September,2011

CriticalCareRadiology:
TheRoleofImagingin
AcuteRespiratoryDistress
Syndrome
AndrewChalupka,MSIII
GillianLieberman,MD

AndrewChalupka,MSIII
GillianLieberman,MD

Overview
Casepresentation:indexpatient
Useofchestradiographytodistinguishbetweencausesofairspace
opacification
Useofchestradiographytodistinguishbetweencardiogenic andnon
cardiogenic pulmonaryedema
AcuteRespiratoryDistressSyndrome(ARDS):

Definition
Associateddisorders
Diagnosticcriteria
Pathophysiology

ImagingchoicesforARDS
RadiologicfindingsinARDSbystage
ImplicationsofimagingforunderstandingARDSpathophysiology
ImplicationsofimagingformanagingARDS
2

AndrewChalupka,MSIII
GillianLieberman,MD

IndexPatient:BriefHistory
33yearoldman
Twodayhistoryoffeelingunwell
Dayofadmission:onsetofworstheadache
of[his]life, followedbynauseaandvomiting
Atoutsidehospital,CTshowedextensive
subarachnoidhemorrhageand
intraventricular hemorrhage
3

AndrewChalupka,MSIII
GillianLieberman,MD

IndexPatient:BriefHospital
Course
WithinanhourofarrivalintheED,becomes
lethargicandisintubated
AdmittedtoICU
Week1:Tachycardia,hypertension,andfever
Therapeutichypothermiaprotocolinitiated

Week2:Pneumonia
Week3:Extubated
dyspnea,rapidhypoxemia
reintubated
4

AndrewChalupka,MSIII
GillianLieberman,MD

IndexPatient
Thepatientschestradiographfollows.
Itwastaken24hoursaftertheonsetofhis
dyspnea andhypoxemia.
Attempttointerpretthefilmindependently,
thencontinuetoviewfindings.
5

IndexPatient:
Chestradiograph,
24hoursafteronsetofrespiratorydistress

Source:BethIsraelDeaconess
MedicalCenterPACS

IndexPatient:
Chestradiograph

Diffuse,
hazy
opacities

Source:BethIsraelDeaconess
MedicalCenterPACS

IndexPatient:
Chestradiograph

Diffuse,
hazy
opacities

Source:BethIsraelDeaconess
MedicalCenterPACS

IndexPatient:
Chestradiograph

Airbronchograms

Source:BethIsraelDeaconess
MedicalCenterPACS

IndexPatient:
Chestradiograph

Diffuse,
hazy
opacities

Diffuse,
hazy
opacities

Air
bronchogram
s

Source:BethIsraelDeaconess
MedicalCenterPACS

10

AndrewChalupka,MSIII
GillianLieberman,MD

Givenonlyachestradiograph
withanairspace/alveolar
patternofopacification,what
canwedetermineaboutits
etiology?
Quiteabit.

11

AndrewChalupka,MSIII
GillianLieberman,MD

AirspaceOpacification
CauseofOpacification

RadiographicAppearance

Cardiogenicpulmonaryedema

Diffuse
Symmetric
Perihilar
Dependent

Noncardiogenicpulmonaryedema
(e.g.,ARDS)

Patchy
Asymmetric
Peripheral
Dependent
Airbronchograms

Bronchopneumonia

Patchy
Asymmetric
Peripheral
Nondependent

Aspirationpneumonia

Patchy
Asymmetric
Dependent

Septicinfarcts

Peripheral
Wedgeshaped

Adaptedfrom:TrotmanDickensonB.RadiographyfortheCriticalCarePatient.In:McLoudTC,Boiselle
PM,eds. ThoracicRadiology:theRequisites.Philadelphia,PA:Mosby;2010:136159.

12

AndrewChalupka,MSIII
GillianLieberman,MD

Ourpatientsfilmshowedairspace
opacificationthatwasdiffuse,peripheral,
andworseatthebases(i.e.,potentially
dependent)withairbronchograms.
Itdemonstratesmany,butnotall,ofthe
commonradiographicfeaturesof
noncardiogenicpulmonaryedema.
13

AndrewChalupka,MSIII
GillianLieberman,MD

PulmonaryEdema
Abnormalaccumulationoffluidinthe
extravascularcompartmentsofthelung
Netfluidmovement=Kf([Pc Pi] [c i])
Pathophysiologiccategoriesofpulmonaryedema:

increasedhydrostaticpressureedema
permeabilityedemawithdiffusealveolardamage(DAD)
permeabilityedemawithoutDAD
mixededema

Source:KetaiLH,GodwinJD.Anewviewofpulmonaryedemaandacuterespiratorydistress
syndrome.JThoracImaging.1998;13(3):14771.

14

AndrewChalupka,MSIII
GillianLieberman,MD

Havingnarroweddownthecauseofour
patientsairspaceopacificationto
pulmonaryedema,wecanusethe
featuresofhischestradiographto
determinethetype ofpulmonaryedema.
Thechestradiographisapowerfultoolin
thecriticalcaresetting;itcanprovidean
assessmentofvolumestatusandvascular
flowpatterns.
15

AndrewChalupka,MSIII
GillianLieberman,MD

RadiographicFeaturesofPulmonaryEdema:
Cardiacvs.Noncardiac
Signs

CardiogenicEdema

FluidOverload

Cardiomegaly

Vascularredistribution

Widenedvascularpedicle

Pleuraleffusions

Kerleylines

Peribronchialcuffing

Airspaceopacification

Diffuseperihilar

Central
perihilar

ARDS

Patchy
peripheral

Adaptedfrom:TrotmanDickensonB.RadiographyfortheCriticalCarePatient.In:McLoudTC,Boiselle
PM,eds. ThoracicRadiology:theRequisites.Philadelphia,PA:Mosby;2010:136159.

16

AndrewChalupka,MSIII
GillianLieberman,MD

Basedonourpatientsclinicalpresentation,
theairspaceopacificationpatternonhis
chestradiograph,andtheabsenceofCXR
featuresseenincardiogenicorfluid
overloadpulmonaryedema,wesuspect
thathehasAcuteRespiratoryDistress
Syndrome(ARDS).
Letscontinuebybrieflyexaminingthe
etiologyandpathophysiologyofARDS.
17

AndrewChalupka,MSIII
GillianLieberman,MD

ARDS:DefinitionandAssociatedDisorders
Aclinicalsyndromeofabruptonsetdyspneaand
hypoxemiainthesettingofdiffusepulmonaryinfiltrates
DisordersassociatedwithARDS:
Directlunginjury

Indirectlunginjury

Pneumonia

Sepsis

Aspirationofgastriccontents

Shock

Pulmonarycontusion

Severetrauma

Drowning

Multipletransfusions

Fat/amnioticfluidembolism

Salicylateornarcoticoverdose

Smoke/toxicgasinhalation

Pancreatitis

Sources:
LevyBD,ShapiroSD.AcuteRespiratoryDistressSyndrome.In:FauciAS,BraunwaldE,KasperDL,HauserSL,LongoDL,
JamesonJL,LoscalzoJ,eds.Harrison'sPrinciplesofInternalMedicine 17e.NewYork,NY:McGrawHill;2008:16801684.
WheelerAP,BernardGR.Acutelunginjuryandtheacuterespiratorydistresssyndrome:aclinicalreview.Lancet.
2007;369(9572):155364.

18

AndrewChalupka,MSIII
GillianLieberman,MD

ARDS:DiagnosticCriteria
1. Acuteonset(<7days)
2. PaO2/FIO2 <200mmHg
AcuteLungInjury:PaO2/FIO2 <300mmHg

3. Diffuse,bilateralpulmonaryinfiltrateson
frontalradiograph
4. Absenceofleftatrialhypertension
PCWP<18mmHgifmeasured,or
NoclinicalevidenceofelevatedLApressure
Sources:
LevyBD,ShapiroSD.AcuteRespiratoryDistressSyndrome.In:FauciAS,BraunwaldE,KasperDL,HauserSL,LongoDL,
JamesonJL,LoscalzoJ,eds.Harrison'sPrinciplesofInternalMedicine 17e.NewYork,NY:McGrawHill;2008:16801684.
WheelerAP,BernardGR.Acutelunginjuryandtheacuterespiratorydistresssyndrome:aclinicalreview.Lancet.
2007;369(9572):155364.

19

AndrewChalupka,MSIII
GillianLieberman,MD

ARDS:Pathophysiology
Alveolarcapillarymembrane:2separatebarriers
Vascularendothelium
Alveolarepithelium(typeIpneumocyte)

ARDS:Injuryto,andcompromiseof,either
barrier
Increasedvascularpermeability
Alveolarflooding(exudative/proteinrich)
Hyalinemembraneformation

Lossofdiffusioncapacity
DamagetotypeIIpneumocytes widespreadsurfactant
abnormalities
Source:HusainAN.TheLung.In:KumarV,AbbasAK,FaustoN,AsterJC,eds.RobbinsandCotranPathologicBasisof
Disease8e.Philadelphia,PA:Saunders;2010:677737.

20

AndrewChalupka,MSIII
GillianLieberman,MD

ImagingChoicesinARDS
Chestradiograph
TosupportadiagnosisofALI/ARDSinpatientsfulfillingclinical
criteria
Todetectorconfirmasuspectedsubclinicalcomplication(e.g.,
nosocomialpneumonia)
Tomonitorprogressionorregressionofpriorfindings

CT
Toquantifytheextentoflungabnormalityinpatientswith
equivocalCXR
TodeterminetheetiologyoftheARDS
Toidentifyareasofdependent,dense,parenchymal
opacification(compressionatelectasis)
Sources:
DesaiSR.Acuterespiratorydistresssyndrome:imagingoftheinjuredlung.ClinRadiol.2002;57(1):817.
DesaiSR,WellsAU,SuntharalingamG,RubensMB,EvansTW,HansellDM.Acuterespiratorydistresssyndrome
causedbypulmonaryandextrapulmonaryinjury:acomparativeCTstudy.Radiology.2001;218(3):68993.

21

AndrewChalupka,MSIII
GillianLieberman,MD

StagesofARDS
ARDSiscomprisedofthreestages,eachof
whichdemonstratesdistinctradiographic
findings.
1. ExudativeStage
2. ProliferativeStage
3. FibroticStage

22

AndrewChalupka,MSIII
GillianLieberman,MD

StagesofARDS:ExudativeStage
Pathophysiologic:
Interstitialedema,rapidlyprogressingtothe
filling/floodingofalveolarspaceswithanexudate
Hyalinemembraneformation

Radiologic(plainfilm):
First24hours:normalCXR
Early:interstitialedema(perihilar)
Later:alveolarconsolidation(peripheral);air
bronchograms
Sources:
GlueckerT,CapassoP,SchnyderP,GudinchetF,SchallerMD,RevellyJP,ChioleroR,VockP,WickyS.Clinicaland
radiologicfeaturesofpulmonaryedema.Radiographics.1999;19(6):150731.
DesaiSR.Acuterespiratorydistresssyndrome:imagingoftheinjuredlung.ClinRadiol.2002;57(1):817.

23

CompanionPatient1:
Early exudativestage
Chestradiograph

Source:BethIsraelDeaconess
MedicalCenterPACS

24

CompanionPatient1:
Early exudativestage
Chestradiograph

Perihilar,
interstitial
opacities

Source:BethIsraelDeaconess
MedicalCenterPACS

25

IndexPatient:
Later exudativestage
Chestradiograph

Source:BethIsraelDeaconess
MedicalCenterPACS

26

IndexPatient:
Later exudativestage
Chestradiograph

Peripheral,
alveolar
consolidation

Source:BethIsraelDeaconess
MedicalCenterPACS

27

AndrewChalupka,MSIII
GillianLieberman,MD

StagesofARDS:ExudativeStage
CTfindings:Gravitationalgradient
Ventraldorsal
Anterior:normallung
Posterior:denseconsolidation
Inbetween:groundglassopacification

Cephalocaudal
Increasingabnormaldensitycaudally

CTfindings:Airwaychanges
Bronchialdilatation
Sources:
GlueckerT,CapassoP,SchnyderP,GudinchetF,SchallerMD,RevellyJP,ChioleroR,VockP,WickyS.Clinicaland
radiologicfeaturesofpulmonaryedema.Radiographics.1999;19(6):150731.
DesaiSR.Acuterespiratorydistresssyndrome:imagingoftheinjuredlung.ClinRadiol.2002;57(1):817.

28

CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Source:BethIsraelDeaconess
MedicalCenterPACS

29

CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Normallung

Source:BethIsraelDeaconess
MedicalCenterPACS

30

CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Groundglass
opacities

Source:BethIsraelDeaconess
MedicalCenterPACS

31

CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Dense
consolidation

Source:BethIsraelDeaconess
MedicalCenterPACS

32

CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Normallung
Groundglass
opacities
Dense
consolidation

Source:BethIsraelDeaconess
MedicalCenterPACS

33

CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Source:BethIsraelDeaconess
MedicalCenterPACS

34

CompanionPatient2:
Laterexudativestage
CT,axial
Image2

Source:BethIsraelDeaconess
MedicalCenterPACS

35

CompanionPatient2:
Laterexudativestage
CT,axial
Image3

Source:BethIsraelDeaconess
MedicalCenterPACS

36

CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Source:BethIsraelDeaconess
MedicalCenterPACS

37

CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Normal
lung

Source:BethIsraelDeaconess
MedicalCenterPACS

38

CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Groundglass
opacities

Source:BethIsraelDeaconess
MedicalCenterPACS

39

CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Dense
consolidation

Source:BethIsraelDeaconess
MedicalCenterPACS

40

CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Normal
lung
Groundglass
opacities
Dense
consolidation

Source:BethIsraelDeaconess
MedicalCenterPACS

41

CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Source:BethIsraelDeaconess
MedicalCenterPACS

42

CompanionPatient3:
Laterexudativestage
CT,axial
Image2

Source:BethIsraelDeaconess
MedicalCenterPACS

43

CompanionPatient3:
Laterexudativestage
CT,axial
Image3

Source:BethIsraelDeaconess
MedicalCenterPACS

44

CompanionPatient3:
Laterexudativestage
CT,axial
Image4

Source:BethIsraelDeaconess
MedicalCenterPACS

45

CompanionPatient3:
Laterexudativestage
CT,axial
Image5

Source:BethIsraelDeaconess
MedicalCenterPACS

46

CompanionPatient3:
Laterexudativestage
CT,axial
Image6

Source:BethIsraelDeaconess
MedicalCenterPACS

47

AndrewChalupka,MSIII
GillianLieberman,MD

StagesofARDS:ProliferativePhase
Pathophysiologic:
Organizationoffibrinousexudate
Regenerationofalveolarlining

Radiologic:
Inhomogeneousareasofgroundglassopacity
Thickeningofalveolarseptae

Source:GlueckerT,CapassoP,SchnyderP,GudinchetF,Schaller MD,RevellyJP,ChioleroR,VockP,WickyS.Clinicaland
radiologicfeaturesofpulmonaryedema.Radiographics.1999;19(6):150731.

48

AndrewChalupka,MSIII
GillianLieberman,MD

StagesofARDS:FibroticStage
Pathophysiologic:
Scarring/fibrosis
Formationofsubpleuralandintrapulmonarycysts

Radiologic:
Distortionofinterstitialandbronchovascularmarkings
Cysticlesions
Complicationsofcystsorbarotrauma:
Aberrantair:pneumothorax,pneumatocele
Sources:
GlueckerT,CapassoP,SchnyderP,GudinchetF,SchallerMD,RevellyJP,ChioleroR,VockP,WickyS.Clinicaland
radiologicfeaturesofpulmonaryedema.Radiographics.1999;19(6):150731.
GoodmanLR.Congestiveheartfailureandadultrespiratorydistresssyndrome.Newinsightsusingcomputed
tomography.RadiolClinNorthAm.1996Jan;34(1):3346.

49

AndrewChalupka,MSIII
GillianLieberman,MD

ImplicationsofImagingfor
UnderstandingARDS
CTallowsquantitativeanalysisofvolumesofgasandtissue
CTdataofthewholelunghavechangedourunderstanding
ofthepathophysiologyofARDS
Lungvolume=tissuevolume+gasvolume
Wenowunderstandthatthereisamarked reduction inoverall
lungvolume attheexpenseofthevolumeofthelowerlobes
Increaseintissueinupperlobes(edema,inflammation)
Lossofaerationoflowerlobes(compressionbyheart,abdominal
contents)
OldunderstandingofARDS:overallvolumeoflungpreserved
becausegainoftissuewasexpectedtoexceedlossofgas
NewunderstandingofARDS:reduction inoveralllungvolume
becauselossofgasisgreaterthangainoftissue

Lossofaerationdiffersbetweenpatients
Source:RoubyJJ,PuybassetL,NieszkowskaA,LuQ.Acuterespiratorydistresssyndrome:lessonsfromcomputed
tomographyofthewholelung.CritCareMed.2003;31(4Suppl):S28595.

50

AndrewChalupka,MSIII
GillianLieberman,MD

Lowerlobe
predominantpattern
40%ofpatients
Lossofaeration:
Mainlyinlowerlobes
Minimalinvolvementof
upperlobes
Mortality:40%
CTscanfroma74yearoldpatientwith
ARDScausedbyseverebronchopneumonia
Upperlobes:somepartsremainnormally
aerated(black)
Lowerlobes:eitherpoorlyaerated(gray)or
nonaerated(red).
Image:RoubyJJ,PuybassetL,NieszkowskaA,LuQ.Acuterespiratory
distresssyndrome:lessonsfromcomputedtomographyofthewhole
lung.CritCareMed.2003;31(4Suppl):S28595.

51

AndrewChalupka,MSIII
GillianLieberman,MD

Lowerlobeexclusive
pattern
Onethirdofpatients
Lossofaeration:
Exclusivelyinlower
lobes
Mortality:40%
CTscanfrom50yroldpatientwithARDS
causedbyaspirationpneumonia
Upperlobes:normallyaerated(black).
Lowerlobes:eitherpoorlyaerated(gray)or
nonaerated(red).

Image:RoubyJJ,PuybassetL,NieszkowskaA,LuQ.Acuterespiratory
distresssyndrome:lessonsfromcomputedtomographyofthewhole
lung.CritCareMed.2003;31(4Suppl):S28595.

52

AndrewChalupka,MSIII
GillianLieberman,MD

Diffusepattern
25%ofpatients
Lossofaeration:
Massive
Equallydistributed
throughoutlung
Mortality:70%
CTscanfromina53yearoldpatientwith
ARDScausedbyPneumocystis jirovecii
Entirelung:nonaerated (red)orpoorly
aerated(gray).

Image:Rouby JJ,Puybasset L,Nieszkowska A,LuQ.Acuterespiratorydistresssyndrome:lessonsfromcomputedtomographyof

thewholelung.Crit CareMed.2003;31(4Suppl):S28595.

53

AndrewChalupka,MSIII
GillianLieberman,MD

ImplicationsofImagingfor
ARDSManagement
CThasledtosaferandmoreeffective
managementofARDS
Understandingthatoveralllungvolumeand
cephalocaudal lungdimensionsarereducedatthe
expenseofthelowerlobes
Proneandsemirecumbentpositioningofpatients

Assessmentofalveolarrecruitmentanddetectionof
lungoverinflation
OptimizationofPEEP:maximizingrecruitmentwhile
limitingbarotrauma
Source:Rouby JJ,Puybasset L,Nieszkowska A,LuQ.Acuterespiratorydistresssyndrome:lessonsfromcomputed
tomographyofthewholelung.Crit CareMed.2003;31(4Suppl):S28595.

54

AndrewChalupka,MSIII
GillianLieberman,MD

Summary

Thedifferentcausesofairspaceopacification onplainfilmhavedistinctive
radiographicappearances.
Pulmonaryedemaisonesuchcause.Itispossibletodeducethe originof
pulmonaryedema(cardiac,fluidoverload,orARDS)basedonthe
radiographicfeaturesofachestfilm.
ARDSisaclinicalsyndromeofseveredyspnea ofrapidonsetand
hypoxemiainthesettingofdiffusepulmonaryinfiltrates.
ARDSiscausedbydiffuselunginjurythatleadstoleakageofalveolar
capillaries,allowingfloodingofalveolarspaceswithanexudate.
ThemenuofimagingforARDSincludesplainfilmandCT.
ARDShasthreephases(exudative,proliferative,andfibrotic),eachof
whichhasdistinctradiographicfeatures.
CThaschangedourunderstandingofthepathophysiologyofARDS.
CThaschangedourapproachtothemanagementofARDS.
55

AndrewChalupka,MSIII
GillianLieberman,MD

References

DesaiSR.Acuterespiratorydistresssyndrome:imagingoftheinjuredlung.Clin Radiol.
2002;57(1):817.
DesaiSR,WellsAU,Suntharalingam G,RubensMB,EvansTW,Hansell DM.Acuterespiratory
distresssyndromecausedbypulmonaryandextrapulmonary injury:acomparativeCTstudy.
Radiology.2001;218(3):68993.
Gluecker T,Capasso P,Schnyder P,Gudinchet F,SchallerMD,Revelly JP,Chiolero R,Vock P,Wicky
S.Clinicalandradiologicfeaturesofpulmonaryedema.Radiographics.1999;19(6):150731.
GoodmanLR.Congestiveheartfailureandadultrespiratorydistresssyndrome.Newinsightsusing
computedtomography.Radiol Clin NorthAm.1996Jan;34(1):3346.
HusainAN.TheLung.In:KumarV,Abbas AK,Fausto N,AsterJC,eds.RobbinsandCotran
PathologicBasisofDisease8e.Philadelphia,PA:Saunders;2010:677737.
Ketai LH,GodwinJD.Anewviewofpulmonaryedemaandacuterespiratorydistresssyndrome.J
Thorac Imaging.1998;13(3):14771.
LevyBD,ShapiroSD.AcuteRespiratoryDistressSyndrome.In:Fauci AS,Braunwald E,KasperDL,
HauserSL,LongoDL,JamesonJL,Loscalzo J,eds.Harrison'sPrinciplesofInternalMedicine 17e.
NewYork,NY:McGrawHill;2008:16801684.
Rouby JJ,Puybasset L,Nieszkowska A,LuQ.Acuterespiratorydistresssyndrome:lessonsfrom
computedtomographyofthewholelung.Crit CareMed.2003;31(4Suppl):S28595.
TrotmanDickensonB.RadiographyfortheCriticalCarePatient.In:McLoud TC,Boiselle PM,eds.
ThoracicRadiology:theRequisites.Philadelphia,PA:Mosby;2010:136159.
WheelerAP,BernardGR.Acutelunginjuryandtheacuterespiratorydistresssyndrome:aclinical
review.Lancet.2007;369(9572):155364.
56

AndrewChalupka,MSIII
GillianLieberman,MD

Acknowledgements
Thefollowingindividualsprovidedinvaluable
assistanceinacquiringandinterpreting
images:
JavierPerezRodriguez,M.D.
AlexanderBankier,M.D.
DianaLitmanovich,M.D.
PaulSprin,M.D.

ThanksalsotoEmilyHansonforherlogistical
assistance.
57