T3 - Pulmonary edema and ICU imaging

What are the three stages of pulmonary edema and the corresponding CXR findings

1) Vascular redistribution, sign of increased pulmonary vessel pressure. Increased caliber of upper lobe vessels compared to lower lobe vessels

2) Interstitial edema, caused by increased fluid within pulmonary veins. Leads to increased interstitial markings, indistinctness of pulmonary vasculature, peribronchial cuffing, Kerley B lines

3) Alveolar edema, caued by filling of the alveoli with fluid. Edema typically has perihilar/central distribution. Pleural effusion and caridomegaly often present.

Pulmonary edema, CT findings

Dependent/central GGO and interlobular septal thickening. Usually symmetric and dependent.

Obs! Classic cause of asymmetrical pulmonary edema is acute mitral regurgitation secondary to myocardial infarction and papillary muscle rupture → isolated RUL pulmonary edema

What is reexpansion pulmonary edema

Complication of aggressive thoracentesis, caused by rapid reexpansion of lung in state of collapse for more than 3 days

ET-tube position

1) 4-6 cm above carina with neck in neutral alignment

2) If low pulmonary compliance (ARDS, etc), tip position closer to carina may reduce barotrauma

Important possible malposition of ET-tube

Direct intubation to either right or left mainstem bronchus (right more common than left). May cause atelectasis of un-intubated lung.

CVC positioning

1) Tip should be in lower SVC or cavoatrial junction (the same in PICC-line)

Possible PICC-line malposition

Azygous malposition (1%) in bedside-placed PICCs. Associated with increased risk of venous perforation and catheter-associated thrombosis, repositioning is recommended

Dialysis catheter position

Right atrium

Pulmonary artery catheter position (Swan-Ganz)

In main, right or left pulmonary artery

Pulmonary artery catheter malposition and other complications

If distal to proximal interlobar pulmonary artery, there is risk of pulmonary artery rupture or pseudoaneurym.

Other complications incl. intracardiac catheter knot and arrhythmia