Jurnal Radiologi Kel e Edit

8/13/2019 Jurnal Radiologi Kel e Edit

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Reading chest radiographs in the critically ill

(Part II): Radiography of lung pathologies

common in the ICU patientAli Nawaz Khan, Hamdan Al-Jahdali, Sarah AL-Ghanem, and Alaa GoudaKing Fahad Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Address for correspondence:Dr. Ali Nawaz Khan King Abdulaziz Medical Ci!,

King "ahad Naional Guard Ho#$ial, %.&. 'o( ))*+, i!adh *)/, Saudi

Arabia. 0-mail1 dr2han+//3m#n.com

ecei4ed December 5, )67 Acce$ed Januar! )+, )+.

Co$!righ8 Annal# o9 :horacic Medicine

:hi# i# an o$en-acce## aricle di#ribued under he erm# o9 he Creai4e Common#

Aribuion Licen#e, which $ermi# unre#riced u#e, di#ribuion, and re$roducion

in an! medium, $ro4ided he original wor2 i# $ro$erl! cied.

Abstract

:hi# i# $ar ;; o9 wo #erie# re4iew o9 reading che# radiogra$h# in he criicall! ill.Con4enional che# radiogra$h! remain# he corner#one o9 da! o da!

managemen o9 he criicall! ill occa#ionall! #u$$lemened b! com$ued

omogra$h! or ulra#ound 9or #$eci9ic indicaion#. ;n hi# #econd re4iew we di#cu##

radiogra$hic 9inding# o9 cardio$ulmonar! di#order# common in he inen#i4e care

$aien and #ugge# guideline# 9or iner$reaion ba#ed no onl! on imaging bu al#o

on he $aho$h!#iolog! and clinical ground#.

Keywords: Che# (-ra!, inen#i4e care uni, cardio$ulmonar! di#order#

;ner$reing che# radiogra$h# in he criicall! ill $aien# in inen#i4e care uni#

$o#e# a challenge no onl! 9or he inen#i4e care $h!#ician# bu al#o 9or he

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http://www.ncbi.nlm.nih.gov/pubmed/?term=Khan%20AN%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Al-Jahdali%20H%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=AL-Ghanem%20S%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Gouda%20A%5Bauth%5Dmailto:[email protected]://www.ncbi.nlm.nih.gov/pmc/about/copyright.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Al-Jahdali%20H%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=AL-Ghanem%20S%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Gouda%20A%5Bauth%5Dmailto:[email protected]://www.ncbi.nlm.nih.gov/pmc/about/copyright.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Khan%20AN%5Bauth%5D


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radiologi#. :he#e challenge# ari#e becau#e o9 #e4eral 9acor#1?@ ;C= $aien# are

$rone o #e4eral cardio$ulmonar! di#order# which when #u$erim$o#ed on he

underl!ing $aholog! ha $rom$ed admi##ion creae# a com$le( radiological

a$$earance, which ma! be di99icul o iner$re on imaging 9inding# alone.?)@ :he

#andard $o#ero-anerior radiogra$h i# re$laced b! he #ubo$imal A%

radiogra$h in he ;C= $aien.?@ ;n#rumenaion, mechanical 4enilaion,

eBui$men 9or monioring o9 cardiac and oher 4ial #ign#, 9eeding ube#, ec.,

di#rac 9rom oher 9inding# on he ;C= che# radiogra$h.?*@ adiologi##;nen#i4e

care $h!#ician# are under $re##ure 9or ra$id iner$reaion o9 che# (-ra!# when

reaing criicall! ill $aien#, o9en wih inadeBuae clinical in9ormaion $arl! due

o he 9ac ha hing# can change ra$idl! in he criicall! ill.?5@ adiological

iner$reaion i# ham$ered b! he bewildering arra! o9 line $lacemen# in he ;C=

$aien, where incorrec $lacemen i# no uncommon, which ma! no be ob4iou# o

he ob#er4er wihou clinical in$u.?/@ Air #$ace #hadowing in he ;C= $aien ma!

ha4e idenical a$$earance# in a 4arie! o9 cardio$ulmonar! $ahologie#. Alhough

he imaging modali! o9 choice in he ;C= $aien remain# ha o9 che#

radiogra$h!, com$ued omogra$h! i# o9en $er9ormed a# com$uerized

omogra$h! $ulmonar! arer! wih #u#$eced $ulmonar! emboli#m.

=lra#ound i# u#ed o con9irm $leural and $ericardial e99u#ion# and when $leural

iner4enion 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= $aien and #ugge# guideline# 9or iner$reaion

ba#ed no onl! on he che# radiogra$h bu al#o on he $aho$h!#iolog! and clinical

ground#7?)@ o de#cribe he normal $o#iion o9 monioring de4ice# and correc

$lacemen o9 oher line#, and $rom$ recogniion when he! are mi#$laced or when

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hic2ening a# a re#ul o9 9luid reenion in he lung iner#iium. Se$al line#

re$re#en 9luid in he dee$ #e$ae and l!m$haic# and a$$ear a#?@ Kerle!F# A line#,

which range 9rom 5 o cm in lengh and e(end 9rom he hilum o9 he lung

oward he $eri$her! in a #raigh or #lighl! cur4ed cour#e7 and?)@ Kerle!F# '

line#, a$$ro(imael! )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# mm Hg and i# u#uall! $receded b! iner#iial $ulmonar!

edema ?"igure )@. Che# radiogra$hic 9inding# include bilaeral o$aciie# ha

e(end in a 9an #ha$e ouward 9rom he hilum in a bawing $aern ?"igure @.

ih wor#ening al4eolar edema, he lung o$aci9icaion become increa#ingl!

homogenou#. Normall! he bronchi in he lung $eri$her! are no #een becau#e o9

air den#i! wihin he bronchi and he #urrounding lung $arench!ma. Howe4er,

along wih 9luid-9illed al4eoli 9rom $ulmonar! edema or in9ecion , he

air-9illed bronchi can be ea#il! #een, an a$$earance 2nown a# air bronchogram

?"igure *@. Air bronchogram# a##ociaed wih 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# o9en enlarged.

Diagno#i# o9 $ulmonar! edema i# no alwa!# #raigh9orward, and a!$ical $aern#

can $re#en diagno#ic di99iculie# on radiogra$hic 9inding# alone. A!$ical

radiogra$hic $aern# o9 $ulmonar! edema include unilaeral, lobar, miliar! or

lower-zone# edema7 and oher a#!mmeric or unu#ual di#ribuion $aern# ?"igure

5@. Miliar! edema ma! $recede 9ull-blown lung edema. Lower-zone# edema and

lobar $ulmonar! edema generall! occur in $aien# wih chronic ob#ruci4e

$ulmonar! di#ea#e and $ulmonar! em$h!#ema.

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Conge#i4e cardiac 9ailure cau#ing cardiogenic $ulmonar! edema i# u#uall! he

re#ul o9 le9 4enricular 9ailure, which i# in urn due o $oor cardiac ou$u and

increa#ed $ulmonar! 4enou# h!dro#aic $re##ure#. Generall! i i# a combinaion o9

a 9ailing cardiac $um$ and 9luid o4erload ha i$# $aien# ino conge#i4e hear

9ailure. :he che# radiogra$h i# an im$oran 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 acue i#chemic cardiac in#ul i# #ugge#ed on he che# radiogra$h# in )5I o

*I o9 $aien# be9ore he on#e o9 #!m$om#. ;deall! he be# echniBue in hi#

#eing i# a #andard %A che# radiogra$h becau#e he accurac! o9 deecing

cardiomegal! and redi#ribuion o9 $ulmonar! blood 9low on #u$ine A% 9ilm# i#

$oor. &baining an erec %A radiogra$h ma! no be alwa!# $o##ible in an ;C=

$aien7 and here9ore a# a com$romi#e, #emi-erec and decubiu# 9ilm# are

recommended. Cardiomegal!, increa#ed $ulmonar! 4a#culaure, and $leural

e99u#ion# are e4iden in he $aien #u99ering 9rom conge#i4e hear 9ailure.

A che# radiogra$h ma! di99ereniae beween cardiac and noncardiac $ulmonar!

edema. :he radiogra$hic 9eaure# 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 a9oremenioned change# ha4e no had ime o

de4elo$ i# acue m!ocardial in9arcion. :here are a muliude o9 cau#e# o9

noncardiogenic $ulmonar! edema, which include inhaled irrian# cau#ing a more

moled a$$earance and more $eri$heral di#ribuion o9 lung $arench!mal change#.

&her cau#e# o9 noncardiogenic $ulmonar! edema include near-drowning, aliude

#ic2ne##, o(!gen hera$!, ran#9u#ion reacion#, 9a emboli#m, cenral ner4ou#

#!#em di#order, ADS or a#$iraion, renal di#order orand drug reacion#, o name

Eu# a 9ew.?5@.

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Adult Respiratory !istress "yndrome

Adul re#$iraor! di#re## #!ndrome i# a erm a$$lied o a #!ndrome where

#ign# and #!m$om# o9 $ulmonar! edema occur in he ab#ence o9 ele4aed

$ulmonar! 4enou# $re##ure#. ADS i# a##ociaed wih high morali!, a# much a#

5I, and i# common in he ;C= $aien#. ADS re#ul# 9rom a 4arie! o9 cau#e#,

including #e$#i# or $ulmonar! in9ecion, #e4ere rauma, and a#$iraion o9 ga#ric

conen#.?@ :he 9inal $ahwa! in ADS i# common o all cau#e#, which i#

damage o he al4eolar ca$illar! endohelium, increa#ed 4a#cular $ermeabili!, and

#ub#eBuen de4elo$men o9 9ir#, iner#iial, and hen, al4eolar $ulmonar! edema.

%aien# wih ADS $re#en wih #e4ere re#$iraor! di#re## characerized b!

mar2ed h!$o(ia ha re#$ond# $oorl! e4en o admini#raion o9 high concenraion#

o9 o(!gen. :he $ulmonar! ca$illar! wedge $re##ure i# generall! normal, bu here

i# decrea#ed #ur9acan $roducion, which lead# o $oor lung com$liance and

aeleca#i# ha re#ul# in an inra$ulmonar! #hun wih $er9u#ion bu no e99eci4e

4enilaion. %o#ii4e end-e($iraor! $re##ure can hel$ o decrea#e aeleca#i# and

#huning while im$ro4ing o(!genaion. :he ulimae $rogno#i# i# 4ariable1 whil##ome ma! reco4er 9ull!, oher# $rogre## o $ulmonar! 9ibro#i#. :here i# #ome

correlaion beween he duraion and #e4eri! o9 ADS and long-erm

com$licaion#. %rogno#i# i# al#o de$enden on age and $ree(i#ing C&%D.

Di99ereniaion beween $ulmonar! edema o9 ADS and conge#i4e hear 9ailure

on he ba#i# o9 radiogra$hic #ign# alone can be challenging7 moreo4er, he wo

condiion# ma! coe(i# ?"igure# ?"igure#/ / and and@.@. Alhough boh eniie#

ma! #hare he che# (-ra! 9inding o9 bilaeral air #$ace o$aci9icaion or whie ou,

ADS i# no u#uall! a##ociaed wih 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

#$ace o$aci9icaion and on A% che# #u$ine radiogra$h. Air #$ace o$aci9icaion in

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CH" can occur in he $re#ence o9 a normal-#ized hear. :o ma2e he i##ue more

com$licaed, $aien# wih ADS could al#o ha4e $ree(i#en cardiomegal! or be

9luid o4erloaded becau#e o9 #e$#i#.?)@ Lung conu#ion ma! be di99icul o

di99ereniae 9rom ADS. Conu#ion howe4er u#uall! occur# earlier, i# u#uall!

localized o he area a99eced b! inEur!

and im$ro4e# o4er *6-) hour#. ADS end# o be more generalized, i# laer in

on#e and #lower o re#ol4e ?"igure# 6@.

Atelectasis

Aeleca#i# occur# when here i# 9ailure o9 he lung o e($and com$leel!.:hi# ma! be cau#ed b! an! $roce## which reduce# al4eolar 4enilaion, including

bloc2ed airwa!, e.g., ob#rucion 9rom mucu# $lugging, a umor, general

ane#he#ia, $neumonia, #$lining 9rom $ain 9ollowing #urger!.?)6,),@ 0(en#i4e

al4eolar h!$o4enilaion ma! cau#e h!$o(ia a# a re#ul o9 an e99eci4e righ-o-le9

#hun. ; i# a common abnormali! #een on he ;C= $aienF# che# radiogra$h.

Aeleca#i# in ;C= $aien# i# #een mo# 9reBuenl! in he le9 lower lobe. ; i#

$o#ulaed ha hi# i# due o com$re##ion o9 he lower lobe bronchu# b! he hear,

in he #u$ine $aien. A conribuor! 9acor ma! be relai4el! di99icul! o9 blind

#ucioning o9 he le9 lower lobe. =#uall! aeleca#i# i# more e(en#i4e han i#

#ugge#ed b! he radiogra$h. Aeleca#i# can boh be re4er#ed and $re4ened wih

he u#e o9 h!$er4enilaion and inceni4e #$iromer!, $aricularl! in he

$o#o$erai4e $aien.

Aeleca#i# ma! 4ar! 9rom a oal lung colla$#e o #ub#egmenal colla$#e o

relai4el! normal-a$$earing lung# on he che# radiogra$h a# an acue mucu#

$lugging ma! cau#e onl! a #mall reducion in lung 4olume wihou 4i#ible

abnormali!. Nowih#anding radiogra$hic a$$earance#, he $h!#iological e99ec#

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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 9eaure# o9

aeleca#i# are #ummarized in :able .

Minimal ba#al #ub#egmenal or di#coid aeleca#i# a$$earing a# linear #rea2# i#

common in he ;C= $aien and ma! no be $h!#iologicall! #igni9ican ?"igure @.

Aeleca#i# ma! al#o mimic $ulmonar! con#olidaion, which ma! be di99icul o

di#ingui#h 9rom oher cau#e# o9 con#olidaion. :o di#ingui#h beween aeleca#i#-

relaed con#olidaion and con#olidaion# relaed o oher cau#e# i# im$oran, and

cerain di#ingui#hing 9eaure# do e(i#. Aeleca#i# will o9en re#$ond o increa#ed

4enilaion while oher cau#e# o9 $ulmonar! con#olidaion will no. &her 9eaure#

ha #ugge# aeleca#i# becau#e o9 lo## o9 4olume in he in4ol4ed lung include

crowding o9 $ulmonar! 4e##el#, di#$lacemen o9 inerlobar 9i##ure# and ele4aion

o9 he hemidia$hragm oward# area# o9 aeleca#i#. Colla$#ed lung #egmen# and

lobe# al#o 9ollow well-recognized anaomical $ahwa!#, unli2e oher cau#e# o9

con#olidaion.

:he righ u$$er lobe colla$#e# ino a riangular o$aci!, wih he le##er 9i##ure

migraing oward he anerior, #u$erior and medial $orion o9 he che#, clo#ing li2e

a Chine#e 9an. &n an A% che# radiogra$h, he mo# #ri2ing 9eaure i# a #u$erior

and medial di#$lacemen o9 he minor 9i##ure. &n he laeral radiogra$h, he maEor

9i##ure mo4e# aneriorl!, while he #u$erior mo4emen o9 he minor 9i##ure i# al#o

#een ?"igurea )and and @.

ighmiddle-lobe aeleca#i# ma! cau#e minimal change# on an A% #u$ine che#

radiogra$h. A con#an 9eaure i# lo## o9 de9iniion o9 he righ hear border. A

colla$#ed righ middle lobe i# more clearl! de9ined on laeral radiogra$h, which i#

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no commonl! a4ailable in he ;C= $aien. Aenion o he 9i##ure# re4eal# ha

he horizonal and lower $orion# o9 he maEor 9i##ure# mo4e oward# each oher

re#uling in a wedge o9 o$aci! $oining o he hilum. A middle-lobe aeleca#i#

ma! mimic middle-lobe $neumonic con#olidaion ?"igure *@.

Aeleca#i# o9 eiher he righ or le9 lower lobe $re#en# a #imilar a$$earance. ;n

righlower-lobe aeleca#i# he colla$#ing lobe mo4e# cenrall! and in9eriorl!

oward# he lower dor#al #$ine, where i i# #een a# a riangular o$aci!. Silhoueing

o9 he righ hemidia$hragm and air bronchogram# i# a common #ign o9 righ

lower-lobe aeleca#i#. :he minor 9i##ure #how# #ome in9erior di#$lacemen. A# he

righ lower lobe colla$#e#, $ar o9 he greaer 9i##ure ma! become 4i#ible on he A%

radiogra$h. A laeral radiogra$h, i9 obained, ma! #how in9erior and $o#erior

di#$lacemen o9 boh he maEor and minor 9i##ure#. ighlower-lobe aeleca#i#

can be di99ereniaed 9rom righmiddle-lobe aeleca#i# b! he $er#i#ence o9 he

righ hear border ?"igure# ?"igure#5 5 and and/ / @.

A le9u$$er-lobe aeleca#i# $re#en# a di99eren $aern com$ared o a righ

u$$er-lobe aeleca#i# a# he le9 lung lac2# a minor 9i##ure. hen he le9 u$$er

lobe colla$#e#, he lobe $redominanl! mo4e# aneriorl!, wih lo## o9 he le9 u$$er

cardiac border. :here i# com$en#aor! em$h!#ema o9 he le9 lower lobe, which

e($and# and migrae# o a locaion boh #u$erior and $o#erior o he le9 u$$er

lobe. :he le9 main bronchu# al#o roae# o a nearl! horizonal $o#iion. :he A%

che# radiogra$h re4eal# haz! o$aci9icaion o9 he le9 hilum, ele4aion o9 he le9

hilum, near-horizonal cour#e o9 he le9 main bronchu#, $o#erior le9ward roaion

o9 he hear and he Lu9#ichel or air cre#cen #ign, he name gi4en o he

a$$earance o9 aeraed lung abuing he arch o9 he aora, beween he media#inum

and he colla$#ed le9 u$$er lobe ?"igure @. An a$$earance on a laeral

9
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radiogra$h, i9 a4ailable, o9 he ;C= $aien ma! #how rero#ernal o$aci! and

di#$lacemen o9 he greaer 9i##ure aneriorl!.

: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 laeral border.

Silhoueing o9 he le9 hemidia$hragm u#uall! occur#, which ma! be a##ociaed

wih an air bronchogram. ; i# al#o ea#il! mi##ed, e#$eciall! on an under$eneraed

9ilm, where no deail i# #een behind he hear.?6/@

Pneumonia in the ICU

Ho#$ial-ba#ed $neumonia#, which b! de9iniion occur da!# a9er

ho#$ial admi##ion, di99er 9rom communi!-acBuired $neumonia# in boh cau#aion

and $rogno#i#. No#ocomial $neumonia i# he leading cau#e o9 deah in he ;C=

$aien.?*@ :he ;C= $aien# are $aricularl! #u#ce$ible o $neumonia# a# he!

ma! be immune com$romi#ed and #e4eral iarogenic 9acor# are a $la!, which

increa#e hi# #u#ce$ibili!. ;arogenic 9acor# ha ma! $redi#$o#e o $neumonia#

include endoracheal ube#7 ri#2 o9 a#$iraion7 medicaion# u#ed o reduce ga#ric

acid, which ma! $romoe bacerial growh in he #omach7 and he u#e o9

anibioic#, which ma! #eleci4el! encourage he growh o9 #ome $ahogenic

baceria. =nli2e communi!-acBuired $neumonia#, which u#uall! are cau#ed b!

gram-$o#ii4e #$ecie#, no#ocomial $neumonia# are o9en $ol!microbial and cau#ed

b! gram-negai4e eneric $ahogen#. Clinical and laboraor! 9inding# #uch a# 9e4er,

leucoc!o#i# and #$uum culure# ma! no be u#e9ul indicaor# and are o9en

ma#2ed b! #e4ere underl!ing di#ea#e. :he che# 9ilm mu# be correlaed wih

clinical daa in order o ma2e he diagno#i# o9 $neumonia in he ;C= $aien.

adiogra$hicall! $neumonia# can be di99icul o di99ereniae 9rom oher cau#e# o9

10
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air #$ace #hadowing, including aeleca#i# and earl! ADS. =#uall! $neumonia

iniiall! a$$ear# a# $ach! con#olidaion or ill-de9ined nodule# ?"igure 6@.

%neumonia i# a bilaeral muli9ocal di#ea#e and o9en in4ol4e# gra4i!-de$enden

area# o9 he lung ?"igure +@. Aeleca#i# and lung edema ha4e a #imilar

di#ribuion, ma2ing di99ereniaion 9rom $neumonia di99icul. A #!mmeric $aern

#imulaing $ulmonar! edema can occur wihE-coliand $#eudomona# $neumonia#,

which can ra$idl! in4ol4e he enire lung#. %ach! air #$ace #hadowing, ill-de9ined

#egmenal con#olidaion or air bronchogram# eiher o9 he#e wih a##ociaed

$leural e99u#ion# #u$$or# he diagno#i# o9 $neumonia. Howe4er, unli2e

communi!-acBuired $neumonia, $leural e99u#ion# cau#ed b! gram-negai4e

organi#m# are more li2el! o re$re#en em$!ema and here9ore reBuire drainage.

&her #eriou# com$licaion# o9 $neumonia# in he ;C= $aien# include ab#ce##

9ormaion and broncho$leural 9i#ula#.?*@

Aspiration

:he ;C= $aien i# a a $aricular ri#2 o9 a#$iraion $neumonii#, o9en a# a re#ul o9

a com$romi#ed airwa!. ;m$aired con#ciou#ne##, $lacemen o9 0: and NG ube#

are among# man! conribuor! 9acor#. :he $ulmonar! re#$on#e o a#$iraion

de$end# on he !$e, $H and 4olume o9 a#$irae. A#$iraion o9 ga#ric conen#

$ro4o2e# a chemical $neumonii# called Mendel#onF# #!ndrome. :he lung re#$ond#

o $H ).5 wih #e4ere broncho#$a#m and he relea#e o9 in9lammaor! mediaor#.

%aien# become #!m$omaic almo# immediael! 9ollowing a#$iraion o9 ga#ric

conen#, wih cough, d!#$nea, wheezing and di99u#e crac2le#. "e4er and

leucoc!o#i# are he norm. :he iniial re#$on#e i# a chemical $ulmonar! edema.

Secondar! in9ecion occur# in #ome ca#e#. %aien re#$on#e o a#$iraion 4arie#

9rom #hoc2 o re#oluion wihou #eBuelae. %aien# ha $roceed o $neumonii#

ma! re4eal $ulmonar! con#olidaion wihin he 9ir# wo da!#. :he air #$ace

11
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#hadowing i# bilaeral, u#uall! $erihilar alhough a#!mmeric. adiogra$hicall! he

con#olidaion u#uall! begin# o re#ol4e b! he hird da! ?"igure# ?"igure#) ) and

and)@.)@. ;n #ome, he con#olidaion ma! wor#en wih added com$licaion# o9

lung ab#ce##e# and $leural e99u#ion.?*,*)@

Pulmonary mbolism

Morbidi! and morali! 9rom $ulmonar! emboli#m in he ;C= remain high, and he! coninue o

be underdiagno#ed in he inen#i4e care #eing. %ulmonar! emboli#m in he ;C= #eing ma! be

com$leel! #ilen, bu i i# a cau#e o9 #udden deah. S!m$om# are non#$eci9ic and include

d!#$nea, ach!$nea, hemo$!#i#, h!$o(emia and $leuriic che# $ain. Man! ri#2 9acor# e(i#,

mo# im$oran among# hem being a hi#or! o9 a $re4iou# embolic e4en. &her ri#2 9acor#

include immobilizaion, rauma, #urger!, #hoc2, obe#i!, $regnanc!, $ol!c!hemia 4era and

anihrombin-;;; de9icienc!. :he $aho$h!#iolog! o9 $ulmonar! emboli#m con#i## o9 boh

hemod!namic and re#$iraor! embarra##men. Hemod!namic con#eBuence# occur when more

han hal9 he cro##-#ecional area o9 he $ulmonar! 4a#cular bed i# occluded b! he embolic

e$i#ode, leading o acue $ulmonar! h!$eren#ion, h!$o(emia, re#$iraor! 9ailure and righ-#ided

hear 9ailure. %ulmonar! in9arcion en#ue# rarel! in he ab#ence o9 a##ociaed bronchial arerial

com$romi#e. :!$icall!, in9arcion# end o be hemorrhagic and occur in he lower lobe#.

:he che# radiogra$h ha# $oor #en#ii4i! in e#abli#hing he diagno#i# o9

$ulmonar! emboli#m, and he role o9 a che# radiogra$h i# in ruling ou oher

$ahologie# ha ma! ha4e a clinical $re#enaion #imilar o ha o9 $ulmonar!

emboli#m. :he che# (-ra! al#o #er4e# a u#e9ul $ur$o#e when iner$reing

4enilaion-$er9u#ion #can#. Sudie# ha4e #hown ha he 4a# maEori! o9 $aien#

wih $ulmonar! emboli#m in rero#$ec do ha4e abnormaliie# on he che# (-ra!

9inding#, bu he#e 9inding# are oo non#$eci9ic o be o9 clinical 4alue ?"igure#

?"igure#)) )))*@. ;n he ab#ence o9 $ulmonar! in9arcion, onl! a 9ew #ign# o9

$ulmonar! emboli are #een on a che# radiogra$h, which include di#coid

aeleca#i#, ele4aion o9 he hemidia$hragm, enlargemen o9 he main $ulmonar!

12
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arer! ino wha ha# been de#cribed a# he #ha$e o9 a #au#age or a 2nuc2le

, and $ulmonar! oligemia be!ond he $oin o9 occlu#ion

. A con#ellaion o9 radiogra$hic #ign# ma! be #een when

$ulmonar! in9arcion com$licae# $ulmonar! emboli#m. Muli9ocal con#olidaion

ma! 9ollow wih e#abli#hed $ulmonar! in9arcion# wihin ) o )* hour# 9ollowing

he embolic e$i#ode. A relai4el! lae #ign o9 $ulmonar! in9arcion i# a rounded

$leural-ba#ed con#olidaion ha i# rounded cenrall! and i# called a Ham$omF#

Hum$. A Ham$omF# Hum$ can be di99ereniaed 9rom a $neumonic con#olidaion

a# he 9ormer lac2# an air bronchogram. ;$#ilaeral or bilaeral $ulmonar! e99u#ion#

alhough non#$eci9ic are a##ociaed wih a$$ro(imael! 5I o9 $ulmonar! emboli,

alhough he#e are cerainl! non#$eci9ic 9inding#. ;n9arc# o9en are con9u#ed wih,

or are indi#ingui#hable 9rom, aeleca#i# or $neumonia# on che# radiogra$h#.

Howe4er, de#$ie he low #en#ii4i! o9 che# radiogra$h! in he diagno#i# o9

$ulmonar! emboli#m, i remain# an im$oran 9ir# #e$ in he diagno#i# o9

$ulmonar! emboli#m, $rimaril! o e(clude oher cau#e# o9 h!$o(emia and o aid in

he iner$reaion o9 he 4enilaion$er9u#ion #can.?*5@

Conclusion

:o #ummarize, radiogra$h! o9 lung $ahologie# common in he ;C= $aien i#

di#cu##ed, including $ulmonar! edema, ADS, aeleca#i#, $ulmonar! emboli#m,

a#$iraion and ;C=-acBuired $neumonia in erm# o9 $ahogene#i# and radiogra$hic

recogniion o9 he abnormaliie#. Di99erenial diagno#i# o9 he radiogra$hic #ign#

encounered i# di#cu##ed. e9erence i# made where oher imaging #uch a# C: or

ulra#ound i# indicaed. A #ummar! o9 radiogra$hic recogniion o9 aeleca#i# i#

$re#ened.

13
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#ootnotes

"ource of "upport:Nil

Conflict of Interest:None declared.

References

. i##cher M'. :he gene#i# o9 $ulmonar! edema. Circ e#. +5*7)1)+. ?%ubMed1

)6@

). Chai A, Cohen H0, Melzer L0, anDurme J%. :he bed#ide che# radiogra$h in he

e4aluaion o9 inci$ien hear 9ailure. adiolog!. +)7515//. ?%ubMed1 *)/*@

. %i#ole#i M, Miniai M, Milne 0N, Giunini C. :he che# roengenogram in $ulmonar!

edema. Clin Che# Med. +657/15**. ?%ubMed1 ++*@

*. Cuillo AG. :he clinical a##e##men o9 lung waer. Che#. +67+)1+)5. ?%ubMed1

6*6@

5. Maha! MA. e#oluion o9 $ulmonar! edema. New in#igh#. e# J Med.

++75*15). ?%MC;D1 %MC)5)@ ?%ubMed1 ))65+@

/. Swen#en SJ, %eer# SG, Leo! AJ, Ga! %C, S!2e# M, :ra#e2 ". adiolog! in he

inen#i4e-care uni. Ma!o Clin %roc. ++7//1+/*. ?%ubMed1 )++@

. Colice GL. Deecing he $re#ence and cau#e o9 $ulmonar! edema. %o#grad Med.

++7+1//. /+. ?%ubMed1 6*66)@

6. Hodg2in#on D, &FDri#coll ', Dri#coll %A, Nichol#on DA. A'C o9 emergenc!

radiolog!. Che# radiogra$h#--;;. 'MJ. +71). ?%MC;D1 %MC/+/)@

?%ubMed1 6//6@

+. Gluec2er :, Ca$a##o %, Schn!der %, Gudinche ", Schaller MD, e4ell! J%, Chiolero ,

oc2 %, ic2! S. Clinical and radiologic 9eaure# o9 $ulmonar! edema. adiogra$hic#.

+++7+15. di#cu##ion 5)-. ?%ubMed1 555/)@

. Gehlbach 'K, Ge$$er 0. :he $ulmonar! mani9e#aion# o9 le9 hear 9ailure. Che#.

)*7)51//+6). ?%ubMed1 */+5@

. are L', Maha! MA. Clinical $racice. Acue $ulmonar! edema. N 0ngl J Med.

)5751)66+/. ?%ubMed1 /6)/5@

14


15/43

). Monne O, :eboul JL, ichard C. Cardio$ulmonar! ineracion# in $aien# wih hear

9ailure. Curr &$in Cri Care. )71/.

. %elo#i %, occo %, Negrini D, %a##i A. :he e(racellular mari( o9 he lung and i# role

in edema 9ormaion. An Acad 'ra# Cienc. )7+1)65+. ?%ubMed1 /)5/6)@

*. Sarori C, Allemann P, Scherrer =. %ahogene#i# o9 $ulmonar! edema1 Learning 9rom

high-aliude $ulmonar! edema. e#$ir %h!#iol Neurobiol. )75+16*+. ?%ubMed1

5)))@

5. Qa4or#2! GS. 04idence o9 $ulmonar! oedema riggered b! e(erci#e in healh! human#

and deeced wih 4ariou# imaging echniBue#. Aca %h!#iol. )76+15.

/. Morgan %, Goodman L. %ulmonar! edema and adul re#$iraor! di#re## #!ndrome.

adiol Clin Norh Am. ++ Se$7)+1+*/. e4iew. 0rraum in1 adiol Clin Norh

Am ++ No47)+1i(. ?%ubMed1 6)/@

. De#ai S, Han#ell DM. Lung imaging in he adul re#$iraor! di#re## #!ndrome1 Curren

$racice and new in#igh#. ;nen#i4e Care Med. ++7)15. ?%ubMed1 +/*@

6. uben9eld GD, Caldwell 0, Granon J, Hud#on LD, Maha! MA. ;nerob#er4er

4ariabili! in a$$l!ing a radiogra$hic de9iniion 9or ADS. Che#. +++7/1*5.

?%ubMed1 55++6@

+. are L', Maha! MA. :he acue re#$iraor! di#re## #!ndrome. N 0ngl J Med.

)7*)1**+. ?%ubMed1 +/@

). Morellii M%, Manning HL. Acue re#$iraor! di#re## #!ndrome. Am "am %h!#ician.

))7/516). ?%ubMed1 )665@

). =dobi K", Child# 0, :ouiEer K. Acue re#$iraor! di#re## #!ndrome. Am "am %h!#ician.

)7/15)). ?%ubMed1 )5/)5@

)). Lichen#ein D, Gold#ein ;, Mourgeon 0, Cluzel %, Grenier %, oub! JJ. Com$arai4e

diagno#ic $er9ormance# o9 au#culaion, che# radiogra$h!, and lung ulra#onogra$h! in

acue re#$iraor! di#re## #!ndrome. Ane#he#iolog!. )*71+5. ?%ubMed1

*/+56@

). Hui DS, ong K:, Anonio G0, Lee N, u A, ong , e al. Se4ere acue re#$iraor!

#!ndrome1 Correlaion beween clinical oucome and radiologic 9eaure#. adiolog!.

)*7)15+65. ?%ubMed1 55))5@

15


16/43

)*. Genilello L, :hom$#on DA, :onne#en AS, Hernandez D, Ka$adia AS, Allen SJ,

Houchen# 'A, Miner M0. 099ec o9 a roaing bed on he incidence o9 $ulmonar!

com$licaion# in criicall! ill $aien#. Cri Care Med. +667/16/. ?%ubMed1

+/)@

)5. Swen#en SJ, %eer# SG, Leo! AJ, Ga! %C, S!2e# M, :ra#e2 ". adiolog! in he

inen#i4e-care uni. Ma!o Clin %roc. ++7//1+/*. ?%ubMed1 )++@

)/. iner-Muram H:, ubin SA, Miniai M, 0lli# J. Guideline# 9or reading and

iner$reing che# radiogra$h# in $aien# recei4ing mechanical 4enilaion. Che#.

++)7)15/5SS. ?%ubMed1 *)*+@

). :ocino ;. Che# imaging in he inen#i4e care uni. 0ur J adiol. ++/7)1*/5.

?%ubMed1 66)@

)6. %roo A. Lobar colla$#e1 'a#ic conce$#. 0ur J adiol. ++/7)1+)). ?%ubMed1

66)@

)+. Heden#ierna G, ohen H=. Aeleca#i# 9ormaion during ane#he#ia1 c au#e# and

mea#ure# o $re4en i. J Clin Moni Com$u. )7/1)+5. ?%ubMed1 )56)/@

. 'ouder2a MA, "a2hir ', 'ouaggad A, Hmamouchi ', Hamoudi D, Hari A. 0arl!

racheo#om! 4er#u# $rolonged endoracheal inubaion in #e4ere head inEur!. J :rauma.

)*751)5*. ?%ubMed1 5*5+/+@

. Keel M, Meier C. 1 Che# inEurie# - wha i# newR Curr &$in Cri Care. )71/*+.

?%ubMed1 +56+@

). ;#hi2awa S, :a2aha#hi :, &ha2i A, Sao P, Suzu2i M, Ha#egawa P, e al. %eri$heral

$ulmonar! aeleca#i# and o(!genaion im$airmen 9ollowing coronar! arer! b!$a##

gra9ing. J Cardio4a#c Surg ))7*1*+)).

. arga# "S, Cu2ier A, :erra-"ilho M, Hueb , :ei(eira L, Ligh . ;n9luence o9

aeleca#i# on $ulmonar! 9uncion a9er coronar! arer! b!$a## gra9ing. Che#.

++7*1**. ?%ubMed1 6+/)@

*. arga# "S, Cu2ier A, :erra-"ilho M, Hueb , :ei(eira L, Ligh . elaion#hi$

beween $leural change# a9er m!ocardial re4a#cularizaion and $ulmonar! mechanic#.

Che#. +))7)1/. ?%ubMed1 *)*6*/@

5. Charnio JC, Qerhouni K, Kambouchner M, Marinod 0, igna N, Azorin J, e al.

%er#i#en #!m$omaic $leural e99u#ion 9ollowing coronar! b!$a## #urger!1 Clinical and

16


17/43

hi#ologic 9eaure#, and reamen. Hear e##el#. )7))1/). 0$ub ) Jan )/.

?%ubMed1 )65**@

/. Nara!an %, Ca$uo M, Jone# J, Al-:ai S, Angelini GD, ilde %. %o#o$erai4e che#

radiogra$hic change# a9er on- and o99-$um$ coronar! #urger!. Clin adiol.

)57/1/++. ?%ubMed1 /6/+@

. Holza$9el L, Che4re S, Madinier G, &hen ", Demingeon G, Cou$r! A, Chaude M.

;n9luence o9 long-erm oro- or na#oracheal inubaion on no#ocomial ma(illar! #inu#ii#

and $neumonia1 e#ul# o9 a $ro#$eci4e, randomized, clinical rial. Cri Care Med.

++7)1)6. ?%ubMed1 6+5/@

6. Hen#ch2e C;, Pan2ele4iz D", and A, Da4i# SD, Shiau M. Accurac! and e99icac! o9

che# radiogra$h! in he inen#i4e care uni. adiol Clin Norh Am. ++/7*1).

?%ubMed1 65+5@

+. Drie# DJ, McGonigal MD, Malian MS, 'or 'J, Sulli4an C. %roocol-dri4en 4enilaor

weaning reduce# u#e o9 mechanical 4enilaion, rae o9 earl! reinubaion, and 4enilaor-

a##ociaed $neumonia. J :rauma. )*75/1+*5. di#cu##ion +5-). ?%ubMed1

5+)@

*. Lero! &, Me!bec2 A, dF0#cri4an :, De4o# %, Ki$ni# 0, Gonin O, George# H. Ho#$ial-

acBuired $neumonia in criicall! ill $aien#1 Morali! ri#2 #rai9icaion u$on on#e. :rea

e#$ir Med. )*71). ?%ubMed1 56))@

*. KhawaEa ;:, 'u99a SD, 'rand#eer D. A#$iraion $neumonia. A hrea when

degluiion i# com$romi#ed. %o#grad Med. ++)7+)1/56. -, 6. ?%ubMed1

/*+@

*). Landa! MJ. A#$iraion o9 ga#ric conen#. AJ Am J oengenol. +++71)**.

?%ubMed1 +*@

*. %elier L". A 9ew remar2# on 9a emboli#m. J :rauma. +/67616)). ?%ubMed1

*65)@

**. Hir#h J, Hull D, a#2ob G0. Diagno#i# o9 $ulmonar! emboli#m. J Am Coll Cardiol.

+6/761)6'/'.

*5. Sein %D, :errin ML, Hale# CA, %ale4#2! H;, Salzman HA, :hom$#on ':, e al.

Clinical, laboraor!, roengenogra$hic, and elecrocardiogra$hic 9inding# in $aien# wih

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acue $ulmonar! emboli#m and no $re-e(i#ing cardiac or $ulmonar! di#ea#e. Che#.

++715+6/. ?%ubMed1 ++/@

*/. or#le! D", Ala4i A, Aronchic2 JM, Chen J:, Green#$an H, a4in C0. Che#

radiogra$hic 9inding# in $aien# wih acue $ulmonar! emboli#m1 &b#er4aion# 9rom he

%;&%0D Sud!. adiolog!. ++76+1/. ?%ubMed1 6)6)@

*. Han#ell DM. :horacic imaging--hen and now. 'r J adiol. ++71S5/. ?%ubMed1

+5*)6@

*6. Lu %, Chin ''. Simulaneou# che# radiogra$hic 9inding# o9 Ham$onF# hum$,

e#ermar2F# #ign, and 4a#cular redi#ribuion in $ulmonar! emboli#m. Clin Nucl Med.

++67)1). ?%ubMed1 ++5@

*+. 0llio CG, Goldhaber SQ, i#ani L, Deo#a M. Che# radiogra$h# in acue $ulmonar!

emboli#m. e#ul# 9rom he ;nernaional Coo$erai4e %ulmonar! 0mboli#m egi#r!.

Che#. )7616. ?%ubMed1 6+5/@

5. Sreeni4a#an S, 'enne S, %ar9i J1 ;mage# in cardio4a#cular medicine. e#ermar2F#

and %allaF# #ign# in acue $ulmonar! emboli#m. Circulaion. )751e). ?%ubMed1

)5)*+@

#igures and $ables

#igure %

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"ronal che# radiogra$h #howing 9eaure# o9 iner#iial $ulmonar! edema.

adiogra$hic #ign# ha #ugge# iner#iial $ulmonar! edema

include lo## o9 de9iniion o9 large $ulmonar! 4e##el#, he a$$earance# o9 #e$al

line#, inerlobar #e$al hic2ening and di99u#e reicular $aern a##ociaed wih

cardiomegal!. 'oh Kerle!F# A and Kerle!F# ' line# are #een. :he magni9ied 4iew

o9 he le9 co#o$hrenic angle i# 9rom anoher $aien, de$icing Kerle!F# ' line#

.

#igure &

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"ronal che# radiogra$h #howing 9eaure# o9 al4eolar $ulmonar! edema. :he

9inding# include o$aci9icaion o9 boh lung# wih increa#ing den#i! oward# he

lung ba#e# due o a combinaion o9 air #$ace #hadowing and $leural e99u#ion#,

cardiomegal!, u$$er lobe blood di4er#ion

and an air bronchogram in he righ u$$er zone.

#igure '

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A 9ronal che# radiogra$h and a(ial C: #how 9eaure# o9 bawing al4eolar

$ulmonar! edema. Che# radiogra$hic 9inding# include bilaeral o$aciie# ha

e(end in a 9an #ha$e ouward 9rom he hilum in a bawing7 $aern. ih

wor#ening al4eolar edema, he lung o$aci9icaion become# increa#ingl!

homogenou#.

#igure

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Su$ine $orable che# radiogra$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 wih a##ociaed $leural e99u#ion# #econdar! o hear 9ailure. Noe

he air bronchogram# in he righ u$$er zone, #omeime# #een wih conge#i4e hear

9ailure.

#igure

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A 9ronal che# radiogra$h #howing a unilaeral edema

#igure *

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A $aienF# A% che# radiogra$h #howing wor#ening o9 he air #$ace #hadowing

wih a 9urher com$licaion o9 a righ-#ided $neumohora(.

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#igure +

25


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27/43

#igure ,

"igure# "igure#6,6, ,+ + and and #how a #erie# o9 che# (-ra!# and C: #can#

o4er a $eriod o9 6 hour# o9 a $aien 9ollowing blun horacic rauma. :he iniial

che# (-ra! ?"igure 6@ a$$ear# normal.

27
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0009/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0010/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0009/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0010/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/


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#igure -

Same $aien a# in "igure 67 change# de4elo$ ra$idl! iniiall! a# mild o$aci9icaion

a he righ lung ba#e 9ollowed b! lung $arench!mal in9ilrae a##ociaed wih a

#mall $leural e99u#ion.

#igure %.

Same $aien a# in "igure 67 he o$aci! i# in he $eri$heral lung, near he inEured

che# wall. :he le#ion ra$idl! $rogre##e# o ca4iaion a# #een on he a(ial C:

28
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0008/


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#can#. :he a$$earance# are ho#e o9 a lung conu#ion. Conu#ion howe4er u#uall!

occur# earlier, i# u#uall! localized o he area a99eced b! inEur! and im$ro4e# o4er *6-) hour#. ADS end# o be more

generalized, i# laer in on#e and #lower o re#ol4e

$able %

adiogra$hic 9eaure# o9 aeleca#i#

0le4aion o9 a hemidia$hragm

Di#$lacemen o9 a 9i##ure

Crowding o9 he 4a#culaureS$la!ing o9 he 4a#culaure #een in he non-a99eced lobe due o

com$en#aor! em$h!#ema

Media#inal #hi9

Silhoueing

#igure %%

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%lae aeleca#i#di#coid aeleca#i# i# common 9ollowing horaco-

abdominal #urger! and admini#raion o9 a general ane#heic.

#igure %&

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:he righ u$$er lobe colla$#e# ino a riangular o$aci! wih he le##er 9i##ure

migraing oward he anerior, #u$erior and medial $orion# o9 he che#, clo#ing

li2e a Chine#e 9an. &n an A% che# radiogra$h, he mo# #ri2ing 9eaure i# a

#u$erior and medial di#$lacemen o9 he minor 9i##ure. Noe al#o he rai#ed righ

hemidia$hragm. &n he laeral radiogra$h , he maEor 9i##ure mo4e#

aneriorl!, while he #u$erior mo4emen o9 he minor 9i##ure i# al#o #een. :hi#

aeleca#i# wa# #econdar! o a mucu#$lug.

#igure %'

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A 9ronal radiogra$h #how# a #egmenal colla$#e o9 he righ u$$er lobe. Noe he

ele4aion o9 he le##er 9i##ure and he righ hilum and a minor media#inal #hi9 o

he righ. :hi# wa# an a#hmaic $aien, wih a mucu# $lug

#igure %

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ighmiddle-lobe aeleca#i# ma! cau#e minimal change# on an A% #u$ine che#

radiogra$h. Noe he lo## o9 de9iniion o9 he righ hear border. A colla$#ed righ

middle lobe i# more clearl! de9ined on laeral radiogra$h, which i# no commonl!

a4ailable in he ;C= $aien. Aenion o he 9i##ure# re4eal# ha he horizonal

and lower $orion# o9 he maEor 9i##ure# mo4e oward# each oher re#uling in a

wedge o9 o$aci! $oining o he hilum. :hi# i# a middle-lobe con#olidaion

mimic2ing middle-lobe aeleca#i#.

#igure %

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An A% che# radiogra$h #howing aeleca#i# o9 he righ lower lobe. Noe ha hecolla$#ing lobe ha# mo4ed cenrall! and in9eriorl! oward# he lower dor#al #$ine,

where i i# #een a# a riangular o$aci! $ariall! #ilhoueing he righ

hemidia$hragm and a##ociaed wih a #uble air bronchogram. :he minor 9i##ure

#how# in9erior di#$lacemen. ighlower-lobe aeleca#i# can be di99ereniaed

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9rom righmiddle-lobe aeleca#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 laeral border.

Silhoueing o9 he le9 hemidia$hragm u#uall! occur#, which ma! be a##ociaed

wih an air bronchogram. ; i# al#o ea#il! mi##ed, e#$eciall! on an under$eneraed

9ilm, where no deail i# #een behind he hear.

#igure %+

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A 9ronal che# radiogra$h #howing a le9u$$er-lobe aeleca#i#. :he radiogra$h

re4eal# haz! o$aci9icaion o9 he le9 hilum, ele4aion o9 he le9 hilum, near-

horizonal cour#e o9 he le9 main bronchu#, $o#erior le9ward roaion o9 he hear

and he Lu9#ichel or air cre#cen #ign, he name gi4en o he a$$earance o9 aeraed

lung abuing he arch o9 he aora, beween he media#inum and he colla$#ed le9

u$$er lobe. An a$$earance on a laeral radiogra$h, i9 a4ailable, o9 he ;C= $aien

ma! #how rero#ernal o$aci! and di#$lacemen o9 he greaer 9i##ure aneriorl!.

#igure %,

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A che# radiogra$h #howing con#olidaion o9 le9 u$$er zone a##ociaed wih

an air bronchogram #econdar! o ho#$ial-acBuired $neumonia. :he le9 image i#

an a(ial C: #can de$icing an air bronchogram wih bilaeral $neumonic

con#olidaion in anoher $aien.

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#igure %-

An A% #u$ine radiogra$h on an inubaed $aien #howing $ach! con#olidaion in

boh lung 9ield#, more $rominen on he le9 due o ho#$ial-acBuired $neumonia.

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#igure &.

An A% che# radiogra$h o9 a $aien wih racheo#om! #howing de4elo$men o9

a#$iraion $neumonia a he righ lung ba#e.

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#igure &%

A #erie# o9 A% radiogra$h# on he #ame $aien a# in "igure )#howing e4oluion

o9 a#$iraion $neumonia a he righ lung ba#ewihin.

40
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0020/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714572/figure/F0020/


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#igure &&

A 9ronal che# radiogra$h o9 a $aien $re#ening wih #horne## o9 breah and

h!$o(emia, which #how# no #igni9ican abnormali!. Howe4er, C:%A #how# e(en#i4e $ulmonar! emboli#m.

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#igure &'

A relai4el! lae #ign o9 $ulmonar! in9arcion i# a rounded $leural ba#ed

con#olidaion ha i# rounded cenrall! and i# called a Ham$omF# Hum$. A

Ham$om,# Hum$ can be di99ereniaed 9rom a $neumonic con#olidaion a# he

9ormer lac2# an air bronchogram. Noe al#o a #mall righ co#o$hrenic e99u#ion

rac2ing u$ ino he le##er 9i##ure.

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#igure &

A $leural-ba#ed #egmenal o$aci! due o in9arcion , #ub#eBuenl! con4ering

ino a hic2-walled ca4i! .

Jurnal Radiologi Kel e Edit

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