Book Review

Reading the Chest Radiograph: A Physiologic Approach

N Engl J Med 1993; 329:1210-1211October 14, 1993

Article

Reading the Chest Radiograph: A Physiologic Approach
By Eric N.C. Milne and Massimo Pistolesi. 383 pp., illustrated. St. Louis, Mosby-Year Book, 1993. $99. ISBN: 0-8016-3303-6

The authors' intent in this work is to increase the reader's skill in extracting physiologic information from the plain chest film. They state that one source of inspiration was a lecture by a great chest radiologist, Leo Rigler, published in July 1959, in which he noted that the conventional roentgenogram was not just a static anatomical image but, within certain limits, could be seen as a moving, functional tool. Rigler was aware of the skepticism with which the free translation of roentgenographic images into physiologic terms was regarded, but noted that physiologic interpretation was to be an addition to, not a substitution for, the more conventional approach of naming structures and labeling disease. Over the years, radiologic-physiologic studies have been criticized, leading to a loss of confidence in the ability to abstract hemodynamic information from chest films. The authors confront these criticisms, explain why they might not be valid, and suggest areas for further research.

This work presents a way of appreciating the elements of microanatomy and physiology that appear as radiologic findings. In addition to theoretical concepts, it provides a practical user's guide. The authors show how to identify and quantify pulmonary edema and how to differentiate types of pulmonary edema: hydrostatic-pressure edema, injury-induced (increased permeability) edema, and complex mixtures of edema. The work provides a step-by-step program for evaluating cardiac function, emphasizing the more precise determination of left atrial pressure.

Guidelines are provided for quantifying intravascular and extravascular water. The authors explain the differences between emphysema and chronic bronchitis as substitutes for the more general term “chronic obstructive lung disease.” They show how to assess systemic pulmonary blood volume, flow, and pressure in both principle and practice.

A chapter on radiology for the intensive care unit brings many of the concepts into practical focus. Radiologists are encouraged to use physiologic criteria to extract more from films than is conveyed by phrases such as “bibasilar opacities due to edema or pneumonia.” Portable films are not to be dismissed as inaccurate because of the use of an anteroposterior projection and supine positioning. Factors are provided for adjusting cardiothoracic ratios on portable films. The lack of deep inspiration provides valuable information about lung compliance.

Provided with the book is a pocket reference pamphlet that contains drawings of common patterns of pathophysiologic findings. This compendium emphasizes 15 observations to be incorporated into every film evaluation. These include consideration of the size of several structures: the azygos vein, the vascular pedicle, the aorta, and the main pulmonary artery and its peripheral divisions. The size and shape of the heart as well as the ratio of arterial size to venous size are to be noted. Also to be assessed are the pulmonary blood volume; the distribution of pulmonary blood flow; the presence of peribronchial cuffing, septal lines, pulmonary edema, and pleural effusions; the distribution of edema, if present; and soft-tissue thickness.

Using these tools, the authors guide the reader through many common diagnostic problems. Medical students will find the descriptions of physiology succinct and readable. Physiologists can use the book as a reference, although the authors cover only the physiologic information that is important for radiologic interpretation. For intensive care specialists, pulmonologists, and radiologists, the book has an abundance of insightful observations.

The images are of high quality, allowing the reader to see clear examples of the differences in vascular size in the upper and lower lung, arterial sinuosity, peribronchial cuffing, blurring of vascular margins, the “segmentation” of vessels, and the “nodular” pattern of some types of pulmonary edema. The compendium of pathophysiology serves as a quick, nonverbal review of radiographic findings. The greatest strength of the book is its logical progression from physiologic principles to radiographic appearance, which entices radiologists to apply this approach immediately.

Stephen M. Bloom, M.D.
New England Medical Center, Boston, MA 02111