William Herring, M.D.

2002

Recognizing
Congestive
Heart Failure
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Congestive Heart Failure

X-ray patterns

Pulmonary Interstitial Edema

Pulmonary Alveolar Edema

Congestive Heart Failure

Four Signs of Pulmonary interstitial edema

Thickening of the interlobular septa

Kerley B lines

Peribronchial cuffing
Wall is normally hairline thin

Thickening of the fissures

Fluid in the subpleural space in

continuity with interlobular septa

Pleural effusions

Left Atrial Pressures

Correlated With Pathologic Findings

Normal

5-10 mm Hg

Cephalization

10-15 mm

Kerley B Lines

15-20

Pulmonary Interstitial Edema

20-25

Pulmonary Alveolar Edema

> 25

Kerley B Lines

B=distended interlobular septa

Location and appearance
Bases
1-2 cm long
Horizontal in direction
Perpendicular to pleural surface

Multiple Kerley B lines at

the left lung base
These are faint whites
lines perpendicular to
the pleural surface and
1-2cm long

Kerley A and C Lines

A=connective tissue near bronchoarterial

bundle distends with fluid

Location and appearance
Near hilum
Run obliquely
Longer than B lines

C=reticular network of lines

C Lines probably dont exist

Intersecting
network of lines
are Kerley A lines
in proper clinical
setting

Peribronchial Cuffing
Bronchial wall is usually not visible
Interstitial fluid accumulates around bronchi
Causes thickening of bronchial wall
When seen on end, looks like little

doughnuts
Meaningful when seen distal to hilar area

Numerous small circular

doughnuts seen in
lung represent fluid in
bronchial walls when
seen in conjunction with
other signs of CHF

Fluid in The Fissures

Fluid

collects in the subpleural space

Between visceral pleura and lung

parenchyma

Normal fissure

is thickness of a
sharpened pencil line
Fluid may collect in any fissure
Major, minor, accessory fissures, azygous

fissure

Fluid in the minor fissure

Fissures may be seen
normally but are usually
no thicker than the point
of a sharpened pencil

Pleural Effusion

Either in the pleural space or subpleural in

location
Laminar effusions collect beneath visceral
pleura (subpleural)
In loose connective tissue between lung
and pleura
Same location as pseudotumors

Laminar effusion in CHF

Left Atrial Pressures

Correlated With Pathologic Findings

Normal

5-10 mm Hg

Cephalization

10-15 mm

Kerley B Lines

15-20

Pulmonary Interstitial Edema

20-25

Pulmonary Alveolar Edema

> 25

Congestive Heart Failure

Pulmonary alveolar edema

Fluffy, indistinct patchy densities

Outer third of lung frequently spared
Bat-wing or butterfly configuration

Lower lung zones more affected than

upper

Pulmonary alveolar
edema has a
butterfly or batwing configuration

Pulmonary Alveolar Edema

Clearing

Generally clears in 3 days or less

Resolution usually begins

peripherally and moves centrally

Pulmonary Edema
Types

Cardiogenic
Neurogenic
Increased capillary permeability
E.g. Allergic reactions

Congestive Heart Failure

Common Causes of

Coronary artery disease

Hypertension
Cardiomyopathy
Valvular lesions
AS, MS

L to R shunts

Congestive Heart Failure

Clinical

Usually from

left heart failure

Shortness of breath
Paroxysmal nocturnal dyspnea
Orthopnea
Cough

Right heart failure

Edema

Important Points
The four reliable signs of CHF are:
Kerley B lines
Fluid in the fissures
Peribronchial cuffing
Pleural effusion

NOT cardiomegaly
NOT cephalization

Which of the following patients has

CHF?

Click to go forward
Click to go back

Does this patient have CHF?

Yes

No

Go ahead

Does this patient have CHF?

Yes

No

Go ahead

Does this patient have CHF?

Yes

No

Go ahead

Does this patient have CHF?

Yes

No

Go ahead

Correct
This is CHF

There are

Kerley A
and B lines
at the right
lung base
and a
small right
effusion
Go ahead

Correct
This is CHF

There is

diffuse
airspace
(alveolar)
disease which
has somewhat
of a bat-wing
appearance
Go ahead

Correct
There is No CHF
There are multiple
nodules in both lungs
from metastatic disease

Go ahead

Correct
This is CHF
There are Kerley B lines
visible at both lung bases

Go ahead

Wrong
Look Again

Remember to look

for the 4 signs of

CHF
Kerley B lines
Fluid in the fissures
Peribronchial cuffing
Pleural effusion

Go Back

Congratulations, You Graduate

I know
CHF
when I
see it

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