1. Case presentation on congestive heart failure and pulmonary edema
Tetiana Grygoruk
Professor Denise Aris

2. Case report
A 94 years-old male arrives to health care unit with severe cough, weakness and dizziness. Obvious signs of swelling legs, ankles and feet were present. Chief complaint- chest discomfort. Physical examination was performed including pulse rate measurements, blood pressure, temperature and breath sounds. The patient was sent to radiology department to obtain chest radiographs: PA and Lateral views. The reason for exam - congestive heart failure, evaluate pulmonary edema.

3. CHF
Congestive heart failure (CHF) refers to the inability of the heart to propel blood at a rate and volume sufficient to provide an adequate supply to the tissues. Causes of CHF include an intrinsic cardiac abnormality, hypertension, and any obstructive process that abnormally increases the peripheral resistance to blood flow. Intrinsic cardiac abnormalities include insufficient or defective cardiac filling and impaired contractions for emptying.

4. Pulmonary Edema
Pulmonary edema refers to an abnormal accumulation of fluid in the extravascular pulmonary tissues. The most common cause of pulmonary edema is an elevation of the pulmonary venous pressure. This pressure is most often attributable to left-sided heart failure but may also be caused by pulmonary venous obstruction (mitral valve disease and left atrial tumor) or lymphatic blockade (fibrotic, inflammatory, or metastatic disease involving the mediastinal lymph nodes). Other causes of pulmonary edema include uremia, narcotic overdose, exposure to noxious fumes, excessive oxygen, high altitudes, fat embolism, adult respiratory distress syndrome, and various neurologic abnormalities.

5. Radiographs obtained in radiology department, NYU Langone
Radiographs obtained in radiology department, NYU Langone. February 26, 2019
Lateral view in a stretcher, horizontal beam. Patient is in semi – erect position.
Two views performed according to protocol of the hospital.
Gonadal shield was used during the entire procedure.
AP - 70 kvp and 2.0 mAs applied manually, 60 inches SID. Lateral – 120 kvp and 6.3 mAs while 72 inches SID applied.
No contrast media.
Digital Room used during the entire procedure.
AP view, semi-erect in stretcher.
Patient is unable to stand.

6. Findings:
The cardiac silhouette is enlarged and uncharged. There is improvement of the bilateral airspace opacities likely secondary to improving edema. There are bilateral small moderate pleural effusions with bibasal atelectasis. February 26, 2019
Based on the impression (improved pulmonary edema) – back to medical history of the patient.
December 13, PA and Lateral views of the chest were obtained. Cardiac silhouette is enlarged. Prominent pulmonary vascularity with perihilar airspace opacity, right greater than left consistent with the clinical history of congestive heart failure and pulmonary edema although pneumonia is not excluded. Possible small bilateral pleural effusions. No pneumothorax.

7. Discussion (AP) Collimation is slightly decreased;
Entire lung field visualized from the apices to the costophrenic angles;
Patient is not properly aligned;
Trachea filled with air is not clearly visible;
Heart shadow, left and right ventricles enlarged;
Both lungs collapsed, bilateral effusions;
Fluid collection at the bases of the lungs;
Artifacts present . Proper marker.

8. Discussion (Lat)
Entire lung field visualized from the apices to the costophrenic angles;
Arms are not overlapping the superior part of the lungs;
Body is slightly rotated, posterior ribs are not completely superimposed;
Sternum is not in a true lateral;
Open thoracic intervertebral spaces;
Heart shadow visualized, enlarged right ventricle anteriorly;
Aortic arch;
Hilum of the lungs;
Artifacts present, proper marker;
Centering and collimation could be improved.

9. Treatment of Congestive Heart Failure and Pulmonary Edema
The nonpharmacologic approach to the treatment of CHF and pulmonary edema involves avoiding excessive physical stress, decreasing dietary salt, and wearing compressive stockings to decrease the incidence of deep vein thrombosis (DVT).
Pharmacologic therapy includes some combination of the following drugs: diuretics, angiotensin- converting enzyme inhibitors, digoxin (digitalis), parenteral inotropic agents, calcium channel blockers, beta-blockers, and antithrombotic therapy.
Treatment of Congestive Heart Failure and Pulmonary Edema

10. Thank You! Professor Denise Aris NYU Langone Hospital
Institution guidance
Thank You!