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Acute Respiratory Distress Syndrome ARDS CXR findings

Acute Respiratory Distress Syndrome (ARDS): Chest X-Ray Findings Author: Iffat Naeem Direct or indirect lung injury causing acute respiratory distress syndrome (see Acute Respiratory Distress Syndrome slide for pathogenesis and clinical findings) Activation of dysregulated inflammatory cascade Absent pleural effusion Normal heart size Absent Kerly B lines No perihilar infiltrate pattern Bilateral infiltrate that can present in all regions of lung Air bronchograms Silhouette sign Reviewers: Victória Silva, Mao Ding Tara Lohmann* *MD at the time of publication Edema not due to a cardiogenic cause Damage to alveolar epithelium Necrosis of epithelial cells Erosion of alveolar basement membrane ↑ Alveolar epithelium permeability Damage to lung capillary endothelium Release of inflammatory cytokines Neutrophils migrate into alveoli Fluid-filled alveoli show as white/grey opacities Air-filled bronchi appear dark when surrounded by grey/white opacification of fluid-filled alveoli Increased opacification from fluid-filled alveoli results in lack of differentiation of heart borders Diffuse and widespread damage to alveoli and interstitium that show as white/grey opacities ↑ Capillary endothelium permeability Alveolar edema Degradation of alveolar- capillary barrier Proliferative phase Alveolar epithelium attempts to recover Chronic phase Can either resolve or progress to fibrotic thickening and scaring of alveoli ↑ Leakage of fluid from capillaries into alveoli and lung interstitium Pulmonary fibrosis (scarring) ‘White lung’ appearance Image credit: Radiopaedia Legend: Pathophysiology Mechanism Sign/Symptom/Lab Finding Complications Published November 25, 2023 on www.thecalgaryguide.com Acute Respiratory Distress Syndrome (ARDS): Chest X-Ray Findings Direct or indirect lung injury causing acute Author: Iffat Naeem Reviewers: Victória Silva respiratory distress syndrome* Activation of dysregulated inflammatory cascade Bilateral infiltrate that show as white/grey can present in Damage to alveolar epithelium Necrosis of epithelial cells Erosion of alveolar basement membrane ↑ Alveolar epithelium permeability Damage to lung capillary endothelium Fluid-filled alveoli opacities Air-filled bronchi appear dark when surrounded by grey/white opacification of fluid-filled alveoli Increased opacification from fluid-filled alveoli results in lack of differentiation of heart borders Diffuse and all regions of lung Release of inflammatory cytokines Neutrophils migrate into alveoli Alveolar edema Air bronchograms ↑ Capillary endothelium permeability Degradation of alveolar-capillary barrier Proliferative phase Alveolar epithelium attempts to recover Chronic phase Can either resolve or progress to fibrotic thickening and scaring of alveoli ↑ Leakage of fluid from capillaries into alveoli and lung interstitium Silhouette Sign widespread Pulmonary damage to alveoli ‘White lung’ appearance fibrosis (scarring) and interstitium that show as white/grey opacities *See corresponding Calgary Guide slides for more details Image credit: Radiopaedia Legend: Pathophysiology Mechanism Sign/Symptom/Lab Finding Complications Published X, 2023 on www.thecalgaryguide.com Acute Respiratory Distress Syndrome (ARDS): Chest X-Ray Findings Direct or indirect lung injury causing acute respiratory Author: Iffat Naeem Reviewers: Victória Silva distress syndrome* Activation of dysregulated inflammatory cascade Bilateral infiltrate that show as white/grey can present in Damage to alveolar epithelium Necrosis of epithelial cells Denudation of alveolar basement membrane ↑ epithelium permeability Degradation of alveolar-capillary barrier Alveolar epithelium attempts to recover through (proliferative phase) Damage to lung capillary endothelium Fluid-filled alveoli opacities Air-filled bronchi appear dark when surrounded by grey/white opacification of fluid-filled alveoli Increased opacification from fluid-filled alveoli results in lack of differentiation of heart borders Diffuse and all regions of lung Air bronchograms Release of proinflamm atory cytokines Neutrophil migration into airspace Alveolar Edema ↑ capillary endothelium permeability ↑ leakage of fluid from vasculature into airspace and lung interstitium Can either resolve or progress to fibrotic Silhouette Sign widespread Pulmonary damage to alveoli ‘White lung’ appearance thickening and scaring of Fibrosis alveoli (chronic phase) and interstitium that show as white/grey opacities Image credit: Radiopaedia *See corresponding Calgary Guide slides for more details Legend: Pathophysiology Mechanism Sign/Symptom/Lab Finding Complications Published X, 2023 on www.thecalgaryguide.com Acute Respiratory Distress Syndrome (ARDS): Chest X-Ray Findings Absent pleural effusion Normal heart size Absent Kerly B lines No perihilar infiltrate pattern Author: Iffat Naeem Reviewers: Victória Silva Acute Lung Injury (see ‘ARDS: Pathogenesis and Clinical findings’ slide) causing impaired oxygenation Lung injury not due to cardiogenic cause (see ‘ARDS: Pathogenesis and Clinical findings’ slide) Alveolar endothelium damage promotes inflammatory marker release Exudative phase (1-6 days): neutrophils adhere to damaged endothelium and release pro- inflammatory mediators Accumulation of intra-alveolar fluid that is rich in neutrophils, macrophages, and red blood cells Proliferative phase (7-14 days): proliferation of alveolar epithelial Fibroblasts deposit collagen tissue in alveolar walls and spaces Can either resolve or progress to fibrotic thickening and scaring Alveolar Edema Fluid-filled alveoli show as white/grey opacities Air-filled bronchi appear dark when surrounded by grey/white opacification of fluid-filled alveoli Increased opacification from fluid-filled alveoli Bilateral infiltrate present in all regions Air bronchograms results in lack of Silhouette Sign differentiation of heart borders Diffuse alveolar damage ‘White lung’ appearance Image credit: Radiopaedia *See corresponding Calgary Guide slides for more details Legend: (chronic phase) Pathophysiology Mechanism Sign/Symptom/Lab Finding Complications Published X, 2023 on www.thecalgaryguide.com Lung injury not due to a cardiogenic cause Absent pleural effusion Normal heart size Absent Kerly B lines No perihilar infiltrate pattern Acute Respiratory Distress Syndrome (ARDS): Chest X-Ray Findings