From the Guidelines
To differentiate and manage bilateral perihilar changes versus pulmonary overload changes, it is crucial to integrate lung ultrasound within the clinical context, focusing on the appearance of interstitial syndrome and lung consolidation as markers of increased lung density, as recommended by the European Society of Intensive Care Medicine 1.
Key Considerations
- Bilateral perihilar changes typically present as symmetric hilar enlargement or increased markings radiating from the hila, while pulmonary overload shows vascular redistribution, Kerley B lines, and pleural effusions.
- For bilateral perihilar changes due to lymphadenopathy, management depends on the underlying cause, such as infections requiring antimicrobial therapy or sarcoidosis needing corticosteroids.
- For pulmonary overload, diuretics like furosemide are the mainstay of treatment, along with addressing the underlying cause, such as heart failure or renal failure.
Diagnostic Approach
- Lung ultrasound is a valid tool to improve the differential diagnosis of lung parenchymal diseases impairing lung aeration, as it allows for the identification of additional sonographic findings, such as B-line distribution, B-line density, and subpleural consolidation 1.
- Echocardiography is valuable for assessing cardiac function in suspected overload cases, while CT chest with contrast provides better characterization of hilar lymphadenopathy.
Management Strategy
- A multifaceted approach should be used to attempt identifying the etiology of respiratory failure, including integration with the clinical context and identification of additional sonographic findings, as recommended by the European Society of Intensive Care Medicine 1.
- Serial chest imaging helps monitor response to treatment, and the distinction between bilateral perihilar changes and pulmonary overload matters because misdiagnosis could lead to inappropriate treatment.
- In critically ill patients, such as those with pulmonary arterial hypertension, careful consideration of inotropes, vasopressors, and other therapies, like inhaled nitric oxide, is necessary to avoid detrimental effects on right ventricular function 1.
From the Research
Differentiation of B/l Perihilar Changes and Pulmonary Overload Changes
- B/l perihilar changes are typically associated with pulmonary edema, which can be a result of heart failure, whereas pulmonary overload changes are related to an excess of fluid in the lungs, often due to heart failure or other conditions 2.
- The diagnosis of these conditions can be made based on signs and symptoms, laboratory, and non-invasive tests, such as echocardiography and chest X-rays 3, 2.
Management of B/l Perihilar Changes and Pulmonary Overload Changes
- The management of B/l perihilar changes and pulmonary overload changes involves decongestive treatment, such as intravenous diuretics and/or vasodilators, tailored according to the initial hemodynamic status 3, 4.
- In addition to decongestive treatment, evidence-based drug treatments, such as sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta blockers, aldosterone antagonists, and SGLT2 inhibitors, may be considered for patients with heart failure 4.
- A noninvasive risk score derived from echocardiography and clinical parameters can be used to screen for pulmonary hypertension with elevated pulmonary vascular resistance in patients with diseases of chronic volume overload, such as heart failure or chronic kidney disease 5.
Prioritization and Risk Assessment
- The prioritization of patients with heart failure and multiple comorbidities can be enhanced using an automated decision-support Patient Prioritization (PP) Tool that utilizes a tailored machine learning (ML) model to prioritize patients based on their mortality risk level 6.
- The use of machine learning models can help healthcare professionals manage heart failure patients more effectively and allocate resources to those in immediate need, whether in hospital or telehealth settings 6.