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1 ARDS - a must know Poster No.: C-1683 Congress: ECR 2016 Type: Authors: Keywords: DOI: Educational Exhibit M. Cristian; Turda/RO Education and training, Edema, Acute, Localisation, Education, Digital radiography, CT-High Resolution, CT, Trauma, Thorax, Respiratory system /ecr2016/C-1683 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 14

2 Learning objectives to acknowledge the importance of this possible fatal condition to depict its radiological features to emphasize the role of cross-sectional imaging in understanding ARDS Background Acute respiratory distress syndrome (ARDS) is basically a clinical situation suggested by an abrupt-onset dyspnea, hypoxemia that is refractory to oxygen therapy and diffuse pulmonary infiltrates. Disorders associated with ARDS ehibit either direct lung injuries (e.g. drowning, lung contusion, pneumonia), or indirect lung injuries (e.g. severe trauma, shock, sepsis). The diagnostic criteria are: acute onset (<7 days) PaO 2 /FiO 2 < 200 mmhg diffuse, bilateral pulmonary infiltrates on frontal radiograph absence of left atrial hypertension ARDS has three stages: exudative stage with interstitial edema and hyaline membrane formation, proliferative stage with organisation of fibrinous exudate and thickening of alveolar septae, and fibrotic stage with fibrosis and pulmonary cyst formation. Pathophysiology reveals compromised vascular endothelium or alveolar epithelium with secondary alveolar flooding. These findings do not normally correlate with imaging studies. Mortality is up to 50 % high. Findings and procedure details Chest radiographs and computed tomography are the imaging techniques of choice. The first one is primarily used to support the diagnosis, to spot the complication and for Page 2 of 14

3 continuous monitoring; the latter is preferred for a better characterisation of the disease, its extension and its complications. Chest radiographs Chest radiograph findings of ARDS vary widely depending on the stage of the disease. Diffuse alveolar opacities pointing out consolidation are counted as the first imagistic result Fig. 1 on page 4. Air bronchogram is visible. The opacities progress into a more asymmetrical and extended shape. One cannot usually find septal lines thickening or pleural effusion. These are more specific to a congestive heart failure Fig. 2 on page 5 Fig. 3 on page 6. This is the exudative stage. Serial chest radiographs may help distinguish between ARDS and other pathologies because a severe change in the imagistic aspect after 5-7 days may indicate another diagnosis Fig. 4 on page 7. If the patient survives, the disease enters in the fibrotic stage. The aspects of the chest radiography may reveal interstitial syndrome, which is not necessarily due to fibrosis. A correlation between pathological specimens and conventional radiographs was not possible. The latter tend to stabilise in days, but a complete recovery can last up to a couple of months, depending on the cause and the patient's response to treatment. Computed tomography CT scans depicts a 3-layered pattern due to the gravitational gradient. On the ventral side one can find normal lung images. As the pressure sums up towards the dorsal side ground glass opacities appear and they multiply in number Fig. 6 on page 9. On the most posterior aspect full consolidations emerge, pointing to the greatest gravitational gradient Fig. 7 on page 10. Also a caudal augmentation of the lesions can be seen. A review of chest CT scans in 74 patients with ARDS revealed the following findings: Areas of consolidation with air bronchograms (89%) Fig. 9 on page 12 Bilateral abnormalities in almost all the patients, predominantly dependent abnormalities (86%) Basilar predominant abnormalities (68%) Patchy abnormalities (42%) Fig. 5 on page 8 Mixed ground-glass appearance and consolidation (27%) Homogeneous abnormalities (23%) Ground-glass attenuation (8%) Page 3 of 14

4 The same study revealed that in two thirds of the cases the CT scans brought significant additional information. ARDS that is due to pulmonary disease tends to be asymmetrical, with a mix of consolidation and ground-glass opacification, whereas ARDS that is due to extrapulmonary causes has predominantly symmetric ground-glass opacification Fig. 8 on page 11. Air bronchograms and pleural effusions have a bigger prevalence than pneumatoceles and Kerley B lines. CT scans are a valuable asset in revealing ARDS complications such as pleural abnormalities (pneumothorax), parenchymal disease (nodules, focal opacities, interstitial emphysema) and mediastinal disease (enlarged lymph nodes). By comparison with the chest radiographs, the CT scans have a role in the detection of suspected fibrosis as the changes that accompany fibrosis become more apparent, such as: traction bronchiectasis, lobular distortion, and in advanced cases, cystic lung destruction or honeycombing. The implications of imaging in understanding ARDS has changed in the last years. It is now known that there is a marked reduction in overall lung volume at the expense of the volume of the lower lobes. Two mechanisms contribute to this: in the upper lobes there is an increase in tissue (edema, inflammation), in the lower lobes there is a loss of aeration (abdominal content, compression by heart). These facts helped the optimisation of PEEP treatment. CT proves to be important in improving the treatment, by examining the evolution of the disease after a drug treatment or a procedure and especially in long term check-ups. Images for this section: Page 4 of 14

5 Fig. 1: Chest radiography: ARDS Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org. From the case rid: Page 5 of 14

6 Fig. 2: Chest radiography: Pulmonary edema Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org. From the case rid: 3011 Page 6 of 14

7 Fig. 3: Chest radiography: Congestive heart failure Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org. From the case rid: Page 7 of 14

8 Fig. 4: Chest radiography: ARDS suspicion - Turda/RO Page 8 of 14

9 Fig. 5: Axial CT: ARDS - upper lobes Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org. From the case rid: Page 9 of 14

10 Fig. 6: Axial CT: ARDS - middle thorax Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org. From the case rid: Page 10 of 14

11 Fig. 7: Axial CT: ARDS - lower lobes Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org. From the case rid: Page 11 of 14

12 Fig. 8: Frontal reconstruction CT: ARDS suspicion - Turda/RO Page 12 of 14

13 Fig. 9: Axial CT: ARDS Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org. From the case rid: Page 13 of 14

14 Conclusion ARDS is a clinical syndrome of severe dyspnea with rapid onset, hypoxemia that is refractory to oxygen therapy and diffuse pulmonary infiltrates. It has three phases, each of which has distinct radiographic features. The imaging palette for ARDS includes chest radiographs and CT scans. CT scans changed the understanding and the management of ARDS. Personal information cristianmuresan.mri@gmail.com References Page 14 of 14

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