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Original article

Vol. 149 No. 3536 (2019)

Kerley B lines in the lung apex – a distinct CT sign for pulmonary congestion

  • Laura I. Loebelenz
  • Lukas Ebner
  • Verena C. Obmann
  • Adrian T. Huber
  • Andreas Christe
DOI
https://doi.org/10.4414/smw.2019.20119
Cite this as:
Swiss Med Wkly. 2019;149:w20119
Published
02.09.2019

Summary

AIMS OF THE STUDY

The purpose of this study was to establish a new computed tomography (CT) sign for pulmonary congestion (Kerley B lines in the lung apex in patients with cardiac or renal insufficiency) and to find the best signs to differentiate between pulmonary congestion and interstitial lung disease (ILD).

METHODS

180 consecutive patients undergoing CT were retrospectively included: 43 patients with cardiac, 17 with renal and 30 with mixed cardiac/renal insufficiency. In addition, we selected 90 patients with known ILD (usual interstitial pneumonia and nonspecific interstitial pneumonia). The cases were retrieved by means of a full text search of radiological reports and electronic patient files. The cardiothoracic ratio and diameters of the superior and inferior vena cava were measured. Pleural effusion, peribronchial cuffing, Kerley B lines (interlobular septa), ground glass opacity (GGO) and consolidation were analysed for prevalence, distribution and quantity (1 to 3). Fisher’s exact and Mann-Whitney-test were applied using Bonferroni correction.

RESULTS

Kerley B lines in the lung apex were present in 81% and 76% of the cardiac and renal groups, respectively, which was significantly more than in the ILD group (26%, p <0.0001). In the insufficiency group, Kerley B lines were distributed more homogenously throughout the lungs compared with the ILD group in which they increased in amount from 32% in the upper lobe to 90% in the lower lobe. The septal lines were thinner in the ILD than in the insufficiency group (p <0.0001). Peribronchial cuffing was significantly more frequent in the cardiac group (67%) compared with the renal group (29%, p = 0.040) and the ILD group (0%, p <0.0001). Other pulmonary congestion signs such as cardiothoracic ratio, enlargement of the superior and inferior vena cava and pleural effusion did not vary between the cardiac and the renal groups but were significantly lower in the ILD group. However, ILD patients showed more GGO in the lower lobes (87%) then patients with insufficiency (42%, p <0.0001).

CONCLUSION

Interlobular septal thickening (Kerley B lines) in the lung apex is a specific sign for pulmonary congestion, although not exclusive (since in ILD there may be apical reticulation). In combination with peribronchial cuffing and increased cardiothoracic ratio, it allows differentiation between cardiac/renal insufficiency and pulmonary ILD.

References

  1. Matthys H. Klinische Pneumologie. Heidelberg: Springer Medizin Verlag; 2008.
  2. Starling EH. On the Absorption of Fluids from the Connective Tissue Spaces. J Physiol. 1896;19(4):312–26. doi:.https://doi.org/10.1113/jphysiol.1896.sp000596
  3. Milne EN, Pistolesi M, Miniati M, Giuntini C. The radiologic distinction of cardiogenic and noncardiogenic edema. AJR Am J Roentgenol. 1985;144(5):879–94. doi:.https://doi.org/10.2214/ajr.144.5.879
  4. Vergani G, Cressoni M, Crimella F, L’Acqua C, Sisillo E, Gurgitano M, et al. A Morphological and Quantitative Analysis of Lung CT Scan in Patients With Acute Respiratory Distress Syndrome and in Cardiogenic Pulmonary Edema. J Intensive Care Med. 2017:885066617743477. doi:.https://doi.org/10.1177/0885066617743477
  5. Komiya K, Ishii H, Murakami J, Yamamoto H, Okada F, Satoh K, et al. Comparison of chest computed tomography features in the acute phase of cardiogenic pulmonary edema and acute respiratory distress syndrome on arrival at the emergency department. J Thorac Imaging. 2013;28(5):322–8. doi:.https://doi.org/10.1097/RTI.0b013e31828d40b2
  6. Gluecker T, Capasso P, Schnyder P, Gudinchet F, Schaller MD, Revelly JP, et al. Clinical and radiologic features of pulmonary edema. Radiographics. 1999;19(6):1507–31, discussion 1532–3. doi:.https://doi.org/10.1148/radiographics.19.6.g99no211507
  7. Reed JC. Chest radiology, plain film patterns and differential diagnoses. Maryland Heights, Missouri: Mosby Inc; 2003.
  8. Elicker BM, Webb WR. Fundamentals of High-Resolution Lung CT. Philadelphia, PA: Lippincott Williams and Wilkins; 2013
  9. Reuter M, Biederer J. Mustererkennung im hochauflösenden Computertomogramm (HRCT) der Lunge [Identification of lung architecture using HRCT]. Radiologe. 2009;49(2):159–72. German. doi:.https://doi.org/10.1007/s00117-008-1735-5
  10. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Jr, Colvin MM, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776–803. doi:.https://doi.org/10.1016/j.jacc.2017.04.025
  11. Levin A, Stevens PE. Summary of KDIGO 2012 CKD Guideline: behind the scenes, need for guidance, and a framework for moving forward. Kidney Int. 2014;85(1):49–61. doi:.https://doi.org/10.1038/ki.2013.444
  12. Webster AC, Nagler EV, Morton RL, Masson P. Chronic Kidney Disease. Lancet. 2017;389(10075):1238–52. doi:.https://doi.org/10.1016/S0140-6736(16)32064-5
  13. Wells AU. Managing diagnostic procedures in idiopathic pulmonary fibrosis. Eur Respir Rev. 2013;22(128):158–62. doi:.https://doi.org/10.1183/09059180.00001213
  14. Travis WD, Costabel U, Hansell DM, King TE, Jr, Lynch DA, Nicholson AG, et al.; ATS/ERS Committee on Idiopathic Interstitial Pneumonias. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013;188(6):733–48. doi:.https://doi.org/10.1164/rccm.201308-1483ST
  15. Lynch DA, Sverzellati N, Travis WD, Brown KK, Colby TV, Galvin JR, et al. Diagnostic criteria for idiopathic pulmonary fibrosis: a Fleischner Society White Paper. Lancet Respir Med. 2018;6(2):138–53. doi:.https://doi.org/10.1016/S2213-2600(17)30433-2
  16. Baenkler H-W, Arastéh K, Bieber C. Duale Reihe Innere Medizin. Stuttgart: Georg Thieme Verlag KG; 2009.
  17. Milne EN. What is “congested” in cardiac failure? A newer approach to plain film interpretation of cardiac failure. Rays. 1997;22(1):94–106.
  18. Miniati M, Pistolesi M, Milne EN, Giuntini C. Detection of lung edema. Crit Care Med. 1987;15(12):1146–55. doi:.https://doi.org/10.1097/00003246-198712000-00016
  19. Miniati M, Pistolesi M, Paoletti P, Giuntini C, Lebowitz MD, Taylor AE, et al. Objective radiographic criteria to differentiate cardiac, renal, and injury lung edema. Invest Radiol. 1988;23(6):433–40. doi:.https://doi.org/10.1097/00004424-198806000-00005
  20. Christe A, Vock P. Radiologische Differentialdiagnose des Lungenödems[Radiologic criteria to differentiate pulmonary edema]. Ther Umsch. 2004;61(11):665–70. In German. doi:.https://doi.org/10.1024/0040-5930.61.11.665
  21. Winklhofer S, Berger N, Ruder T, Elliott M, Stolzmann P, Thali M, et al. Cardiothoracic ratio in postmortem computed tomography: reliability and threshold for the diagnosis of cardiomegaly. Forensic Sci Med Pathol. 2014;10(1):44–9. doi:.https://doi.org/10.1007/s12024-013-9504-9
  22. Jotterand M, Doenz F, Grabherr S, Faouzi M, Boone S, Mangin P, et al. The cardiothoracic ratio on post-mortem computer tomography. Int J Legal Med. 2016;130(5):1309–13. doi:.https://doi.org/10.1007/s00414-016-1328-1
  23. Gollub MJ, Panu N, Delaney H, Sohn M, Zheng J, Moskowitz CS, et al. Shall we report cardiomegaly at routine computed tomography of the chest? J Comput Assist Tomogr. 2012;36(1):67–71. doi:.https://doi.org/10.1097/RCT.0b013e318241e585

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