Radiographic measures of intravascular volume status: the role
of vascular pedicle width
Russell R. Miller and E. Wesley Ely
Purpose of review
A valid, low-cost, high-yield instrument to assess
intravascular volume status in critically ill patients does not
exist. The portable chest X-ray is a common part of any
intensivist’s or chest clinician’s daily rounds.
Recent findings
A simple, objective, valid measure of intravascular volume
status, the vascular pedicle width, remains
underappreciated in the medical literature. While more
invasive, more expensive, and less common technologies
are looked upon to assist in the clinical evaluation of volume
status among critically ill patients, the vascular pedicle
width stands alone in its low-cost, nearly risk-free potential
to impact clinical practice. Even as the daily chest X-ray has
become less common in practice, the role of measuring
vascular pedicle width is potentially significant, particularly
among mechanically ventilated patients. A standardized
approach to reading the portable chest X-ray (supine or
erect) is needed to facilitate interpretation of complex
medical problems among the critically ill. Prospective
evaluation of its appropriate use, particularly as compared
with other, typically more invasive measures of intravascular
volume, is warranted.
Summary
Vascular pedicle width measurement using a standardized
approach to daily chest X-ray interpretation represents
untapped potential for improving the non-invasive
assessment of volume status in critically ill patients.
Keywords
chest radiography, intensive care unit, pulmonary edema,
vascular pedicle width, volume status
Curr Opin Crit Care 12:255–262. ß 2006 Lippincott Williams & Wilkins.
Department of Medicine, Division of Allergy/Pulmonary/Critical Care Medicine of
the Vanderbilt University School of Medicine, Nashville, Tennessee, USA
Correspondence to Russell R. Miller, MD, MPH, Division of Allergy/Pulmonary/
Critical Care Medicine, Center for Health Services Research, 6th Floor Medical
Center East, Vanderbilt University Medical Center, Nashville, TN 37232-8300, USA
Tel: +1 615 936 5068; fax: +1 615 936 1269;
e-mail: russell.miller@vanderbilt.edu
Current Opinion in Critical Care 2006, 12:255–262
Abbreviations
ARDS acute respiratory distress syndrome
CTR cardiothoracic ratio
CXR chest X-ray
ICU intensive care unit
VPW vascular pedicle width
ß 2006 Lippincott Williams & Wilkins
1070-5295
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Introduction
Following the completion of several trials addressing the
risks and benefits of pulmonary artery catheter placement
in critically ill patients [1–5], the role of non-invasive
diagnostic studies of intravascular volume status has
never been more pertinent. Clinical assessment alone
is notoriously insensitive to changes in fluid status that
make accurate determination of intravascular volume
status difficult [6]. A combination of clinical assessment
and echocardiography [7,8] or the use of chest X-rays
(CXRs) are two such non-invasive methods. As with
pulmonary artery catheters, enthusiasm for the use
of echocardiography must be tempered because the
preponderance of evidence supports invasive, transeso-
phageal echocardiography rather than transthoracic
ultrasound [9,10]. Additionally, esophageal Doppler
monitoring [11,12] stretches the definition of non-inva-
sive. Finally, while respiratory variations in arterial pres-
sure have been shown to correlate with intravascular
volume [13], arterial lines are not routine components
of care among critically ill patients in our experience. The
information available from portable, supine CXRs of
intensive care unit (ICU) patients is probably the least
costly and least invasive method of determining volume
status and is routinely available. The width of the vas-
cular pedicle, which is the mediastinal silhouette of the
great vessels, is the focus of this discussion. Another
reported radiographic sign, the pulmonary artery to
bronchus ratio, may also contribute to estimates of intra-
vascular volume status using the portable CXR [14].
However, this sign is likely more difficult to measure
than the vascular pedicle width (VPW) and it has not
been established whether coupling this sign with VPW
assessment improves intravascular volume estimates.
Evidence supporting the application of VPW measure-
ments obtained by portable CXRs in clinical practice and
its limitations will serve as the theme of this review.
Measuring the vascular pedicle
As described in detail by Milne and colleagues [15,16]
over 20 years ago and in recent publications [17] the VPW
is measured by dropping a perpendicular line from the
point at which the left subclavian artery exits the aortic
arch and measuring across to the point at which the
superior vena cava crosses the right mainstem bronchus
(Fig. 1). When the right border of the pedicle is indistinct,
the vertical lateral border of the superior vena cava or
right brachiocephalic vein have been used in VPW
255
 256 Cardiopulmonary monitoring
Figure 1 Measuring vascular pedicle width
The vascular pedicle width is measured by (1) dropping a perpendicular
line from the point at which the left subclavian artery exits the aortic arch
and (2) measuring across to the point at which the superior vena cava
crosses the right mainstem bronchus.
measurements [15,18]. On upright posteroanterior films
(n = 83), Milne et al. [15] reported the normal VPW to be
48  5 mm. Supine, anteroposterior positioning would
increase the VPW to 58–64 mm, or by approximately
20% [15].
Potential modifying factors in determining
vascular pedicle width
Intensive care practitioners and chest clinicians recognize
that many factors can influence the measurement of
VPW, thereby reducing its predictive value. For instance,
patient posture plays a predictably significant role.
Measurement of VPW in the supine position results in
overestimation by nearly 17% in relation to true, upright
position [15]. Rotation of the patient to the right increases
the VPW, while rotation to the left decreases the
measurement. Furthermore, patient height, body build,
and focal film distance can affect the measurement of true
VPW. Reproduction of an upright, non-rotated portable
chest radiograph taken at a consistent focal film distance
minimizes these alterations.
In addition to patient positioning and technical factors,
some have raised concern that disease process or respir-
atory effort might affect the assessment of VPW. Indeed,
when components of the silhouette have been altered by
mediastinal disease, vascular engorgement, or the effects
of prior trauma, radiation, or thoracic surgery, the utility
of the VPW may be compromised. In a critical review of
261 patients, Chiou et al. [19] found that widening of the
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ascending aorta and vascular pedicle is a normal post-
operative CXR finding following cardiac transplantation.
Increased VPW may also occur in patients with extra-
vascular bleeding. On the other hand, while elevated
intravascular volume predominantly causes widening to
the right of the midline, aortic injury causes widening
predominantly to the left of the midline, together with
‘vanishing’ of the right paratracheal stripe and azygous
vein [20].
Milne et al. [15] also observed little change in VPW with
inspiration and expiration. Although mechanical venti-
lation may have profound effects upon other radiographic
findings such as the pattern and severity of parenchymal
infiltrates [21,22], VPW measurements have been found
to be consistent between spontaneous and positive pres-
sure breaths (unpublished observations from a previously
reported cohort [21]).
Differentiating patterns of pulmonary edema
Differentiating the etiology of pulmonary edema by
radiographic appearance has classically revolved around
patterns of infiltration and measurement of VPW
[16,23,24]. Milne et al. [16] in 1985 first used distribution
of pulmonary edema, width of the vascular pedicle, and
distribution of pulmonary flow to distinguish etiologies of
abnormalities in 216 predominantly upright posteroan-
terior films [16]. A VPW below 43 mm was most pre-
dictive of patients with an injury pattern of edema,
whereas a widened VPW (i.e. > 53 mm in upright films)
was predictive of volume-overload states such as cardiac
or renal failure (Fig. 2) [16]. Subsequent retrospective
evaluation of 119 CXRs using a standardized approach
to reading them was found to differentiate reliably
among patients with pulmonary edema due to left-heart
Figure 2 Measurements of the vascular pedicle width (VPW) are
significantly larger in patients with pulmonary edema due to
congestive heart failure (P < 0.01) or renal failure (P < 0.001)
compared with patients with pulmonary edema due to acute
lung injury
CXR, chest X-ray; PA, posteroanterior. Reproduced with permission
from Milne et al. [16].
 Portable chest X-rays and vascular pedicle width Miller and Ely 257
decompensation, renal failure, and lung microvascular
injury [23]. Stepwise discriminant analysis resulted in
correct classification in 86.6% of the patients, with VPW
having the second highest discriminating power (behind
the qualitative appearance of infiltrates) among 15 radio-
graphic findings [23]. The authors not only pointed out
the utility of a standard approach but also lauded the
VPW for its ability to differentiate etiologies of pulmon-
ary edema.
Acceptance of the VPW for use in critically ill patients
has been uneven. There are many potential reasons for
this in the medical community, including over-reliance
upon expensive, invasive tests that are presumed to be
more accurate by virtue of their expense and technical
nature, over-expectation of the clinical utility of the
VPW despite lack of clear evidence supporting many
similar interpretations in critically ill patients, and per-
sistent, general unfamiliarity with this sign. Additionally,
intensivists and cardiologists have historically relied
upon clinical diagnoses rather than, for example, data
derived from pulmonary artery catheterizations or from
postural variations of film technique (i.e. use of upright
rather than of supine films) as the reference standard in
prior investigations of the utility of new techniques.
Finally, many portable CXRs obtained in the ICU are
not upright but rather anteroposterior, supine films,
which are thought to yield less reliable and/or less
consistent findings.
However, the ability of the VPW to distinguish various
forms of pulmonary edema among supine critically ill
patients has been suggested by three groups. In 1998
Thomason et al. [25] assessed the role of portable, supine,
anteroposterior CXRs in differentiating acute respiratory
distress syndrome (ARDS) from pulmonary edema due to
volume overload. The accuracy of CXR interpretation
could be improved by over 30% (from 41 to 73%) by
incorporating the VPW and/or cardiothoracic ratio (CTR).
Taken by itself, the optimal cut-off for VPW to optimize
statistical accuracy in distinguishing between per-
meability and hydrostatic forms of pulmonary edema
was found to be 68 mm. The VPW correlated with
pulmonary artery occlusion pressure (r = 0.45, P = 0.008)
and CTR (r = 0.52, P = 0.01), and VPW and CTR were
correlated with one another (r = 0.49, P = 0.003). Impor-
tantly, two clinical scenarios (both familiar to intensivists
and radiologists) in which the use of the VPW would offer
an accurate estimate of current intravascular volume
status as measured by the pulmonary artery occlusion
pressure, but the explanation would be predictably
different from the original explanation of the patient’s
pulmonary edema, were identified: (1) diuresis of
patients with cardiogenic edema and (2) volume load-
ing of hypotensive patients with ARDS. In these
two scenarios, the VPW had become reduced and
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
enlarged in size, respectively, as a result of antecedent
therapy.
These findings were subsequently prospectively con-
firmed in two studies, both of which relied upon volume
status as measured by pulmonary artery catheters as
compared with supine CXRs among ICU patients. Using
logistic regression and receiver-operating characteristic
curve analyses of digital supine CXRs among 100
patients, the VPW and CTR were confirmed as the
two most important individual, radiographic predictors
of volume status [17,26]. Regardless of the presence
(66%) or absence (33%) of pulmonary edema, the best
VPW cut-off for differentiating a high versus normal to
low intravascular volume status on the supine, portable
CXR was 70 mm. In 2004 Salahuddin et al. [27] prospec-
tively measured the VPW among 45 patients. Using
receiver-operating characteristic curve analyses, a VPW
of 72 mm reflected a state of volume overload. Of course,
the utility of the VPW as a static measure of volume status
seems less reliable than a dynamic one to many people.
Usefulness of serial measurements
The true utility of the VPW in reflecting intravascular
volume status has been demonstrated on serial measure-
ments from portable CXRs. Documenting that these
serial measurements of VPW (Fig. 3) provide clinically
useful information also lends credibility in the world of
ever-changing volume status experienced by critically ill
patients. In a study of upright, non-mechanically venti-
lated patients undergoing cardiac catheterization [24],
the VPW and total blood volume were highly correlated
(r = 0.80, P < 0.001). Furthermore, a change in volume
status correlated with change in VPW (r = 0.93,
P < 0.001). An increase of 1 l in total blood volume
resulted in an increase of VPW by 5 mm when CXRs
were serially obtained in the upright position [24]. The
authors also verified that because veins are much more
compliant than arteries, alterations in intravascular fluid
volume are reflected by a greater change in the right side
of the pedicle compared with the left [15].
These observations are also consistent with serial clinical
findings in burn patients treated with intravascular
volume expansion and hemodialysis patients who under-
went volume contraction. Among 42 patients with
cutaneous burns and risks for inhalational injury, widen-
ing of the vascular pedicle on serial films in burned
patients preceded development of pulmonary edema
following fluid resuscitation [28]. Specifically, develop-
ment of pulmonary edema during the first 3.3 days after
injury was associated with increased VPW (by 69 mm)
during the initial 24 hours of fluid resuscitation (Fig. 4).
Patients who later developed pulmonary edema had
received more intravenous fluid (16.0 compared with
8.9 l) during this period. While 12 of 13 patients whose
 258 Cardiopulmonary monitoring

Figure 3 Portable digital chest X-ray

(a) A 53-year-old male with end-stage renal disease (anuria), hypertension, and dementia who was admitted for fever, altered mental status,
hypoglycemia, and subsequent hypotension thought to be due to septic shock following hemodialysis with removal of 400 ml volume. This upright,
portable, digital chest X-ray showed mild, diffuse interstitial lung disease and a moderate left pleural effusion. Both the cardiothoracic ratio (< 0.55) and
vascular pedicle width (VPW; < 0.70 mm) were normal in appearance. His body weight at the time of the chest X-ray was 70.0 kg. (b) The same patient
shown in (a) is shown here 12 h later after improvement of hypotension but with worsening oxygenation, requiring 100% non-rebreather. In the interim,
he received 10 500 ml of net fluid intake and recorded a marked development of anasarca. His body weight at the time of this chest X-ray was 79 kg. On
this semi-erect, portable, digital chest X-ray, the interstitial infiltrates were more prominent and both the cardiothoracic ratio (> 0.55) and the vascular
pedicle width (86 mm) had increased markedly.

VPW increased at least 1 cm later developed pulmonary
edema, no patient with a decrease in VPW developed this
problem (Fig. 5). In their review of 36 pairs of CXRs
immediately before and after hemodialysis in patients
with chronic renal failure, Don and colleagues [18] noted
that VPW decreased significantly. They considered the
VPW a useful indicator of volume status, particularly in
estimating dry weight when clinical assessment is diffi-
cult. Moreover, decreases in the VPW and the transverse
diameter of the heart correlated with the percentage
reduction in body weight following dialysis. Similarly,
in patients with renal failure and pulmonary edema due
to missed dialysis, we have observed decreases in VPW
after reinstitution of dialysis. Together, serial CXRs in
burn and hemodialysis patients support the reliable,
predictive potential of the VPW.
Further validation of these findings was prospectively
undertaken by Martin and colleagues [29]. These authors
prospectively measured changes in net fluid intake and in
patient weight and compared these with serial VPW
measurements. Among 133 portable, supine CXRs in
36 mechanically ventilated patients with acute lung
injury, they noted that a clinically detectable and signifi-
cant reduction in VPW over a 5-day period (P = 0.02) was
associated with a mean net diuresis of 3.3 l and weight
loss of 10 kg.
and ventilator–patient interactions (discussed above).
However, the reproducibility of technique of serial
CXRs (i.e. using the same body position, focal film
distance, and exposure) underlies the potential clinical
application of VPW measurements. Thus limitations
imposed by these and other factors should encourage
standardization of interpreting portable CXRs [30,31]
rather than deter their use, so that we can optimize
pertinent, readily available information on our patients’
films.
Role of daily chest X-rays in clinical practice
Recently, some have called into question the utility of
routine, serial CXRs in critically ill adults [32]. Most
importantly, some suggest that the yield of CXRs varies
widely and is greater in non-routine films. Indeed, the
overall rate of unexpected, new abnormalities on CXRs in
ICU patients varies from 6 [30] to > 90% [33], with an
average of 35%. Others have thus called into question the
clinical impact of routine CXRs [32], suggesting that
abnormalities that prompt a meaningful clinical change
(e.g. adjusting placement of a central line or endotracheal
tube) was generally less than 40% [34–36], even on
prospective evaluation. Graat et al. [37], for example,
that only 2.2% of all daily, routine CXRs reported among
2457 radiographs (48 of 754 consecutive ICU patients)
yielded clinically relevant findings.

Clinical use of each of these radiographic signs requires We are concerned with these arguments for two reasons.
an awareness of the potential confounding effects of First, these are sufficiently high enough percentages, in
variations in a patient’s posture, radiographic technique, our opinion, to warrant daily CXRs in patients with

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Figure 4 Serial vascular pedicle width measurements in 42
patients with cutaneous burns
Change of vascular pedicle width (cm)
2.0
1.5
1.0
0.5
0 CTR are highly reproducible, with intra-reader and inter-
−0.5
−1.0
Pulmonary
edema
Vascular pedicle width increased significantly in patients who sub-
sequently developed pulmonary edema (P < 0.01) but was unchanged
in those without this complication. Reproduced with permission from
Haponik et al. [28].
unknown or presumably changing intravascular volume.
The yield is low for many procedures – often ones more
invasive than a CXR – performed in the ICU, yet we
persist not because of the overall yield but because of
the potential clinical impact. Second, although daily,
routine CXRs may not bear clinical impact for all ICU
patients, we feel that those whose intravascular volume
status is in question would potentially benefit with mini-
mal risk. In short, while the utility of serial measures of
VPW depends upon the standardized performance of
routine, serial CXRs, we believe the benefits outweigh
risks for a non-trivial proportion of ICU patients.
Applying assessment of vascular pedicle
width to daily patient care
Portable, supine CXRs are the most commonly used non-
invasive studies to identify the presence, severity, or
change in pulmonary edema in the ICU [38,39]. Accord-
ingly, optimizing the use of portable, supine CXRs is
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Portable chest X-rays and vascular pedicle width Miller and Ely 259
imperative. We are not proposing that measurement of
VPW replace other potential sources of information on
intravascular volume status, such as esophageal Doppler
monitoring, arterial waveform analysis, transesophageal
echocardiography, or even pulmonary artery catheteriza-
tion. However, defining who will benefit from such
invasive monitoring rather than minimally invasive
techniques requires further study. Clearly, there are
patients in whom the intensivist does not intend to, does
not wish to, or cannot use invasive techniques to deter-
mine volume status because the risks outweigh the
benefits. In such patients in particular, the information
already available on the patient’s CXR should be used to
its maximum potential.
The lack of a standardized approach to reading ICU
CXRs on daily ICU rounds suggests the need for, appeal
of, and potential impact of simplifying and/or standardiz-
ing the application of this tool [30,31]. The VPW and
reader correlation coefficients ranging from 0.84 to 0.96
[17,25]. In their comprehensive analysis of radiographic
findings, Milne et al. [16] found the least inter-observer
variability (2%) in the assessment of VPW. In clinical
reports, VPW measurement has been feasible in approxi-
mately three-quarters of patients [17,18,28], an obser-
vation that reflects perhaps the need for a standardized
approach more so than the disutility of measuring VPW.
No pulmonary Arguably, the mere subjective assessment of VPW (e.g. as
edema normal compared with wide, increasing compared with
decreasing), rather than rigorous objective measurement
of its value, suffices as a worthwhile clinical tool. We
suspect that such a subjective impression has been used
unconsciously for years by clinicians as they view and
interpret CXRs. Regardless, the objective standardiza-
tion of assessing VPW would likely enhance decision
making at relatively little additional cost.
Such commonly used, conventional, radiographic find-
ings as the presence of pleural effusion, septal lines,
peribronchial cuffing, distribution of edema, and/or the
presence of vascular redistribution have not distin-
guished between the causes of pulmonary edema [25].
The VPW and CTR have likelihood ratios above 3.0 in
differentiating ARDS from volume overload. By contrast,
the likelihood ratios of other radiographic signs often
used in this determination were unacceptably close to
1.0 [17,25]. Able to provide modest but not large shifts
from pre- to post-test probability, VPW measurement
remains as good or better than many other widely
accepted diagnostic tests in pulmonary and critical care
medicine [17,40,41].
Interestingly, neither analyses of CXRs obtained during
major multicenter investigations of respiratory failure,
 260 Cardiopulmonary monitoring
Figure 5 Changes of vascular pedicle width in burned patients
Vascular pedicle width enlargement was
associated with pulmonary edema. Twelve of
13 patients with pedicle enlargement
 10 mm developed pulmonary edema, and
no patients with reduction in VPW developed
pulmonary edema. Reproduced with
permission from Haponik et al. [28].
Vascular pedicle width (cm)
nor classic pulmonary and critical care textbooks used by
intensivists and cardiologists alike, nor recent publi-
cations instructing physicians how to use the CXR in
their research or clinical practices, have addressed the use
of VPW [30,31,42–44]. However, a recent review of acute
pulmonary edema included the VPW as a potentially
useful factor in differentiating cardiogenic from noncar-
diogenic pulmonary edema [45]. We believe that the
VPW is a valid radiographic sign for use by radiologists
and clinicians in reviewing CXRs and in relating the
clinical context in which the CXR was obtained. As such,
it deserves further exposure.
How should the vascular pedicle width
measurement be applied clinically?
A potential though simplistic approach to use of the VPW
is outlined in Fig. 6 [46]. Two caveats to this approach
exist. Though it has yet to be established whether a
decrease of the VPW (suggesting diuresis or blood loss) or
increase in the VPW (suggesting volume overload) in
patients without parenchymal opacities should influence
care, evidence suggests that the value of VPW is similar
regardless of the presence or absence of pulmonary
edema [17]. Therefore, VPW enlargement, especially
on serial films, should trigger a review of the patient’s
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No pulmonary edema (n=24) Pulmonary edema (n=18)
9.0 9.0
8.0 8.0
Vascular pedicle width (cm)
7.0 7.0
6.0 6.0
5.0 5.0
4.0 4.0
0 0
Baseline Followup Baseline Followup
intake and output and overall clinical picture, alerting to
the possibility of intravascular volume expansion. Days of
repetitive net fluid intake could go unnoticed otherwise,
progressing insidiously until the patient succumbs to
abrupt alveolar flooding and hypoxemic respiratory fail-
ure. In such circumstances, the VPW could point the
clinician to the increased likelihood of a hydrostatic
mechanism for a patient’s decline or even prompt earlier
intervention to avoid the problem altogether. Because a
narrow VPW on a supine, portable CXR is an unlikely
finding in the setting of increased systemic blood volume
and hydrostatic edema, such a finding despite clinical
deterioration might suggest an alternate etiology for
radiographic opacification, such as ARDS, atelectasis,
or infection, and may influence thresholds for empiric
therapy or performance of confirmatory diagnostic pro-
cedures.
Critically ill patients often have varying mechanisms of
pulmonary edema that evolve throughout the course of
their illnesses and are modified by therapy and/or super-
vening problems. VPW may provide further insight into
the initial diagnostic efforts, the subsequent course of
complex illnesses, and the clinical evaluation of patients
who have sequential or simultaneous hydrostatic and

Figure 6 Proposed algorithm for use of vascular pedicle width (VPW) in patients’ clinical assessment and management decisions
ARDS, acute respiratory distress syndrome;
CXR, chest X-ray. Reproduced with permission
from Ely and Haponik [46].
VPW narrow or
decreasing (e.g. <70 mm)
Normal finding, or
diuresis or bleeding?
permeability etiologies for their pulmonary edema. In
heart/lung transplantation patients with septal lines and
new or increasing pleural effusions, for example, stability
of VPW and CTR was suggestive of acute lung rejection
and had an overall accuracy of 83% [47]. Alternatively,
among immunocompromised hosts with unexplained
bilateral pulmonary infiltrates, we have occasionally
observed that VPW enlargement prompted diuresis, with
subsequent clearing of infiltrates obviating the need for
biopsy procedures under consideration.
Conclusion
Using either upright or supine, portable, digital CXRs to
objectively measure VPW in patients with unknown
presence of pulmonary edema, unknown etiology of
intravascular volume expansion, or changing clinical fea-
tures can increase the accuracy of clinical and radio-
graphic assessment of volume status by 15–30%
[17,25], particularly when VPW is assessed serially in a
given patient. When intravascular volume status remains
unclear after radiographic assessment using the VPW,
echocardiography with or without esophageal Doppler
monitoring, empiric therapy, or pulmonary artery
catheter placement according to the patient’s clinical
status and risk/benefit considerations must be pursued.
It remains untested whether management strategies such
as those outlined in Fig. 6 offer superior outcomes among
those in whom routine, daily CXRs are commonly per-
formed. We believe that appraisal of VPW and other
radiographic signs should be incorporated into newly
implemented, comparative studies of ICU echocardio-
graphy, esophageal Doppler monitoring, portable com-
puted tomography scans, arterial waveform analysis, and
other costlier and/or more invasive technologies. Further
study in this important area will further refine the appli-
cation of the portable CXR. The evidence reviewed in
this manuscript supports the notion that conventional,
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Portable chest X-rays and vascular pedicle width Miller and Ely 261
Use of the vascular pedicle width
from portable supine CXR
Parenchymal infiltrates
on portable CXR?
NO infiltrates YES - infiltrates
measure VPW measure VPW
VPW wide or VPW narrow or VPW wide or
increasing (e.g. >70 mm) decreasing (e.g. <70 mm) increasing (e.g. >70 mm)
Check I's and O's Permeability edema Hydrostatic edema
volume overloaded? ARDS, pneumonia, hemorrhage heart or kidney failure
digital, supine CXRs, while old-fashioned, will retain an
important role in the diagnosis of intravascular volume
status and management of many critically ill patients.
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Papers of particular interest, published within the annual period of review, have
been highlighted as:
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