From the Guidelines
I cannot show you an actual x-ray image of pulmonary congestion or pulmonary edema as I don't have the capability to display medical images. Pulmonary edema on chest x-rays typically appears as bilateral opacities in the lung fields, often with a butterfly or bat-wing pattern radiating from the hilum, as described in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. Key radiographic findings include:
- Increased interstitial markings
- Peribronchial cuffing
- Kerley B lines (short horizontal lines at the lung periphery)
- And sometimes pleural effusions In more severe cases, alveolar flooding creates fluffy, cotton-like opacities throughout the lungs. The heart may appear enlarged if the edema is due to heart failure, which can be identified through symptoms and signs of congestion, such as orthopnoea, paroxysmal nocturnal dyspnoea, and pulmonary rales, as outlined in Table 12.2 of the guidelines 1. For proper diagnosis of pulmonary edema, you should consult with a radiologist or pulmonologist who can provide and interpret actual patient x-rays, as this requires clinical expertise and access to medical imaging that I cannot provide. Chest X-ray is a useful test for the diagnosis of acute heart failure (AHF), with findings such as pulmonary venous congestion, pleural effusion, interstitial or alveolar oedema, and cardiomegaly being the most specific for AHF, although in up to 20% of patients with AHF, chest X-ray is nearly normal 1.
From the Research
Pulmonary Congestion and Edema
- Pulmonary congestion is the main cause of hospital admission among heart failure patients, and lung ultrasound can be used as a reliable and easy way to evaluate pulmonary congestion through assessment of B-lines 2.
- A B-lines cutoff ≥30 identified patients most likely to develop acute pulmonary edema at 120-days, and no acute pulmonary edema occurred in patients without significant pulmonary congestion at LUS (number of B-lines <15) 2.
- The definition, identification, quantification, and monitoring of congestion are essential in acute heart failure syndrome (AHFS), and most hospitalizations for AHFS are related to "congestion" rather than to low cardiac output 3.
Treatment of Pulmonary Edema
- Morphine has been used in patients with acute pulmonary oedema due to its anticipated anxiolytic and vasodilatory properties, but the evidence for this mechanism is relatively poor, and morphine-induced anxiolysis may possibly be the most important factor of morphine in pulmonary oedema 4.
- Nitroglycerin is beneficial in the management of presumed pre-hospital pulmonary edema, while morphine and furosemide may not add anything to its efficacy, and may be potentially deleterious in some of these patients 5.
- Nebulized furosemide is not superior to intravenous furosemide in reducing dyspnea and crackles in patients with acute pulmonary edema, but significantly improved respiratory rate and arterial blood oxygen and has less hemodynamic changes than the intravenous furosemide 6.
Imaging and Diagnosis
- Unfortunately, there are no research papers provided that include images of x-rays with pulmonary congestion indicating pulmonary edema.
- Lung ultrasound can be used to evaluate pulmonary congestion, and a B-lines cutoff ≥30 can identify patients most likely to develop acute pulmonary edema at 120-days 2.