Chest X-ray Level 2 Tutorial: Congestive Heart Failure
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Tutorial: Congestive Heart Failure
Learn an approach to CHF findings on chest x-ray
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Tutorial: Congestive Heart Failure Peribronchial Cuffing
Times Practiced
Cases Completed
1h 24m
Total Time spent
1m 24s
Average Time
Peribronchial Cuffing
As the hydrostatic pressure in the pulmonary vessels increases, fluid will leak out of the vessels into the interstitial space of the lung. One anatomic structure in which fluid can accumulate are the airways.

When the airways become edematous, a couple things happen. First, the walls of the airways become thicker with fluid and therefore appear thicker and fluffy white on x-ray. Second, the diameter of the airways become smaller. Although not greatly appreciated on chest x-ray, this is greatly appreciated by the patient. The resistance in their airways increases as the diameter decreases and they start to work to exhale and can develop an expiratory wheeze. This is also called cardiac asthma, but that is a stupid name because it is not asthma at all. It should be called by its proper name: congestive heart failure. All that wheezes is NOT asthma.

So back to the x-ray appearance: when an airway is parallel to the x-ray beam, it will have a black center. If the walls of the airway are edematous, the walls will be thicker and whiter and fluffy so the appearance of the airway changes and this is called peribronchial cuffing because there is a fluffy white cuff around the bronchus.

These images show a normal bronchus seen "end on" (parallel to the x-ray beam):

And for fun, a lateral x-ray example:

So what you should observe in the above images is that the thickness of the bronchus is thin and well defined. These are all normal.

Now, compare now examples of peribronchial cuffing. Keep in mind that due to the edema, the appearance is fuzzy and less "clean" than the normal examples:

Black circles surrounded by fuzzy white halos. That is what we are looking for.