Aust. Radiol. (1975). 19,20
Unilateral Pulmonary Edema
-Differential Diagnosis
FARHAD AZIMI,M.D.*, ALANH. WOLSON,M.D.**, MURRAY K. DALINKA, M.D. M.D. and HERMANI. LIBSHITZ, Thomas Jeflerson University Hospital, Department of Radiology, Philadelphia, Pennsylvania
INTRODUCTION The classical bilateral “buttertly” appearance (Hodson 1950, Fleischner 1967, Felson 1960) of pulmonary edema is easily recognized by most radiologists. Atypical patterns are less frequent, but by no means rare (Hublitz and Shapiro 1969, Newman and Jacobson 1951). Unilateral pulmonary edema is unusual and some of its causes differ from those generally associated with the more common bilateral involvement. Our experience with fifteen cases of unilateral pulmonary edema (Table 1). its roentgen appxrance and differential diagnosis form the basis of this communication.
CASEHISTORIES REPRESENTATIVE Case I
Sixty-eight-year-old male presented with right-sided Chat pinand dyspnea On exertion of sudden *t. Physical examination Was normal except for clinical findings of right
FIGURE 1 ~ Chest : radiograph (9/10/70) obtained a few hours after Figure IA following the insertion of a chest tube and application of negative pressure shows almost complete re-expansion of right lung and coniluent fluffy densities with ill-defined margins representative of intra-alveolar edema. Cardiac size is unchanged.
pneumothorax. Laboratory values and EKG were normal. ROENTGEN FINDINGS Chest radiograph of 9/10/70 (Figure 1 ~ ) revealed a right pneumothorax with complete collapse of the lung. Following the insertion of a chest tube and negative pressure, unilateral pulmonary edema developed with almost complete re-expansion of the right lung (Figure I s ) . There was rapid resolution of pulmonary edema after the removal of the chest tube. PRESENT ADDRESS:
*
Department of Radiology, Upstate Medical Center, Syracuse, New York. Department of Radiology, The University of Michigan Medical Center, Ann Arbor, Michigan.
FIGURE la: Chest radiograph (9/10/70) shows cornplete right pneumothorax.
**
20
Ausiralasian Radiology, Vol. X I X , No. 1, March, 1975
UNILATERAL PULMONARY EDEMA-DIFFERENTIAL DIAGNOSIS
FIGURE 2A: Chest radiograph (8/18/71) shows intraalveolar edema in the left lung and cardiomegaly. The right lung is clear.
FIGURE2B: Chest radiograph (8123171) obtained following treatment of the patient for congestive heart failure shows complete resolution of unilateral pulmonary edema. Heart remains enlarged.
COMMENT This case is an example of unilateral pulmonary edema following rapid re-expansion of pneumothorax. This was the cause of unilateral pulmonary edema in four of our patients. Involvement of the right lung in these patients is coincidental. Unilateral pulmonary edema in the left lung following rapid reexpansion of pneumothorax has been reported previously (Childress, et ul. 1971, Humuhrevs and Berne 1970).
postural in nature; on close questioning, tbe patient presented in Case 2 admitted to have the habit of lying on his left side. Involvement of the left lungs in these F i e n t s is coincidental. Unilateral pulmonary edema in the right lung resulting from the posture of the patient in congestive heart failure has previously been reported (Newman and Jacobson
Case 2
Sixty-two-year-old male presented with severe dyspnea of sudden onset. Physical examination revealed engorged neck veins, tachycardia, orthopnea and cyanosis with white sputum foaming from his nose and mouth. The left hemithorax was dull to percussion. EKG showed sinus tachycardia.
1951). Case 3
Thirty-two-year-old male who was involved in an automobile accident and sustained blunt chest trauma. Physical examination was normal, except for dullness to percussion over the right hemithorax.
FINDINGS ROENTGEN Chest radiograph of 8/18/72 showed leftsided pulmonary edema (Figure 2A), which completely resolved by 8/23/72 (Figure 2B).
ROENTGEN FINDINGS Chest radiograph of 7/15/62 revealed confluent patchy densities iovolving the entire right lung in keeping with intra-alveolar fluid (Figue 3a). There was almost complete clearing of the right lung by 7/20/62,except for a traumatic pulmonary cyst in the right upper lobe (Figure 39).
COMMENT The distribution of edema fluid in the lungs may be influenced by gravity and posture, thus, fluid may collect only in the most dependent parts. The cause of unilateral pulmonary edema in four patients was thought t o be
COMMENT pulmonary edema can occur following blunt chest trauma (Daniel and Cate 1948, Falla 1940, Ting 1966). In contrast to traumatic pulmonary hemorrhage, resolution is rapid since the underlying pulmonary parenchyma is
Australasian Radiology, Vol. XIX,No. 1 , March, 197s
21
FARHAD AZIMI,ALANH. WOLSON, MURRAY K. DALINKA AND HERMAN I. LIBSHITZ
FIGURE3 ~ :Chest radiograph (7/15/62) following blunt chest trauma sustained in an automobile accident shows confluent fluffy densities in the right lung representative of intra-alveolar fluid. The left lung is clear and the heart normal in size.
not severely damaged. Blunt chest trauma was the cause of unilateral pulmonary edema in four of our cases. Case 4
Two-year-old male who had undergone a right subclavian artery - right pulmonary artery shunt procedure, a temporary palliative operation for tetralogy of Fallot. ROENTGEN FINDINGS Chest radiograph of 9/14/72 following surgery revealed clear lungs (Figure 4 ~ ) .A second chest radiograph obtained one day later revealed a homogeneous density in the right lung in keeping with unilateral pulmonary edema and a right pleural effusion (Figure 4B).
FIGURE3e: Chest radiograph ( 7 / 2 0 / 6 2 ) shows almost complete clearing of the right lung. A small traumatic cyst is still present in the right upper lobe.
ROENTGEN FINDINGS Chest radiograph of 7/7/72 revealed the left lung to be homogeneously dense in keeping with intra-alveolar fluid (Figure 5), which resolved rapidly within a few days. COMMENT Aspiration of highly acid gastric content can lead to pulmonary edema (Baker and Heublein 1958, Fraser and Par6 1970, Mendelson 1946), usually with rapid resolution. Aspiration is generally bilateral, but was left sided in this case.
Forty-seven-year-old male who had undergone segmental resection of the right upper lobe for a cavitary pulmonary lesion with a rnycetoma. Shortly after surgery, he aspirated.
DISCUSSION The concept of unilateral pulmonary edema is not new (Newman and Jacobson 1951, Nessa and Rigier 1941, Richman and Godar 1961) and a variety of causes have been reported, mostly dealing with a single case report (Childress et al. 1971, Trapnell and Thurston 1970, Albers and Nadas 1967, Humphreys and Berne 1970, Riesman 1902, Ziskind et aE. 1965). We have collected fifteen cases with various etiologies (Table 1 ) . Any process which disturbs the state of equilibrium between the plasma oncotic pressure, intravascular hydrostatic pressure and
22
Australasian Radiology, Vol. XIX,No. I , March, 1975
COMMENT Unilateral pulmonary edema is a rare complication of systemic-pulmonary artery shunt procedures (Albers and Nadas 1967), usually performed as palliative treatment of cyanotic congenital cardiac lesions. Case 5
UNILATERAL PULMONARY EDEMA-DIFFERENTIAL DIAGNOSIS
FIGURE 4A: Cbest radiograph (9/14/71) immediately following a right pulmonary artery-right subclavian artery shunt procedure shows clear lungs.
5 : Chest immedi*bfo"owb segmental resection of right upper lobe for a cavitary lesion containing a mycetoma shows illdefined confluent densities in the left lung rcpraentative of intra-alveolar fluid. The right lung is clear and the heart normal in size.
distribution of edema fluid, however, may be one sided, lobar or even segmental. The basic mechanisms for unilateral pulmonary edema are probably the same as thae responsibk for bilateral involvement. One of the reasons for unilateral distribution of ffuid in patients with pulmonary edema is position and posture with edema fluid collecting in the most dependent parts of the lungs (Newman and Jacobson 1951. Trapnell and Thurston 1970, Gleam and Steiner 1966). The most commonly discussed causes of unilateral pulmonary edema are rapid reexpansion of pneumothorax or the removal of a large pleural effusion (Chiddress et d. 1971, FIGURE4s: Cbyt radiograph (9/15/71) shows Trapnell and Thurston 1970, Humphreys and right pleural effusion and findings in the right lung representative of intra-alveolar fluid. The left lung is Berne 1970, Riesman 1902, Ziskind et al. 1965). The mechanisms responsible for the clear. 4a and 4s courtesy of Dr. John A. Kirk- appearance of edema in these patients are un(FIGURES patrick) certain, but it is usually assumed that the rather strong negative pressure plays a major role. There is no definite correlation between the capillary permeability may result in tran- the amount of negative pressure and the apsudation of fluid into the lung parenchyma and pearance of edema. It has been postulated that ultimately in pulmonary edema. the collapsed lung causes a reduction in the The pathophysiology of pulmonary edema amount of pulmonary surfactant which makes secondary to congestive heart failure is known, reexpansion more difficult (Trapnell and although the reason for its central distribution Thurston 1970). Childress and co-workers is not well understood (Felson 1960). The (1971) have suggested that a blocked bronchus Australasian Radiology, Vol. XIX,No. I . March, 1975
23
FARHAD
AZIMI, ALANH.
WOLSON,
MURRAY K. DALINKA AND HERMAN I. LlBSHlTZ
TABLE 1 CAUSES OF PULMONARY EDEMA
NUMBER OF PATIENTS
~AGE _
Rapid re-expansion of pneumothorax
4
68" 89 62 65
M M M M
Gravity and posture in patients with congestive heart failure
4
62"
M
_
4
_
Following systemic-pulmonary artery shunt procedures
2
Unilateral aspiration of highly acid gastric content
I
32: 22 26 23
_
3
2*
-___ 47*
M M F M
_
Right Right Right Right
Lung Lung Lung Lung
Left Lung Left Lung
----
Blunt trauma to the chest
SITE OF INVOLVEMENT
SEX
1
M M
Right Right Right Right ~ Right Right
M
Left Lung
_
Lung Lung Lung Lung Lung Lung
* Representative case histories must be present in addition to the rapid reexpansion of pneumothorax for pulmonary edema to occur. Daniel and Cate ( I 948) experimentally demonstrated edema fluid within the alveoli, bronchioles and extravascular interstitial spaces in animal lungs following blunt chest trauma. Falla (1940) reported on arterial and capillary dilatation in lungs following chest trauma. Pulmonary edema in these cases is probably secondary to increased capillary permeability with outpouring of fluid into the alveoli followed by rapid reabsorption of edema fluid because the underlying lung parenchyma is not severely damaged. Albers and Nadas (1967) reported linilateral pulmonary edema in children following systemic-pulmonary artery shunt procedures for temporary treatment of cyanotic heart lesions. The mechanims proposed by these authors to be responsible for pulmonary edema are pulmonary venous congestion caused by a large shunt volume and local pulmonary vascular damage resulting from the introduction of systemic arterial pressure into the pulmonary vessels following the shunt operation. Aspiration of highly acid gastric juice is another cause of r>ulmonaryedema (Baker and Heublein 1958, Fraser and Par6 1970, Mendelson 1946). It is usually bilateral and follows general anesthesia. On occasion, aspiration is unilateral and hence pulmonary edema occurs in one lung. It has been shown that edema
develops when the pH of the aspirate is less than 2.5 (Baker and Heublein 1958). The peculiarity of the roentgen findings in correlation with the clinical manifestations and history will usually allow an accurate diagnosis of unilateral pulmonary edema on the part of the radiologist.
24
Australasian Radiology, Vol. XIX,No. I , March, 1975
SUMMARY Our experience with fifteen cases of unilateral pulmonary edema, its roentgen appearance and differential diagnosis is presented. Representative patients with unilateral pulmonary edema caused by rapid re-expansion of pneumothorax, congestive heart failure, blunt chest trauma, aspiration of acid gastric contents and following systemic pulmonary artery shunt procedures in children with cyanotic congenital heart lesions are reported in more detail. ACKNOWLEDGEMENT The authors would like to thank Dr. John A. Kirkpatrick, Professor of Radiology, Temple University Hospital and St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, for his kind permission for the use of Case 4. BIBLIOGRAPHY Albers, W. H. and Nadas, A. S. (1967). Unilateral chronic pulmonary edema and pleural effusion after systemic-pulmonary artery shunts for cyanotic congenital heart disease. Amer. 1. Curdiology, 19, 861-866.
UNILATERAL PULMONARY EDEMA-DIFFERENTIAL DIAGNOSIS Baker, G. L. and Heublein, G. W. (1958). Postoperative aspiration pneumonia. Amer. 1. Roentgenol., 80, 42-48. Childress, M. E., Moy, G. and Mottram, M. (1971). Unilateral pulmonary edema resulting from treatment of spontaneous pneumothorax. Amer. Rev. Resp. Dis., 104, 119-121. Daniel, R. A., Jr. and Cate, W. R., Jr. (1948). “Wet Lung”-An experimental study: I. Effects of trauma and hypoxia. Annals of Surgery, 127, 836-857. Falla, S. T. (1940). Effect of explosion blast on lungs: Report of a case. Brit. Med. J., 12, 255256. Felson, B. (1960). Fundamentals of chest roentgenology. Philadelphia, W. B. Saunders, 253259. Fleischner, F. G. (1967). The butterfly pattern of acute pulmonary edema. Amer. J . Cardiology, 20, 39-46. Fraser, R. G. and Park, J. A. P. (1970). Diagnosis of diseases of the chest. Philadelphia, W. B. Saunders, 958-959. Gleason, D. C. and Steiner, R. E. (1966). The lateral roentgenogram in pulmonary edema. Amer. J . of Roentgenol, 98, 279-290. Hodson, C. J. (1950). Pulmonary edema and the “batswing” shadows. J . Fac. Radiol., 1, 176-186. Hublitz, U. F. and Shapiro, J. (1969). Atypical pulmonary patterns of congestive failure in chronic lung disease. Radiology, 93, 995-1006.
Humphreys, R. L. and Berne, A. S. (1970). Rapid re-expansion of pneumothorax-a cause of unilaterhl pulmonary edema. Radiology, 96, 509512. Mendelson, C. L. (1946). The aspiration of stomach contents into the lungs during obstetrical anesthesia. Amer. 1. Obsfer. Gynecol., 52, 191-205. Nessa, C . B. and Rigler, L. G. (1941). The roentgenological manifestations of pulmonary edema. Radiology, 37, 35-46. Newman, W. and Jacobson, H. G. (1951). Bizarre pulmonary roentgenographic manifestations in heart disease. Amer. Heart J., 42, 184-193. Richman, S. M. and Godar, T. J. (1961). Unilateral pulmonary edema. New England I . Med., 264, 1148-1149. Riesman, D. (1902). Albuminous expectoration following thoracentesis. Amer. 1. Med. Sciences, 123, 620-630. Ting, Y . M. (1966). Pulmonary parenchymal findings in blunt trauma t o the chest. Amer. J . Roentgenol., 98, 343-349. Trapnell, D. H. and Thurston, I. G. B. (1970). Unilateral pulmonary edema after pleural aspiration. Lancet, 1, 1367-1369. Ziskind, M. M., Weill, H. and George, R. A. (1965). Acute pulmonary edema following the treatment of spontaneous pneumothorax with excessive negative intrapleural pressure. Amer. Rev. Resp. Dis., 92. 632-636
T H E ROYAL AUSTRALASIAN COLLEGE OF RADIOLOGISTS SCHERING A. G. BERLIN STUDY GRANTS
5. Applicants are requested to state whether they will be attending the Annual Meeting in the event of not being awarded a grant.
This will have no bearing on the selection of the recipient, and is asked to assist the organisers of the Meeting in drawing up the programme. 6. T h e maximum amount to be awarded to any individual will be Aust$250.00, but the Committee will take into account normal travelling expenses from the Member’s home city in allocating the amount of the Grant. 7. If in the opinion of the College, the applications received do not merit the awarding of the Grants, the funds available may be held over in whole or part for use in a subsequent year. 8. Applications, together with a precis of the paper to be proffered shall be made to the Honorary Secretary of T h e Royal ‘4ustraIasian College of Radioiogists, 45 Macquarie Street, Sydney, not later than Slst May, 1975.
Australasian Radiology, V o f .X I X , NO. I , March. l Q ? j
25
1. Scherinp A. G. Berlin has donated a sum of $500.00 to the College for use in 1975.
2. From this amount, Grants will be made to assist travel to the Annual Meeting of the College, to be held in Melbourne, from 17th to 20th October, 1975. 3. T h e Grants will be available to either(a) A Member of not more than five years’ standing. (b) An Associate Member, or (c) A Student Member. 4. X condition of the Grant shall be that the recipient shall proffer a paper to be presented at the Annual Meeting, a summary of which shall be submitted with the a p plica tion.
Unilateral Pulmonary Edema
-Differential Diagnosis
FARHAD AZIMI,M.D.*, ALANH. WOLSON,M.D.**, MURRAY K. DALINKA, M.D. M.D. and HERMANI. LIBSHITZ, Thomas Jeflerson University Hospital, Department of Radiology, Philadelphia, Pennsylvania
INTRODUCTION The classical bilateral “buttertly” appearance (Hodson 1950, Fleischner 1967, Felson 1960) of pulmonary edema is easily recognized by most radiologists. Atypical patterns are less frequent, but by no means rare (Hublitz and Shapiro 1969, Newman and Jacobson 1951). Unilateral pulmonary edema is unusual and some of its causes differ from those generally associated with the more common bilateral involvement. Our experience with fifteen cases of unilateral pulmonary edema (Table 1). its roentgen appxrance and differential diagnosis form the basis of this communication.
CASEHISTORIES REPRESENTATIVE Case I
Sixty-eight-year-old male presented with right-sided Chat pinand dyspnea On exertion of sudden *t. Physical examination Was normal except for clinical findings of right
FIGURE 1 ~ Chest : radiograph (9/10/70) obtained a few hours after Figure IA following the insertion of a chest tube and application of negative pressure shows almost complete re-expansion of right lung and coniluent fluffy densities with ill-defined margins representative of intra-alveolar edema. Cardiac size is unchanged.
pneumothorax. Laboratory values and EKG were normal. ROENTGEN FINDINGS Chest radiograph of 9/10/70 (Figure 1 ~ ) revealed a right pneumothorax with complete collapse of the lung. Following the insertion of a chest tube and negative pressure, unilateral pulmonary edema developed with almost complete re-expansion of the right lung (Figure I s ) . There was rapid resolution of pulmonary edema after the removal of the chest tube. PRESENT ADDRESS:
*
Department of Radiology, Upstate Medical Center, Syracuse, New York. Department of Radiology, The University of Michigan Medical Center, Ann Arbor, Michigan.
FIGURE la: Chest radiograph (9/10/70) shows cornplete right pneumothorax.
**
20
Ausiralasian Radiology, Vol. X I X , No. 1, March, 1975
UNILATERAL PULMONARY EDEMA-DIFFERENTIAL DIAGNOSIS
FIGURE 2A: Chest radiograph (8/18/71) shows intraalveolar edema in the left lung and cardiomegaly. The right lung is clear.
FIGURE2B: Chest radiograph (8123171) obtained following treatment of the patient for congestive heart failure shows complete resolution of unilateral pulmonary edema. Heart remains enlarged.
COMMENT This case is an example of unilateral pulmonary edema following rapid re-expansion of pneumothorax. This was the cause of unilateral pulmonary edema in four of our patients. Involvement of the right lung in these patients is coincidental. Unilateral pulmonary edema in the left lung following rapid reexpansion of pneumothorax has been reported previously (Childress, et ul. 1971, Humuhrevs and Berne 1970).
postural in nature; on close questioning, tbe patient presented in Case 2 admitted to have the habit of lying on his left side. Involvement of the left lungs in these F i e n t s is coincidental. Unilateral pulmonary edema in the right lung resulting from the posture of the patient in congestive heart failure has previously been reported (Newman and Jacobson
Case 2
Sixty-two-year-old male presented with severe dyspnea of sudden onset. Physical examination revealed engorged neck veins, tachycardia, orthopnea and cyanosis with white sputum foaming from his nose and mouth. The left hemithorax was dull to percussion. EKG showed sinus tachycardia.
1951). Case 3
Thirty-two-year-old male who was involved in an automobile accident and sustained blunt chest trauma. Physical examination was normal, except for dullness to percussion over the right hemithorax.
FINDINGS ROENTGEN Chest radiograph of 8/18/72 showed leftsided pulmonary edema (Figure 2A), which completely resolved by 8/23/72 (Figure 2B).
ROENTGEN FINDINGS Chest radiograph of 7/15/62 revealed confluent patchy densities iovolving the entire right lung in keeping with intra-alveolar fluid (Figue 3a). There was almost complete clearing of the right lung by 7/20/62,except for a traumatic pulmonary cyst in the right upper lobe (Figure 39).
COMMENT The distribution of edema fluid in the lungs may be influenced by gravity and posture, thus, fluid may collect only in the most dependent parts. The cause of unilateral pulmonary edema in four patients was thought t o be
COMMENT pulmonary edema can occur following blunt chest trauma (Daniel and Cate 1948, Falla 1940, Ting 1966). In contrast to traumatic pulmonary hemorrhage, resolution is rapid since the underlying pulmonary parenchyma is
Australasian Radiology, Vol. XIX,No. 1 , March, 197s
21
FARHAD AZIMI,ALANH. WOLSON, MURRAY K. DALINKA AND HERMAN I. LIBSHITZ
FIGURE3 ~ :Chest radiograph (7/15/62) following blunt chest trauma sustained in an automobile accident shows confluent fluffy densities in the right lung representative of intra-alveolar fluid. The left lung is clear and the heart normal in size.
not severely damaged. Blunt chest trauma was the cause of unilateral pulmonary edema in four of our cases. Case 4
Two-year-old male who had undergone a right subclavian artery - right pulmonary artery shunt procedure, a temporary palliative operation for tetralogy of Fallot. ROENTGEN FINDINGS Chest radiograph of 9/14/72 following surgery revealed clear lungs (Figure 4 ~ ) .A second chest radiograph obtained one day later revealed a homogeneous density in the right lung in keeping with unilateral pulmonary edema and a right pleural effusion (Figure 4B).
FIGURE3e: Chest radiograph ( 7 / 2 0 / 6 2 ) shows almost complete clearing of the right lung. A small traumatic cyst is still present in the right upper lobe.
ROENTGEN FINDINGS Chest radiograph of 7/7/72 revealed the left lung to be homogeneously dense in keeping with intra-alveolar fluid (Figure 5), which resolved rapidly within a few days. COMMENT Aspiration of highly acid gastric content can lead to pulmonary edema (Baker and Heublein 1958, Fraser and Par6 1970, Mendelson 1946), usually with rapid resolution. Aspiration is generally bilateral, but was left sided in this case.
Forty-seven-year-old male who had undergone segmental resection of the right upper lobe for a cavitary pulmonary lesion with a rnycetoma. Shortly after surgery, he aspirated.
DISCUSSION The concept of unilateral pulmonary edema is not new (Newman and Jacobson 1951, Nessa and Rigier 1941, Richman and Godar 1961) and a variety of causes have been reported, mostly dealing with a single case report (Childress et al. 1971, Trapnell and Thurston 1970, Albers and Nadas 1967, Humphreys and Berne 1970, Riesman 1902, Ziskind et aE. 1965). We have collected fifteen cases with various etiologies (Table 1 ) . Any process which disturbs the state of equilibrium between the plasma oncotic pressure, intravascular hydrostatic pressure and
22
Australasian Radiology, Vol. XIX,No. I , March, 1975
COMMENT Unilateral pulmonary edema is a rare complication of systemic-pulmonary artery shunt procedures (Albers and Nadas 1967), usually performed as palliative treatment of cyanotic congenital cardiac lesions. Case 5
UNILATERAL PULMONARY EDEMA-DIFFERENTIAL DIAGNOSIS
FIGURE 4A: Cbest radiograph (9/14/71) immediately following a right pulmonary artery-right subclavian artery shunt procedure shows clear lungs.
5 : Chest immedi*bfo"owb segmental resection of right upper lobe for a cavitary lesion containing a mycetoma shows illdefined confluent densities in the left lung rcpraentative of intra-alveolar fluid. The right lung is clear and the heart normal in size.
distribution of edema fluid, however, may be one sided, lobar or even segmental. The basic mechanisms for unilateral pulmonary edema are probably the same as thae responsibk for bilateral involvement. One of the reasons for unilateral distribution of ffuid in patients with pulmonary edema is position and posture with edema fluid collecting in the most dependent parts of the lungs (Newman and Jacobson 1951. Trapnell and Thurston 1970, Gleam and Steiner 1966). The most commonly discussed causes of unilateral pulmonary edema are rapid reexpansion of pneumothorax or the removal of a large pleural effusion (Chiddress et d. 1971, FIGURE4s: Cbyt radiograph (9/15/71) shows Trapnell and Thurston 1970, Humphreys and right pleural effusion and findings in the right lung representative of intra-alveolar fluid. The left lung is Berne 1970, Riesman 1902, Ziskind et al. 1965). The mechanisms responsible for the clear. 4a and 4s courtesy of Dr. John A. Kirk- appearance of edema in these patients are un(FIGURES patrick) certain, but it is usually assumed that the rather strong negative pressure plays a major role. There is no definite correlation between the capillary permeability may result in tran- the amount of negative pressure and the apsudation of fluid into the lung parenchyma and pearance of edema. It has been postulated that ultimately in pulmonary edema. the collapsed lung causes a reduction in the The pathophysiology of pulmonary edema amount of pulmonary surfactant which makes secondary to congestive heart failure is known, reexpansion more difficult (Trapnell and although the reason for its central distribution Thurston 1970). Childress and co-workers is not well understood (Felson 1960). The (1971) have suggested that a blocked bronchus Australasian Radiology, Vol. XIX,No. I . March, 1975
23
FARHAD
AZIMI, ALANH.
WOLSON,
MURRAY K. DALINKA AND HERMAN I. LlBSHlTZ
TABLE 1 CAUSES OF PULMONARY EDEMA
NUMBER OF PATIENTS
~AGE _
Rapid re-expansion of pneumothorax
4
68" 89 62 65
M M M M
Gravity and posture in patients with congestive heart failure
4
62"
M
_
4
_
Following systemic-pulmonary artery shunt procedures
2
Unilateral aspiration of highly acid gastric content
I
32: 22 26 23
_
3
2*
-___ 47*
M M F M
_
Right Right Right Right
Lung Lung Lung Lung
Left Lung Left Lung
----
Blunt trauma to the chest
SITE OF INVOLVEMENT
SEX
1
M M
Right Right Right Right ~ Right Right
M
Left Lung
_
Lung Lung Lung Lung Lung Lung
* Representative case histories must be present in addition to the rapid reexpansion of pneumothorax for pulmonary edema to occur. Daniel and Cate ( I 948) experimentally demonstrated edema fluid within the alveoli, bronchioles and extravascular interstitial spaces in animal lungs following blunt chest trauma. Falla (1940) reported on arterial and capillary dilatation in lungs following chest trauma. Pulmonary edema in these cases is probably secondary to increased capillary permeability with outpouring of fluid into the alveoli followed by rapid reabsorption of edema fluid because the underlying lung parenchyma is not severely damaged. Albers and Nadas (1967) reported linilateral pulmonary edema in children following systemic-pulmonary artery shunt procedures for temporary treatment of cyanotic heart lesions. The mechanims proposed by these authors to be responsible for pulmonary edema are pulmonary venous congestion caused by a large shunt volume and local pulmonary vascular damage resulting from the introduction of systemic arterial pressure into the pulmonary vessels following the shunt operation. Aspiration of highly acid gastric juice is another cause of r>ulmonaryedema (Baker and Heublein 1958, Fraser and Par6 1970, Mendelson 1946). It is usually bilateral and follows general anesthesia. On occasion, aspiration is unilateral and hence pulmonary edema occurs in one lung. It has been shown that edema
develops when the pH of the aspirate is less than 2.5 (Baker and Heublein 1958). The peculiarity of the roentgen findings in correlation with the clinical manifestations and history will usually allow an accurate diagnosis of unilateral pulmonary edema on the part of the radiologist.
24
Australasian Radiology, Vol. XIX,No. I , March, 1975
SUMMARY Our experience with fifteen cases of unilateral pulmonary edema, its roentgen appearance and differential diagnosis is presented. Representative patients with unilateral pulmonary edema caused by rapid re-expansion of pneumothorax, congestive heart failure, blunt chest trauma, aspiration of acid gastric contents and following systemic pulmonary artery shunt procedures in children with cyanotic congenital heart lesions are reported in more detail. ACKNOWLEDGEMENT The authors would like to thank Dr. John A. Kirkpatrick, Professor of Radiology, Temple University Hospital and St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, for his kind permission for the use of Case 4. BIBLIOGRAPHY Albers, W. H. and Nadas, A. S. (1967). Unilateral chronic pulmonary edema and pleural effusion after systemic-pulmonary artery shunts for cyanotic congenital heart disease. Amer. 1. Curdiology, 19, 861-866.
UNILATERAL PULMONARY EDEMA-DIFFERENTIAL DIAGNOSIS Baker, G. L. and Heublein, G. W. (1958). Postoperative aspiration pneumonia. Amer. 1. Roentgenol., 80, 42-48. Childress, M. E., Moy, G. and Mottram, M. (1971). Unilateral pulmonary edema resulting from treatment of spontaneous pneumothorax. Amer. Rev. Resp. Dis., 104, 119-121. Daniel, R. A., Jr. and Cate, W. R., Jr. (1948). “Wet Lung”-An experimental study: I. Effects of trauma and hypoxia. Annals of Surgery, 127, 836-857. Falla, S. T. (1940). Effect of explosion blast on lungs: Report of a case. Brit. Med. J., 12, 255256. Felson, B. (1960). Fundamentals of chest roentgenology. Philadelphia, W. B. Saunders, 253259. Fleischner, F. G. (1967). The butterfly pattern of acute pulmonary edema. Amer. J . Cardiology, 20, 39-46. Fraser, R. G. and Park, J. A. P. (1970). Diagnosis of diseases of the chest. Philadelphia, W. B. Saunders, 958-959. Gleason, D. C. and Steiner, R. E. (1966). The lateral roentgenogram in pulmonary edema. Amer. J . of Roentgenol, 98, 279-290. Hodson, C. J. (1950). Pulmonary edema and the “batswing” shadows. J . Fac. Radiol., 1, 176-186. Hublitz, U. F. and Shapiro, J. (1969). Atypical pulmonary patterns of congestive failure in chronic lung disease. Radiology, 93, 995-1006.
Humphreys, R. L. and Berne, A. S. (1970). Rapid re-expansion of pneumothorax-a cause of unilaterhl pulmonary edema. Radiology, 96, 509512. Mendelson, C. L. (1946). The aspiration of stomach contents into the lungs during obstetrical anesthesia. Amer. 1. Obsfer. Gynecol., 52, 191-205. Nessa, C . B. and Rigler, L. G. (1941). The roentgenological manifestations of pulmonary edema. Radiology, 37, 35-46. Newman, W. and Jacobson, H. G. (1951). Bizarre pulmonary roentgenographic manifestations in heart disease. Amer. Heart J., 42, 184-193. Richman, S. M. and Godar, T. J. (1961). Unilateral pulmonary edema. New England I . Med., 264, 1148-1149. Riesman, D. (1902). Albuminous expectoration following thoracentesis. Amer. 1. Med. Sciences, 123, 620-630. Ting, Y . M. (1966). Pulmonary parenchymal findings in blunt trauma t o the chest. Amer. J . Roentgenol., 98, 343-349. Trapnell, D. H. and Thurston, I. G. B. (1970). Unilateral pulmonary edema after pleural aspiration. Lancet, 1, 1367-1369. Ziskind, M. M., Weill, H. and George, R. A. (1965). Acute pulmonary edema following the treatment of spontaneous pneumothorax with excessive negative intrapleural pressure. Amer. Rev. Resp. Dis., 92. 632-636
T H E ROYAL AUSTRALASIAN COLLEGE OF RADIOLOGISTS SCHERING A. G. BERLIN STUDY GRANTS
5. Applicants are requested to state whether they will be attending the Annual Meeting in the event of not being awarded a grant.
This will have no bearing on the selection of the recipient, and is asked to assist the organisers of the Meeting in drawing up the programme. 6. T h e maximum amount to be awarded to any individual will be Aust$250.00, but the Committee will take into account normal travelling expenses from the Member’s home city in allocating the amount of the Grant. 7. If in the opinion of the College, the applications received do not merit the awarding of the Grants, the funds available may be held over in whole or part for use in a subsequent year. 8. Applications, together with a precis of the paper to be proffered shall be made to the Honorary Secretary of T h e Royal ‘4ustraIasian College of Radioiogists, 45 Macquarie Street, Sydney, not later than Slst May, 1975.
Australasian Radiology, V o f .X I X , NO. I , March. l Q ? j
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1. Scherinp A. G. Berlin has donated a sum of $500.00 to the College for use in 1975.
2. From this amount, Grants will be made to assist travel to the Annual Meeting of the College, to be held in Melbourne, from 17th to 20th October, 1975. 3. T h e Grants will be available to either(a) A Member of not more than five years’ standing. (b) An Associate Member, or (c) A Student Member. 4. X condition of the Grant shall be that the recipient shall proffer a paper to be presented at the Annual Meeting, a summary of which shall be submitted with the a p plica tion.
