Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome

Roberto Copetti, Gino Soldati, Paolo Copetti, Roberto Copetti, Gino Soldati, Paolo Copetti

Abstract

Background: Differential diagnosis between acute cardiogenic pulmonary edema (APE) and acute lung injury/acute respiratory distress syndrome (ALI/ARDS) may often be difficult. We evaluated the ability of chest sonography in the identification of characteristic pleuropulmonary signs useful in the diagnosis of ALI/ARDS and APE.

Methods: Chest sonography was performed on admission to the intensive care unit in 58 consecutive patients affected by ALI/ARDS or by acute pulmonary edema (APE).

Results: Ultrasound examination was focalised on finding in the two groups the presence of: 1) alveolar-interstitial syndrome (AIS) 2) pleural lines abnormalities 3) absence or reduction of "gliding" sign 4) "spared areas" 5) consolidations 6) pleural effusion 7) "lung pulse".AIS was found in 100% of patients with ALI/ARDS and in 100% of patients with APE (p = ns). Pleural line abnormalities were observed in 100% of patients with ALI/ARDS and in 25% of patients with APE (p < 0.0001). Absence or reduction of the 'gliding sign' was observed in 100% of patients with ALI/ARDS and in 0% of patients with APE. 'Spared areas' were observed in 100% of patients with ALI/ARDS and in 0% of patients with APE (p < 0.0001). Consolidations were present in 83.3% of patients with ALI/ARDS in 0% of patients with APE (p < 0.0001). A pleural effusion was present in 66.6% of patients with ALI/ARDS and in 95% of patients with APE (p < 0.004). 'Lung pulse' was observed in 50% of patients with ALI/ARDS and in 0% of patients with APE (p < 0.0001). All signs, except the presence of AIS, presented a statistically significant difference in presentation between the two syndromes resulting specific for the ultrasonographic characterization of ALI/ARDS.

Conclusion: Pleuroparenchimal patterns in ALI/ARDS do find a characterization through ultrasonographic lung scan. In the critically ill the ultrasound demonstration of a dyshomogeneous AIS with spared areas, pleural line modifications and lung consolidations is strongly predictive, in an early phase, of non-cardiogenic pulmonary edema.

Figures

Figure 1
Figure 1
Percentage of the different signs in the two groups.
Figure 2
Figure 2
Spared areas: present in ARDS (panel A), absent in APE (panel B).
Figure 3
Figure 3
Lung consolidations with air bronchograms in posterior lung fields in ARDS (panel A and B).
Figure 4
Figure 4
Pleural line: altered in ARDS (panel A), normal in APE (panel B).
Figure 5
Figure 5
Small subpleural consolidations: present in ARDS (panel A), absent in APE (panel B).
Figure 6
Figure 6
Particular of pleural line with linear probe (10 MHz): above the spared area the pleural line is normal while it is altered above the area of AIS.
Figure 7
Figure 7
Pleural effusion: small pleural effusion in ARDS (panel A), larger pleural effusion in APE (panel B).

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