CXR: Heart Failure

Question 1

List the stage 1 features of heart failure on CXR. (2)

Answer 1

Redistribution of blood supply (upper zone vessels bigger than lower zone vessels)
Cardiomegaly

Question 2

List the stage 2 features of heart failure on CXR. (5)

Answer 2

Interstitial oedema
Kerley lines
Peribronchial cuffing
Hazy contours of vessels
Thickened interlobar fissures (0.1+mm)

Question 3

List the stage 3 features of heart failure on CXR. (5)

Answer 3

Alveolar oedema
Consolidation
Cotton wool appearance
Pleural effusions
Subpulmonic effusion

Question 4

What causes redistribution of blood supply in the lungs? (2)

What stage of heart failure is this?

How is it measured?

Answer 4

Increased pulmonary venous pressure (due to backlog of blood in left heart)

Stage 1 heart failure

Pulmonary artery:bronchus ratio

• Normally, lower zones should have a bigger ratio
• In heart failure, upper zones will have the bigger ratio (bc upper zone arteries are bigger)

Question 5

What is the main feature of interstitial oedema on CXR?

What stage of heart failure is this?

Answer 5

Outlines around the secondary lobules

Stage 2 heart failure

Question 6

Describe the 3 types of Kerley lines.

Which is the most common?

What are they caused by?

Answer 6

Kerley B lines (most common)
Caused by: interstitial oedema
Features:
-1-2cm long
-Seen at lung bases
-Perpendicular to pleural surface

Kerley A lines
Caused by: distension of anastomotic channels between peripheral/central lymphatics
Features:
-Oblique
-Longer than Kerley B lines

Kerley C lines
Features:
-Reticular opacities at lung bases

Question 7

What does peribronchial cuffing indicate?

What is it caused by?

Answer 7

Interstitial oedema

Caused by:

• Interstitial oedema makes fluid collect in the peribronchial space
• This makes the bronchial wall visible

Question 8

What does the hazy contour of pulmonary vessels indicate?

How is it caused?

Answer 8

Interstitial oedema

Caused by:
-Surrounding oedema creates less contrast with vessels

Question 9

Describe the features of subpleural pulmonary oedema on CXR. (3)

What stage of heart failure is this found in?

Answer 9

Sharply defined band of increased density below the lungs
Thick fissures
Lamellar-shaped fluid collection in costophrenic recesses

Stage 2 heart failure

Question 10

Describe the features of alveolar oedema on CXR. (4)

What stage of heart failure is this found in?

Answer 10

Bilateral
Airspace opacity
Bat’s wing or butterfly distribution
Peri-hilar shadowing

Stage 3 heart failure

Question 11

Describe the features of pleural effusion on CXR. (3)

What stage of heart failure is this found in?

Answer 11

Bilateral
Obscures lung bases
Meniscus sign
Obscures heart border
Displace mediastinum

Stage 3 heart failure

Question 12

List 3 common causes of a transudate pleural effusion.

List 3 uncommon causes of a transudate pleural effusion.

Answer 12

COMMON CAUSES
Left ventricular failure
Liver cirrhosis
Nephrotic syndrome

UNCOMMON CAUSES
Myxoedema
Pulmonary oedema
Sarcoidosis

Question 13

List 3 common causes of an exudate pleural effusion.

List 2 uncommon causes of an exudate pleural effusion.

Answer 13

COMMON CAUSES
Pulmonary embolism
Bacterial infection
Bronchial carcinoma

UNCOMMON CAUSES
Fungal/viral infection
Lymphoma

Question 14

Which type of pleural effusion is seen in heart failure?

Answer 14

Transudate

Question 15

What is subpulmonic effusion?

What stage of heart failure is it seen in?

Answer 15

Fluid accumulation below the lungs

Stage 3 heart failure

Question 16

Describe the features of subpulmonic effusion on CXR. (5)

Answer 16

Elevation of hemidiaphragm
Lateral peak of hemidiaphragm
Blunted costophrenic angles
Fluid-filled posterior costophrenic sulcus
Increased distance between lung and gastric air bubble

Question 17

Describe the 3 zones of the lungs.

Answer 17

Upper zone: above 2nd rib
Middle zone: between ribs 2-4
Lower zone: below 4th rib