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 6
MedicalCenterPACS
IndexPatient:
Chestradiograph

Diffuse,
hazy
opacities

Source:BethIsraelDeaconess 7
MedicalCenterPACS
IndexPatient:
Chestradiograph

Diffuse,
hazy
opacities

Source:BethIsraelDeaconess 8
MedicalCenterPACS
IndexPatient:
Chestradiograph

Airbronchograms

Source:BethIsraelDeaconess 9
MedicalCenterPACS
IndexPatient:
Chestradiograph

Diffuse, Diffuse,
hazy hazy
opacities opacities

Air
bronchogram
s

Source:BethIsraelDeaconess 10
MedicalCenterPACS
 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 Patchy
(e.g.,ARDS) Asymmetric
Peripheral
Dependent
Airbronchograms
Bronchopneumonia Patchy
Asymmetric
Peripheral
Nondependent
Aspirationpneumonia Patchy
Asymmetric
Dependent
Septicinfarcts Peripheral
Wedgeshaped

Adaptedfrom:TrotmanDickensonB.RadiographyfortheCriticalCarePatient.In:McLoudTC,Boiselle 12
PM,eds. ThoracicRadiology:theRequisites.Philadelphia,PA:Mosby;2010:136159.
 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 ARDS
Cardiomegaly + +
Vascularredistribution +
Widenedvascularpedicle + +
Pleuraleffusions + +
Kerleylines + +
Peribronchialcuffing + +
Airspaceopacification Diffuseperihilar Central Patchy
perihilar peripheral

Adaptedfrom:TrotmanDickensonB.RadiographyfortheCriticalCarePatient.In:McLoudTC,Boiselle 16
PM,eds. ThoracicRadiology:theRequisites.Philadelphia,PA:Mosby;2010:136159.
 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. 18
2007;369(9572):155364.
 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. 19
2007;369(9572):155364.
 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 20
Disease8e.Philadelphia,PA:Saunders;2010:677737.
 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 21
causedbypulmonaryandextrapulmonaryinjury:acomparativeCTstudy.Radiology.2001;218(3):68993.
 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. 23
DesaiSR.Acuterespiratorydistresssyndrome:imagingoftheinjuredlung.ClinRadiol.2002;57(1):817.
 CompanionPatient1:
Early exudativestage
Chestradiograph

Source:BethIsraelDeaconess 24
MedicalCenterPACS
 CompanionPatient1:
Early exudativestage
Chestradiograph

Perihilar,
interstitial
opacities

Source:BethIsraelDeaconess 25
MedicalCenterPACS
 IndexPatient:
Later exudativestage
Chestradiograph

Source:BethIsraelDeaconess 26
MedicalCenterPACS
 IndexPatient:
Later exudativestage
Chestradiograph

Peripheral,
alveolar
consolidation

Source:BethIsraelDeaconess 27
MedicalCenterPACS
 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. 28
DesaiSR.Acuterespiratorydistresssyndrome:imagingoftheinjuredlung.ClinRadiol.2002;57(1):817.
 CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Source:BethIsraelDeaconess 29
MedicalCenterPACS
 CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Normallung

Source:BethIsraelDeaconess 30
MedicalCenterPACS
 CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Groundglass
opacities

Source:BethIsraelDeaconess 31
MedicalCenterPACS
 CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Dense
consolidation

Source:BethIsraelDeaconess 32
MedicalCenterPACS
 CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Normallung

Groundglass
opacities

Dense
consolidation

Source:BethIsraelDeaconess 33
MedicalCenterPACS
 CompanionPatient2:
Laterexudativestage
CT,axial
Image1

Source:BethIsraelDeaconess 34
MedicalCenterPACS
 CompanionPatient2:
Laterexudativestage
CT,axial
Image2

Source:BethIsraelDeaconess 35
MedicalCenterPACS
 CompanionPatient2:
Laterexudativestage
CT,axial
Image3

Source:BethIsraelDeaconess 36
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Source:BethIsraelDeaconess 37
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Normal
lung

Source:BethIsraelDeaconess 38
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Groundglass
opacities

Source:BethIsraelDeaconess 39
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Dense
consolidation

Source:BethIsraelDeaconess 40
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Normal
lung
Groundglass
opacities
Dense
consolidation

Source:BethIsraelDeaconess 41
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image1

Source:BethIsraelDeaconess 42
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image2

Source:BethIsraelDeaconess 43
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image3

Source:BethIsraelDeaconess 44
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image4

Source:BethIsraelDeaconess 45
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image5

Source:BethIsraelDeaconess 46
MedicalCenterPACS
 CompanionPatient3:
Laterexudativestage
CT,axial
Image6

Source:BethIsraelDeaconess 47
MedicalCenterPACS
 AndrewChalupka,MSIII
GillianLieberman,MD

StagesofARDS:ProliferativePhase
Pathophysiologic:
Organizationoffibrinousexudate
Regenerationofalveolarlining
Radiologic:
Inhomogeneousareasofgroundglassopacity
Thickeningofalveolarseptae

Source:GlueckerT,CapassoP,SchnyderP,GudinchetF,Schaller MD,RevellyJP,ChioleroR,VockP,WickyS.Clinicaland 48
radiologicfeaturesofpulmonaryedema.Radiographics.1999;19(6):150731.
 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 49
tomography.RadiolClinNorthAm.1996Jan;34(1):3346.
 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 50
tomographyofthewholelung.CritCareMed.2003;31(4Suppl):S28595.
 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 51
lung.CritCareMed.2003;31(4Suppl):S28595.
 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 52
lung.CritCareMed.2003;31(4Suppl):S28595.
 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 53

thewholelung.Crit CareMed.2003;31(4Suppl):S28595.
 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 54

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