The Value of Portable Chest Roentgenography in Adult Respiratory Distress Syndrome: Comparison with Computed Tomography

doi:10.1378/chest.100.3.762

Chest

Volume 100, Issue 3, September 1991, Pages 762-769

https://doi.org/10.1378/chest.100.3.762 Get rights and content

In 17 patients with adult respiratory distress syndrome, we used data derived from computed tomographic (CT) scan densitometric analysis to validate the value of portable chest roentgenograms in objectively estimating the amount of pulmonary edema. Chest roentgenograms and CT scans were taken in the same ventilatory conditions (apnea at 10 cm H₂O of positive end-expiratory pressure [PEEP]); blood gas samples and hemodynamic parameters were collected at the same time. Roentgenographic analysis was undertaken by independent observers using two standardized scoring systems proposed in the literature. CT scan analysis was performed using the CT number frequency distribution and the gas lung volume (measured by helium dilution technique) to estimate quantitatively the lung density, the lung weight, and the percentage of normally aerated and nonaerated tissue. Knowing the mean CT number of the pulmonary parenchyma in a group of normal subjects, we also inferred the ideal lung weight expected in the study population and computed the excess tissue mass as the difference between actual and ideal lung weight. Both the roentgenographic scoring systems showed direct correlation with the pulmonary impairment as detected by CT scan densitometric analysis (CT number, percentage of nonaerated tissue, lung weight, and excess tissue mass; p<0.01) and inverse relation with the percentage of normally aerated tissue (p<0.01). We also found a relationship between roentgenographic scores and the impairment in gas exchange as detected by shunt fraction (p<0.05). We conclude that standardized reading of portable chest roentgenograms by means of scoring tables is a valuable tool in estimating the amount of pulmonary edema in a patient with adult respiratory distress syndrome.

(Chest 1991; 100:762-69)

Section snippets

Paient Population

This study was conducted in the frame of a project for the study of ARDS approved by the Human Studies Committee of the Lombardia Region. Informed consent was obtained from the patients or relatives before the study.

The study group consisted of 17 patients (11 males, six females; mean age, 41 ± 18 years) with ARDS of various causes (four bacterial pneumonia; five viral pneumonia; four polytrauma; and four others [peritonitis, sepsis, pulmonary embolism, encephalitis]); there were 11 survivors

Physiologic and Imaging Parameters of the Study Population

Some of the most relevant gas exchange, lung mechanics and hemodynamic parameters of the patient population at the time of the study are summarized in Table 3. These parameters were taken with the patient in paralysis and anesthesia during mechanical ventilation with PEEP of 10 cm H₂O.

The gas exchange parameters are consistent with moderate to severe ARDS, according to previously published criteria.23, 24

The quantitative data derived from CT scan analysis are reported, in average, in Table 2,

DISCUSSION

During the last few years, we used data derived from CT scan analysis to investigate the mechanisms by which the application of a PEEP may affect gas exchange in ARDS patients (recruitment of lung zones expressed as decreased lung densities)²⁵ and to relate the CT scan data to the mechanical proprieties of the diseased lung.²⁶ The population in this study is part of that larger group of ARDS patients in whom a portable chest roentgenogram in standardized condition was performed for comparison

References (0)

Cited by (27)

Pulmonary vascular improvement in severe COVID-19 patients treated with tocilizumab
2020, Immunology Letters
Citation Excerpt :
Lung parenchyma was evaluated by applying the scoring method recently reported by Wong et al. and specifically developed for grading COVID-19 pneumonia: 0 for no involvement, 1 for less than 25 %, 2 for 25–50%, 3 for 50−75%, 4 for more than 75 % of parenchymal involvement on CXR [17]. Hilar vessels were scored by adapting the score previously used by Pistolesi et al. for acute respiratory distress syndrome (ARDS): 0 for normal, 1 for either increased density or dimensions, 2 for both increased density and dimensions [18,19]. A final score was obtained by adding parenchymal and hilar scores (0–6), as summarized in Table 1.
As of October 2020 management of Coronavirus disease 2019 (COVID-19) is based on supportive care and off-label or compassionate-use therapies. On March 2020 tocilizumab - an anti-IL-6 receptor monoclonal antibody - was suggested as immunomodulatory treatment in severe COVID-19 because hyperinflammatory syndrome occurs in many patients similarly to the cytokine release syndrome that develops after CAR-T cell therapy. In our retrospective observational study, 20 severe COVID-19 patients requiring intensive care were treated with tocilizumab in addition to standard-of-care therapy (SOC) and compared with 13 COVID-19 patients receiving only SOC. Clinical respiratory status, inflammatory markers and vascular radiologic score improved after one week from tocilizumab administration. On the contrary, these parameters were stable or worsened in patients receiving only SOC. Despite major study limitations, improvement of alveolar-arterial oxygen gradient as well as vascular radiologic score after one week may account for improved pulmonary vascular perfusion and could explain the more rapid recovery of COVID-19 patients receiving tocilizumab compared to controls.
Pulmonary Edema
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure
2008, American Journal of Emergency Medicine
Citation Excerpt :
However, our aim was to compare ultrasound with standard methods used in the every day practice. Moreover, there are some studies proving that the accuracy of EVLW evaluation through traditional chest radiography is similar to computed tomography [30]. Another limitation is that we excluded patients with lung diseases, thus reducing the possibility of false positive sonographic patterns (B lines not linked to high EVLW).
Multiple artifacts B lines (B+) at transthoracic lung ultrasound have been proposed as a sonographic sign of pulmonary congestion. Our aim is to assess B+ clearance after medical treatment in acute decompensated heart failure (ADHF) and to compare the usefulness of sonography with other traditional tools in monitoring resolution of pulmonary congestion.
Eighty-one patients with a diagnosis of ADHF were submitted to lung ultrasound and chest radiography at admission, and 70 of them underwent the same procedures as control group after 4.2 ± 1.7 days of medical treatment. The ultrasound examination was performed with 11 scans on as many anterolateral thoracic areas (6 on the right side and 5 on the left side). Then, we calculated a sonographic score counting the B+ scans and compared it with radiologic score for extravascular lung water, clinical, and plasma brain natriuretic peptide improvement.
All patients showed B+ pattern at admission and significant clearing after treatment, with median number of 8 positive scans (range, 3-9 scans) vs 0 (range, 0-7 scans) (P < .05). Our sonographic score showed positive linear correlation with radiologic score (r = 0.62; P < .05), clinical score (r = 0.87; P < .01), and brain natriuretic peptide levels (r = 0.44; P < .05). Δ Sonographic score correlated with Δ clinical (r = 0.55; P < .05) and radiologic (r = 0.28; P < .05) scores.
B line pattern mostly clears after adequate medical treatment of ADHF and represents an easy-to-use alternative bedside diagnostic tool for clinically monitoring pulmonary congestion in patients with ADHF.
Pulmonary Edema
2006, Kendig's Disorders of the Respiratory Tract in Children
Hydrostatic Versus Oleic Acid-Induced Pulmonary Edema: High-Resolution Computed Tomography Findings in the Pig Lung
1994, Academic Radiology
Rationale and Objectives. We evaluated the differences between combined hydrostatic and hypervolemic edema and oleic acid-induced edema on high-resolution computed tomography (HRCT) scans.
Methods. Twelve anesthetized and ventilated pigs were studied. Hydrostatic edema was induced by ligation of the abdominal aorta and infusion of normal saline (n = 4); permeability edema was induced by intravenous injection of oleic acid (n = 4). Four pigs were studied as normal controls. Serial scans were obtained before and after induction of edema at a constant position in the caudal lobe of the lung. The distribution of edema was assessed visually. Cross-sectional areas (CSAs) of the pulmonary artery and vein were measured both at the lobar and segmental levels.
Results. Gravity-dependent opacity, peribronchovascular fluid collection, prominent centrilobular core, thickening of the interlobular septa, and air-space consolidation at the dependent site were the sequential HRCT findings of hydrostatic edema. Randomly distributed, diffuse patchy high attenuation areas with a tendency for predilection in the subpleural and peripheral areas of the secondary lobule were the findings of oleic acidinduced edema. Hydrostatic edema increased the mean CSAs of the lobular vein by 137.8% ± 78.7, but oleic acid edema decreased the mean CSAs by 33.2% ± 22.7. Changes in the mean CSAs of the pulmonary arteries were not significant. The mean vein-to-artery ratio increased significantly in hydrostatic edema but decreased in oleic acid edema.
Conclusion. HRCT findings for hydrostatic and oleic acid-induced pulmonary edema differed both in distribution of edema and in pulmonary vascular response.
Demographics, treatments, and outcomes of acute respiratory distress syndrome: The focused outcomes research in emergency care in acute respiratory distress syndrome, sepsis, and trauma (FORECAST) study
2020, Shock

View all citing articles on Scopus

This work was supported in part by grants 87.00750.57 and 87.00018.26.115 from C.N.R., Rome.

Manuscript received September 13; revision accepted February 13.

View full text

Chest

Clinical Investigations in Critical CareThe Value of Portable Chest Roentgenography in Adult Respiratory Distress Syndrome: Comparison with Computed Tomography

Section snippets

Paient Population

Physiologic and Imaging Parameters of the Study Population

DISCUSSION

Clinical Investigations in Critical Care
The Value of Portable Chest Roentgenography in Adult Respiratory Distress Syndrome: Comparison with Computed Tomography