, a# much a# 5,I, and i# common in he ;C= $a ien #. A-DS re#ul # 9rom a 4arie ! o9 cau#e#, including #e$#i# or $ulmonar! in9ec ion, #e4ere rauma, and a#$ira ion o9 ga# ric con en #.?.K@ :he 9inal $a hwa! in A-DS i# common o all cau#e#, which i# damage o he al4eolar ca$illar! endo helium, increa#ed 4a#cular $ermeabili !, and #ub#eBuen de4elo$men o9 9ir# , in er# i ial, and hen, al4eolar $ulmonar! edema. %a ien # wi h A-DS $re#en wi h #e4ere re#$ira or! di# re## charac erized b! mar2ed h!$o(ia ha re#$ond# $oorl! e4en o admini# ra ion o9 high concen ra ion# o9 o(!gen. :he $ulmonar! ca$illar! wedge $re##ure i# generall! normal, bu here i# decrea#ed #ur9ac an $roduc ion, which lead# o $oor lung com$liance and a elec a#i# ha re#ul # in an in ra$ulmonar! #hun wi h $er9u#ion bu no e99ec i4e 4en ila ion. %o#i i4e end-e($ira or! $re##ure can hel$ o decrea#e a elec a#i# and #hun ing while im$ro4ing o(!gena ion. :he ul ima e $rogno#i# i# 4ariable1 whil# #ome ma! reco4er 9ull!, o her# $rogre## o $ulmonar! 9ibro#i#. :here i# #ome correla ion be ween he

dura ion and #e4eri ! o9 A-DS and long- erm com$lica ion#. %rogno#i# i# al#o de$enden on age and $ree(i# ing C&%D. Di99eren ia ion be ween $ulmonar! edema o9 A-DS and conge# i4e hear 9ailure on he ba#i# o9 radiogra$hic #ign# alone can be challenging7 moreo4er, he wo condi ion# ma! coe(i# ?"igure# ?"igure#// and andK@.K@. Al hough bo h en i ie# ma! #hare he che# (-ra! 9inding o9 bila eral air #$ace o$aci9ica ion or Gwhi e ou ,H A-DS i# no u#uall! a##ocia ed wi h cardiomegal! or u$$er lobe blood di4er#ion7 howe4er, u$$er lobe blood di4er#ion i# di99icul o di#cern in he $re#ence o9 air #$ace o$aci9ica ion and on A% che# #u$ine radiogra$h. Air #$ace o$aci9ica ion in CH" can occur in he $re#ence o9 a normal-#ized hear . :o ma2e he i##ue more com$lica ed, $a ien # wi h A-DS could al#o ha4e $ree(i# en cardiomegal! or be 9luid o4erloaded becau#e o9 #e$#i#.?.KJ )A@ Lung con u#ion ma! be di99icul o di99eren ia e 9rom A-DS. Con u#ion howe4er u#uall! occur# earlier, i# u#uall! localized o he area a99ec ed b! inEur! <e.g., unila eral and lower or u$$er zone#> and im$ro4e# o4er *6-K) hour#. A-DS end# o be more generalized, i# la er in on#e and #lower o re#ol4e ?"igure# 6J.,@.

Atelectasis
A elec a#i# occur# when here i# 9ailure o9 he lung o e($and <in9la e> com$le el!. :hi# ma! be cau#ed b! an! $roce## which reduce# al4eolar 4en ila ion, including bloc2ed airwa!, e.g., ob# ruc ion 9rom mucu# $lugging, a umor, general ane# he#ia, $neumonia, #$lin ing 9rom $ain 9ollowing #urger!.?)6,A),AA@ 0( en#i4e al4eolar h!$o4en ila ion ma! cau#e h!$o(ia a# a re#ul o9 an e99ec i4e righ - o-le9 #hun . ; i# a common abnormali ! #een on he ;C= $a ien F# che# radiogra$h. A elec a#i# in ;C= $a ien # i# #een mo# 9reBuen l! in he le9 lower lobe. ; i# $o# ula ed ha hi# i# due o com$re##ion o9 he lower lobe bronchu# b! he hear , in he #u$ine $a ien . A con ribu or! 9ac or ma! be rela i4el! di99icul ! o9 blind #uc ioning o9 he le9 lower lobe. =#uall! a elec a#i# i# more e( en#i4e han i# #ugge# ed b! he radiogra$h. A elec a#i# can bo h be re4er#ed and $re4en ed wi h he u#e o9 h!$er4en ila ion and incen i4e #$irome r!, $ar icularl! in he $o# o$era i4e $a ien . A elec a#i# ma! 4ar! 9rom a o al lung colla$#e o #ub#egmen al colla$#e o rela i4el! normala$$earing lung# on he che# radiogra$h a# an acu e mucu# $lugging ma! cau#e onl! a #mall reduc ion in lung 4olume wi hou 4i#ible abnormali !. No wi h# anding radiogra$hic a$$earance#, he $h!#iological e99ec # ma! be #igni9ican . ;n a mucu# $lug #!ndrome, a #udden on#e o9 h!$o(ia in he $re#ence o9 a normal-loo2ing radiogra$h can rai#e he #u#$icion o9 a $ulmonar! embolu# and warran an unnece##ar! C:%A. :he radiogra$hic 9ea ure# o9 a elec a#i# are #ummarized in :able .. Minimal ba#al #ub#egmen al or di#coid a elec a#i# a$$earing a# linear # rea2# i# common in he ;C= $a ien and ma! no be $h!#iologicall! #igni9ican ?"igure ..@. A elec a#i# ma! al#o mimic $ulmonar! con#olida ion, which ma! be di99icul o di# ingui#h 9rom o her cau#e# o9 con#olida ion. :o di# ingui#h be ween a elec a#i#-rela ed con#olida ion and con#olida ion# rela ed o o her cau#e# i# im$or an , and cer ain di# ingui#hing 9ea ure# do e(i# . A elec a#i# will o9 en re#$ond o increa#ed 4en ila ion while o her cau#e# o9 $ulmonar! con#olida ion will no . & her 9ea ure# ha #ugge# a elec a#i# becau#e o9 lo## o9 4olume in he in4ol4ed lung include crowding o9 $ulmonar! 4e##el#, di#$lacemen o9 in erlobar 9i##ure# and ele4a ion o9 he hemidia$hragm

oward# area# o9 a elec a#i#. Colla$#ed lung #egmen # and lobe# al#o 9ollow well-recognized ana omical $a hwa!#, unli2e o her cau#e# o9 con#olida ion. :he righ u$$er lobe colla$#e# in o a riangular o$aci !, wi h he le##er 9i##ure migra ing oward he an erior, #u$erior and medial $or ion o9 he che# , clo#ing li2e a Chine#e 9an. &n an A% che# radiogra$h, he mo# # ri2ing 9ea ure i# a #u$erior and medial di#$lacemen o9 he minor 9i##ure. &n he la eral radiogra$h, he maEor 9i##ure mo4e# an eriorl!, while he #u$erior mo4emen o9 he minor 9i##ure i# al#o #een ?"igurea .) and and.A.A@. -igh Jmiddle-lobe a elec a#i# ma! cau#e minimal change# on an A% #u$ine che# radiogra$h. A con# an 9ea ure i# lo## o9 de9ini ion o9 he righ hear border. A colla$#ed righ middle lobe i# more clearl! de9ined on la eral radiogra$h, which i# no commonl! a4ailable in he ;C= $a ien . A en ion o he 9i##ure# re4eal# ha he horizon al and lower $or ion# o9 he maEor 9i##ure# mo4e oward# each o her re#ul ing in a wedge o9 o$aci ! $oin ing o he hilum. A middle-lobe a elec a#i# ma! mimic middle-lobe $neumonic con#olida ion ?"igure .*@. A elec a#i# o9 ei her he righ or le9 lower lobe $re#en # a #imilar a$$earance. ;n righ Jlowerlobe a elec a#i# he colla$#ing lobe mo4e# cen rall! and in9eriorl! oward# he lower dor#al #$ine, where i i# #een a# a riangular o$aci !. Silhoue ing o9 he righ hemidia$hragm and air bronchogram# i# a common #ign o9 righ Jlower-lobe a elec a#i#. :he minor 9i##ure #how# #ome in9erior di#$lacemen . A# he righ lower lobe colla$#e#, $ar o9 he grea er 9i##ure ma! become 4i#ible on he A% radiogra$h. A la eral radiogra$h, i9 ob ained, ma! #how in9erior and $o# erior di#$lacemen o9 bo h he maEor and minor 9i##ure#. -igh Jlower-lobe a elec a#i# can be di99eren ia ed 9rom righ Jmiddle-lobe a elec a#i# b! he $er#i# ence o9 he righ hear border ?"igure# ?"igure#.5.5 and and././@. A le9 Ju$$er-lobe a elec a#i# $re#en # a di99eren $a ern com$ared o a righ Ju$$er-lobe a elec a#i# a# he le9 lung lac2# a minor 9i##ure. Dhen he le9 u$$er lobe colla$#e#, he lobe $redominan l! mo4e# an eriorl!, wi h lo## o9 he le9 u$$er cardiac border. :here i# com$en#a or! em$h!#ema o9 he le9 lower lobe, which e($and# and migra e# o a loca ion bo h #u$erior and $o# erior o he le9 u$$er lobe. :he le9 main bronchu# al#o ro a e# o a nearl! horizon al $o#i ion. :he A% che# radiogra$h re4eal# haz! o$aci9ica ion o9 he le9 hilum, ele4a ion o9 he le9 hilum, near-horizon al cour#e o9 he le9 main bronchu#, $o# erior le9 ward ro a ion o9 he hear and he Lu9 #ichel or air cre#cen #ign, he name gi4en o he a$$earance o9 aera ed lung abu ing he arch o9 he aor a, be ween he media# inum and he colla$#ed le9 u$$er lobe ?"igure .K@. An a$$earance on a la eral radiogra$h, i9 a4ailable, o9 he ;C= $a ien ma! #how re ro# ernal o$aci ! and di#$lacemen o9 he grea er 9i##ure an eriorl!. :he le9 lower lobe colla$#e# mediall! and $o# eriorl! o lie behind he hear . ; cla##icall! di#$la!# a riangular o$aci !, which ma! be 4i#ible hrough he cardiac #hadow or ma! o4erlie i , gi4ing he hear an unu#uall! # raigh la eral border. Silhoue ing o9 he le9 hemidia$hragm u#uall! occur#, which ma! be a##ocia ed wi h an air bronchogram. ; i# al#o ea#il! mi##ed, e#$eciall! on an under$ene ra ed 9ilm, where no de ail i# #een behind he hear .?.6JA/@

Pneumonia in the ICU

Ho#$i al-ba#ed <no#ocomial> $neumonia#, which b! de9ini ion occur A da!# a9 er ho#$i al admi##ion, di99er 9rom communi !-acBuired $neumonia# in bo h cau#a ion and $rogno#i#. No#ocomial $neumonia i# he leading cau#e o9 dea h in he ;C= $a ien .?*,@ :he ;C= $a ien # are $ar icularl! #u#ce$ ible o $neumonia# a# he! ma! be immune com$romi#ed and #e4eral ia rogenic 9ac or# are a $la!, which increa#e hi# #u#ce$ ibili !. ;a rogenic 9ac or# ha ma! $redi#$o#e o $neumonia# include endo racheal ube#7 ri#2 o9 a#$ira ion7 medica ion# u#ed o reduce ga# ric acid, which ma! $romo e bac erial grow h in he # omach7 and he u#e o9 an ibio ic#, which ma! #elec i4el! encourage he grow h o9 #ome $a hogenic bac eria. =nli2e communi !-acBuired $neumonia#, which u#uall! are cau#ed b! gram-$o#i i4e #$ecie#, no#ocomial $neumonia# are o9 en $ol!microbial and cau#ed b! gram-nega i4e en eric $a hogen#. Clinical and labora or! 9inding# #uch a# 9e4er, leucoc! o#i# and #$u um cul ure# ma! no be u#e9ul indica or# and are o9 en ma#2ed b! #e4ere underl!ing di#ea#e. :he che# 9ilm mu# be correla ed wi h clinical da a in order o ma2e he diagno#i# o9 $neumonia in he ;C= $a ien . -adiogra$hicall! $neumonia# can be di99icul o di99eren ia e 9rom o her cau#e# o9 air #$ace #hadowing, including a elec a#i# and earl! A-DS. =#uall! $neumonia ini iall! a$$ear# a# $a ch! con#olida ion or ill-de9ined nodule# ?"igure .6@. %neumonia i# a bila eral mul i9ocal di#ea#e and o9 en in4ol4e# gra4i !-de$enden area# o9 he lung ?"igure .+@. A elec a#i# and lung edema ha4e a #imilar di# ribu ion, ma2ing di99eren ia ion 9rom $neumonia di99icul . A #!mme ric $a ern #imula ing $ulmonar! edema can occur wi h E-coli and $#eudomona# $neumonia#, which can ra$idl! in4ol4e he en ire lung#. %a ch! air #$ace #hadowing, ill-de9ined #egmen al con#olida ion or air bronchogram# L ei her o9 he#e wi h a##ocia ed $leural e99u#ion# #u$$or # he diagno#i# o9 $neumonia. Howe4er, unli2e communi !-acBuired $neumonia, $leural e99u#ion# cau#ed b! gramnega i4e organi#m# are more li2el! o re$re#en em$!ema and here9ore reBuire drainage. & her #eriou# com$lica ion# o9 $neumonia# in he ;C= $a ien # include ab#ce## 9orma ion and broncho$leural 9i# ula#.?AKJ*,@

Aspiration
:he ;C= $a ien i# a a $ar icular ri#2 o9 a#$ira ion $neumoni i#, o9 en a# a re#ul o9 a com$romi#ed airwa!. ;m$aired con#ciou#ne##, $lacemen o9 0: and NG ube# are among# man! con ribu or! 9ac or#. :he $ulmonar! re#$on#e o a#$ira ion de$end# on he !$e, $H and 4olume o9 a#$ira e. A#$ira ion o9 ga# ric con en # $ro4o2e# a chemical $neumoni i# called Mendel#onF# #!ndrome. :he lung re#$ond# o $H M).5 wi h #e4ere broncho#$a#m and he relea#e o9 in9lamma or! media or#. %a ien # become #!m$ oma ic almo# immedia el! 9ollowing a#$ira ion o9 ga# ric con en #, wi h cough, d!#$nea, wheezing and di99u#e crac2le#. "e4er and leucoc! o#i# are he norm. :he ini ial re#$on#e i# a chemical $ulmonar! edema. Secondar! in9ec ion occur# in #ome ca#e#. %a ien re#$on#e o a#$ira ion 4arie# 9rom #hoc2 o re#olu ion wi hou #eBuelae. %a ien # ha $roceed o $neumoni i# ma! re4eal $ulmonar! con#olida ion wi hin he 9ir# wo da!#. :he air #$ace #hadowing i# bila eral, u#uall! $erihilar al hough a#!mme ric. -adiogra$hicall! he con#olida ion u#uall! begin# o re#ol4e b! he hird da! ?"igure# ?"igure#),), and and).@.).@. ;n #ome, he con#olida ion ma! wor#en wi h added com$lica ion# o9 lung ab#ce##e# and $leural e99u#ion.?*.,*)@

Pulmonary mbolism

Morbidi ! and mor ali ! 9rom $ulmonar! emboli#m in he ;C= remain high, and he! con inue o be underdiagno#ed in he in en#i4e care #e ing. %ulmonar! emboli#m in he ;C= #e ing ma! be com$le el! #ilen , bu i i# a cau#e o9 #udden dea h. S!m$ om# are non#$eci9ic and include d!#$nea, ach!$nea, hemo$ !#i#, h!$o(emia and $leuri ic che# $ain. Man! ri#2 9ac or# e(i# , mo# im$or an among# hem being a hi# or! o9 a $re4iou# embolic e4en . & her ri#2 9ac or# include immobiliza ion, rauma, #urger!, #hoc2, obe#i !, $regnanc!, $ol!c! hemia 4era and an i hrombin-;;; de9icienc!. :he $a ho$h!#iolog! o9 $ulmonar! emboli#m con#i# # o9 bo h hemod!namic and re#$ira or! embarra##men . Hemod!namic con#eBuence# occur when more han hal9 he cro##-#ec ional area o9 he $ulmonar! 4a#cular bed i# occluded b! he embolic e$i#ode, leading o acu e $ulmonar! h!$er en#ion, h!$o(emia, re#$ira or! 9ailure and righ -#ided hear 9ailure. %ulmonar! in9arc ion en#ue# rarel! in he ab#ence o9 a##ocia ed bronchial ar erial com$romi#e. :!$icall!, in9arc ion# end o be hemorrhagic and occur in he lower lobe#. :he che# radiogra$h ha# $oor #en#i i4i ! in e# abli#hing he diagno#i# o9 $ulmonar! emboli#m, and he role o9 a che# radiogra$h i# in ruling ou o her $a hologie# ha ma! ha4e a clinical $re#en a ion #imilar o ha o9 $ulmonar! emboli#m. :he che# (-ra! al#o #er4e# a u#e9ul $ur$o#e when in er$re ing 4en ila ion-$er9u#ion #can#. S udie# ha4e #hown ha he 4a# maEori ! o9 $a ien # wi h $ulmonar! emboli#m in re ro#$ec do ha4e abnormali ie# on he che# (-ra! 9inding#, bu he#e 9inding# are oo non#$eci9ic o be o9 clinical 4alue ?"igure# ?"igure#))))J)*@. ;n he ab#ence o9 $ulmonar! in9arc ion, onl! a 9ew #ign# o9 $ulmonar! emboli are #een on a che# radiogra$h, which include di#coid a elec a#i#, ele4a ion o9 he hemidia$hragm, enlargemen o9 he main $ulmonar! ar er! in o wha ha# been de#cribed a# he #ha$e o9 a G#au#ageH or a G2nuc2leH <%allaF# #ign>, and $ulmonar! oligemia be!ond he $oin o9 occlu#ion <De# ermar2F# #ign>. A con# ella ion o9 radiogra$hic #ign# ma! be #een when $ulmonar! in9arc ion com$lica e# $ulmonar! emboli#m. Mul i9ocal con#olida ion ma! 9ollow wi h e# abli#hed $ulmonar! in9arc ion# wi hin .) o )* hour# 9ollowing he embolic e$i#ode. A rela i4el! la e #ign o9 $ulmonar! in9arc ion i# a rounded $leural-ba#ed con#olida ion ha i# rounded cen rall! and i# called a Ham$ omF# Hum$. A Ham$ omF# Hum$ can be di99eren ia ed 9rom a $neumonic con#olida ion a# he 9ormer lac2# an air bronchogram. ;$#ila eral or bila eral $ulmonar! e99u#ion# al hough non#$eci9ic are a##ocia ed wi h a$$ro(ima el! 5,I o9 $ulmonar! emboli, al hough he#e are cer ainl! non#$eci9ic 9inding#. ;n9arc # o9 en are con9u#ed wi h, or are indi# ingui#hable 9rom, a elec a#i# or $neumonia# on che# radiogra$h#. Howe4er, de#$i e he low #en#i i4i ! o9 che# radiogra$h! in he diagno#i# o9 $ulmonar! emboli#m, i remain# an im$or an 9ir# # e$ in he diagno#i# o9 $ulmonar! emboli#m, $rimaril! o e(clude o her cau#e# o9 h!$o(emia and o aid in he in er$re a ion o9 he 4en ila ionC$er9u#ion #can.?*AJ5,@

Conclusion
:o #ummarize, radiogra$h! o9 lung $a hologie# common in he ;C= $a ien i# di#cu##ed, including $ulmonar! edema, A-DS, a elec a#i#, $ulmonar! emboli#m, a#$ira ion and ;C=acBuired $neumonia in erm# o9 $a hogene#i# and radiogra$hic recogni ion o9 he abnormali ie#. Di99eren ial diagno#i# o9 he radiogra$hic #ign# encoun ered i# di#cu##ed. -e9erence i# made where o her imaging #uch a# C: or ul ra#ound i# indica ed. A #ummar! o9 radiogra$hic recogni ion o9 a elec a#i# i# $re#en ed.

#ootnotes
"ource of "upport: Nil Conflict of Interest: None declared.

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#igures and $ables

#igure %

"ron al che# radiogra$h <righ > #howing 9ea ure# o9 in er# i ial $ulmonar! edema. -adiogra$hic #ign# <#hown in he 9igure> ha #ugge# in er# i ial $ulmonar! edema include lo## o9 de9ini ion o9 large $ulmonar! 4e##el#, he a$$earance# o9 #e$ al line#, in erlobar #e$ al hic2ening and di99u#e re icular $a ern a##ocia ed wi h cardiomegal!. 'o h Kerle!F# A and Kerle!F# ' line# are #een. :he magni9ied 4iew o9 he le9 co# o$hrenic angle i# 9rom ano her $a ien , de$ic ing Kerle!F# ' line# <le9 >

#igure &

"ron al che# radiogra$h #howing 9ea ure# o9 al4eolar $ulmonar! edema. :he 9inding# include o$aci9ica ion o9 bo h lung# wi h increa#ing den#i ! oward# he lung ba#e# due o a combina ion o9 air #$ace #hadowing and $leural e99u#ion#, cardiomegal!, u$$er lobe blood di4er#ion <unreliable on #u$ine A% radiogra$h> and an air bronchogram in he righ u$$er zone

#igure '

A 9ron al che# radiogra$h and a(ial C: #how 9ea ure# o9 Gba wingH al4eolar $ulmonar! edema. Che# radiogra$hic 9inding# include bila eral o$aci ie# ha e( end in a 9an #ha$e ou ward 9rom he hilum in a ba wing7 $a ern. Di h wor#ening al4eolar edema, he lung o$aci9ica ion become# increa#ingl! homogenou#

#igure (

Su$ine $or able che# radiogra$h #howing e( en#i4e air #$ace #hadowing hroughou he whole o9 he righ lung and he le9 lung ba#e due o al4eolar $ulmonar! edema wi h a##ocia ed $leural e99u#ion# #econdar! o hear 9ailure. No e he air bronchogram# in he righ u$$er zone, #ome ime# #een wi h conge# i4e hear 9ailure

#igure )

A 9ron al che# radiogra$h #howing a unila eral edema

#igure *

A $a ien F# A% che# radiogra$h #howing wor#ening o9 he air #$ace #hadowing wi h a 9ur her com$lica ion o9 a righ -#ided $neumo hora(

#igure +

A% radiogra$h o9 he #ame $a ien wi h A-DS a# in "igure / wi h 9ur her com$lica ion o9 bila eral $neumo horace# #econdar! o $leural drain $lacemen

#igure ,

"igure# "igure#6,6, ,++ and and.,., #how a #erie# o9 che# (-ra!# and C: #can# o4er a $eriod o9 .6 hour# o9 a $a ien 9ollowing blun horacic rauma. :he ini ial che# (-ra! ?"igure 6@ a$$ear# normal

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Same $a ien a# in "igure 67 change# de4elo$ ra$idl! ini iall! a# mild o$aci9ica ion a he righ lung ba#e 9ollowed b! lung $arench!mal in9il ra e a##ocia ed wi h a #mall $leural e99u#ion

#igure %.

Same $a ien a# in "igure 67 he o$aci ! i# in he $eri$heral lung, near he inEured che# wall. :he le#ion ra$idl! $rogre##e# o ca4i a ion a# #een on he a(ial C: #can#. :he a$$earance# are ho#e o9 a lung con u#ion. Con u#ion howe4er u#uall! occur# earlier, i# u#uall! localized o he area a99ec ed b! inEur! <e.g., unila eral and lower or u$$er zone#> and im$ro4e# o4er *6-K) hour#. A-DS end# o be more generalized, i# la er in on#e and #lower o re#ol4e

$able %
-adiogra$hic 9ea ure# o9 a elec a#i# 0le4a ion o9 a hemidia$hragm Di#$lacemen o9 a 9i##ure Crowding o9 he 4a#cula ure S$la!ing o9 he 4a#cula ure #een in he non-a99ec ed lobe due o com$en#a or! em$h!#ema Media# inal #hi9 Silhoue ing

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%la e a elec a#i#Cdi#coid a elec a#i# <arrow> i# common 9ollowing horaco-abdominal #urger! and admini# ra ion o9 a general ane# he ic

#igure %&

:he righ u$$er lobe colla$#e# in o a riangular o$aci ! wi h he le##er 9i##ure migra ing oward he an erior, #u$erior and medial $or ion# o9 he che# , clo#ing li2e a Chine#e 9an. &n an A% che# radiogra$h, he mo# # ri2ing 9ea ure i# a #u$erior and medial di#$lacemen o9 he minor 9i##ure. No e al#o he rai#ed righ hemidia$hragm. &n he la eral radiogra$h <no #hown>, he maEor 9i##ure mo4e# an eriorl!, while he #u$erior mo4emen o9 he minor 9i##ure i# al#o #een. :hi# a elec a#i# wa# #econdar! o a mucu#$lug

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A 9ron al radiogra$h #how# a #egmen al colla$#e o9 he righ u$$er lobe. No e he ele4a ion o9 he le##er 9i##ure and he righ hilum and a minor media# inal #hi9 o he righ . :hi# wa# an a# hma ic $a ien , wi h a mucu# $lug

#igure %(

-igh Jmiddle-lobe a elec a#i# ma! cau#e minimal change# on an A% #u$ine che# radiogra$h. No e he lo## o9 de9ini ion o9 he righ hear border. A colla$#ed righ middle lobe i# more clearl! de9ined on la eral radiogra$h, which i# no commonl! a4ailable in he ;C= $a ien . A en ion o he 9i##ure# re4eal# ha he horizon al and lower $or ion# o9 he maEor 9i##ure# mo4e oward# each o her re#ul ing in a wedge o9 o$aci ! $oin ing o he hilum. :hi# i# a middle-lobe con#olida ion mimic2ing middle-lobe a elec a#i#

#igure %)

An A% che# radiogra$h #howing a elec a#i# o9 he righ lower lobe. No e ha he colla$#ing lobe ha# mo4ed cen rall! and in9eriorl! oward# he lower dor#al #$ine, where i i# #een a# a riangular o$aci ! $ar iall! #ilhoue ing he righ hemidia$hragm and a##ocia ed wi h a #ub le air bronchogram. :he minor 9i##ure #how# in9erior di#$lacemen . -igh Jlower-lobe a elec a#i# can be di99eren ia ed 9rom righ Jmiddle-lobe a elec a#i# b! he $er#i# ence o9 he righ hear border a# in hi# ca#e

#igure %*

:he le9 lower lobe colla$#e# mediall! and $o# eriorl! o lie behind he hear . ; cla##icall! di#$la!# a riangular o$aci !, which ma! be 4i#ible hrough he cardiac #hadow or ma! o4erlie i , gi4ing he hear an unu#uall! # raigh la eral border. Silhoue ing o9 he le9 hemidia$hragm u#uall! occur#, which ma! be a##ocia ed wi h an air bronchogram. ; i# al#o ea#il! mi##ed, e#$eciall! on an under$ene ra ed 9ilm, where no de ail i# #een behind he hear

#igure %+

A 9ron al che# radiogra$h #howing a le9 Ju$$er-lobe a elec a#i#. :he radiogra$h re4eal# haz! o$aci9ica ion o9 he le9 hilum, ele4a ion o9 he le9 hilum, near-horizon al cour#e o9 he le9 main bronchu#, $o# erior le9 ward ro a ion o9 he hear and he Lu9 #ichel or air cre#cen #ign, he name gi4en o he a$$earance o9 aera ed lung abu ing he arch o9 he aor a, be ween he media# inum and he colla$#ed le9 u$$er lobe. An a$$earance on a la eral radiogra$h, i9 a4ailable, o9 he ;C= $a ien ma! #how re ro# ernal o$aci ! and di#$lacemen o9 he grea er 9i##ure an eriorl!

#igure %,

A che# radiogra$h <righ > #howing con#olida ion o9 le9 u$$er zone a##ocia ed wi h an air bronchogram #econdar! o ho#$i al-acBuired $neumonia. :he le9 image i# an a(ial C: #can de$ic ing an air bronchogram wi h bila eral $neumonic con#olida ion in ano her $a ien

#igure %-

An A% #u$ine radiogra$h on an in uba ed $a ien #howing $a ch! con#olida ion in bo h lung 9ield#, more $rominen on he le9 due o ho#$i al-acBuired $neumonia

#igure &.

An A% che# radiogra$h o9 a $a ien wi h racheo# om! #howing de4elo$men o9 a#$ira ion $neumonia a he righ lung ba#e

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A #erie# o9 A% radiogra$h# on he #ame $a ien a# in "igure ), #howing e4olu ion o9 a#$ira ion $neumonia a he righ lung ba#ewi hin

#igure &&

A 9ron al che# radiogra$h o9 a $a ien $re#en ing wi h #hor ne## o9 brea h and h!$o(emia, which #how# no #igni9ican abnormali !. Howe4er, C:%A <coronal recon# ruc ion> #how# e( en#i4e $ulmonar! emboli#m

#igure &'

A rela i4el! la e #ign o9 $ulmonar! in9arc ion i# a rounded $leural ba#ed con#olida ion ha i# rounded cen rall! and i# called a Ham$ omF# Hum$. A Ham$ om,# Hum$ can be di99eren ia ed 9rom a $neumonic con#olida ion a# he 9ormer lac2# an air bronchogram. No e al#o a #mall righ co# o$hrenic e99u#ion rac2ing u$ in o he le##er 9i##ure

#igure &(

A $leural-ba#ed #egmen al o$aci ! due o in9arc ion <le9 >, #ub#eBuen l! con4er ing in o a hic2walled ca4i ! <righ >