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Role of chest ultrasonography in differentiating between acute cardiogenic pulmonary edema and acute respiratory distress syndrome



Sometimes it is difficult to differentiate between acute cardiogenic pulmonary edema (APE) and acute respiratory distress syndrome (ARDS) on clinical basis only. Chest ultrasonography (CUS) may be helpful in providing ultrasonographic pleuropulmonary signs, which aids in such differentiation.


The aim of this study was to evaluate the role of CUS in differentiating between ARDS and APE through the characterization of comparative peculiar ultrasonographic pleuropulmonary signs.

Patients and methods

On admission, CUS was performed in Ain Shams University Hospital and Al-Abbassia Chest Hospital ICUs on 28 consecutive patients who presented with ARDS (15 cases) or APE (13 cases). CUS examination focused on the detection of the following pleuropulmonary signs in both ARDS and APE: alveolar–interstitial syndrome (AIS), pleural line abnormalities, absent or reduced lung sliding, consolidation, and pleural effusion.


AIS was found in 100% of patients with ARDS and in 100% of patients with APE. Pleural line abnormalities were observed in 100% of patients with ARDS and in 0% of patients with APE (P=0.001). Absent or reduced lung sliding was observed in 100% of patients with ARDS and in 0% of patients with APE (P=0.001). Consolidations were present in 93.3% of patients with ARDS in 7.5% of patients with APE (P=0.001). Pleural effusion was present in 40% of patients with ARDS and in 76.9% of patients with APE (P=0.049). All pleuropulmonary signs, except the presence of AIS, presented a statistically significant difference in presentation between ARDS and APE, resulting peculiar ultrasonographic pleuropulmonary signs of ARDS.


CUS represents a useful tool for differentiating ARDS from APE in ICU patients. In fact, the presence of absent or reduced lung sliding, pleural line abnormalities, and lung consolidations on a background of AIS seems diagnostic of ARDS.


  1. Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA 2005; 294(15):1944–1956.

    Article  CAS  Google Scholar 

  2. Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound 2008; 6:16.

    Article  Google Scholar 

  3. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED?. Chest 2011; 139(5):1140–1147.

    Article  Google Scholar 

  4. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. ARDS Definition Task Force Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012; 307(23):2526–2533.

    PubMed  Google Scholar 

  5. Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: Bedside lung ultrasound in critical care practice. Crit Care 2007; 11(1):205

    Article  Google Scholar 

  6. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134(1):117–125.

    Article  Google Scholar 

  7. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 2004; 100(1):9–15.

    Article  Google Scholar 

  8. Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med 2006; 24(6):689–696.

    Article  Google Scholar 

  9. Lichtenstein DA, Mezière GA, Lagoueyte JF, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest 2009; 136(4):1014–1020.

    Article  Google Scholar 

  10. Lichtenstein D. Lung ultrasound in the critically ill. Clin Intensive Care 2005; 16:79–87.

    Article  Google Scholar 

  11. Figueroa-Casas JB, Brunner N, Dwivedi AK, Ayyappan AP. Accuracy of the chest radiograph to identify bilateral pulmonary infiltrates consistent with the diagnosis of acute respiratory distress syndrome using computed tomography as reference standard. J Crit Care 2013; 28 (4):352–357.

    Article  Google Scholar 

  12. Gattinoni L, Caironi P, Pelosi P, Goodman LR. What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 2001; 164(9):1701–1711.

    Article  CAS  Google Scholar 

  13. Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 2006; 354(17):1775–1786.

    Article  CAS  Google Scholar 

  14. Pesenti A, Tagliabue P, Patroniti N, Fumagalli R. Computerised tomography scan imaging in acute respiratory distress syndrome. Intensive Care Med 2001, 27(4):631–639.

    Article  CAS  Google Scholar 

  15. Liteplo AS, Marill KA, Villen T, Miller RM, Murray AF, Croft PE, et al. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal probrain- type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med 2009; 16(3):201–210.

    Article  Google Scholar 

  16. Daabis R, Banawan L, Rabae A, Elnakedy A, Sadek A. Relevance of chest sonography in the diagnosis of acute respiratory failure. Egypt J Chest Dis Tuberc 2014; 63:979–985.

    Article  Google Scholar 

  17. Kataoka H, Takada S. The role of thoracic ultrasonography for evaluation of patients with decompensated chronic heart failure. J Am Coll Cardiol 2000; 35(6):1638–1646.

    Article  CAS  Google Scholar 

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Correspondence to Rasha Mustafa A. Mohamed MSc, MBBCh.

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El-Naggar, T., Sharkawy, S.H., Abdel-Hamid, H.M. et al. Role of chest ultrasonography in differentiating between acute cardiogenic pulmonary edema and acute respiratory distress syndrome. Egypt J Bronchol 10, 319–323 (2016).

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