Rahmi Afifi : 0000-0001-8463-557X

Achmad Fachri : 0000-0002-0130-7122

Amir Sjarifuddin Madjid : 0000-0003-0706-2442

Joedo Prihartono : 0000-0001-5684-9693

Marcel Prasetyo : 0000-0002-7796-3871

Andreas Christian : 0000-0001-6675-3310


Background: Excess intravascular volume evaluation is essential in the intensive care unit (ICU); however, clinical information to differentiate cardiogenic and non-cardiogenic pulmonary edema has been proven ineffective. Thus, this study aimed to distinguish cardiogenic from non-cardiogenic pulmonary edema using the ratio of vascular pedicle width (VPW) to thoracic diameter (VPTR).

Methods: This cross-sectional study was conducted based on secondary data from chest radiographs of 100 patients with clinical symptoms of pulmonary edema in the ICU from January 2013 to December 2015. Cardiogenic and non-cardiogenic pulmonary edema were distinguished using VPW and cardiothoracic ratio measurements (CTR). VPTR was measured to differentiate between the two types of pulmonary edema, and the cut-off value was obtained using a receiver operating characteristic curve.

Results: This study revealed a prevalence of 21% and 79% for cardiogenic and non-cardiogenic pulmonary edema, respectively. A VPTR cut-off value of 25.1% with a sensitivity of 90% and specificity of 86%, may distinguish cardiogenic from non-cardiogenic pulmonary edema.

Conclusions: VPTR is an alternative method to differentiate between cardiogenic and non-cardiogenic pulmonary edema, and this ratio measurement is useful in cases where radiograph films are not standardized.


  1. Wang H, Shi R, Mahler S, Gaspard J, Gorchynski J, D'Etienne J, et al. Vascular pedicle width on chest radiograph as a measure of volume overload: Meta-analysis. West J Emerg Med. 2011;12:426–32.
  2. Salahuddin N, Chishti I, Siddiqui S. Determination of intravascular volume status in critically ill patients using portable chest X-rays: Measurement of the vascular pedicle width. Crit Care. 2007;11:P282.
  3. Farshidpanah S, Klein W, Matus M, Sai A, Nguyen HB. Validation of the vascular pedicle width as a diagnostic aid in critically ill patients with pulmonary oedema by novice non-radiology physicians-in-training. Anaesth Intensive Care. 2014;42:321–9.
  4. Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Negative fluid balance predicts survival in patients with septic shock: A retrospective pilot study. Chest. 2000;117:1749–54.
  5. Jonny J, Hasyim M, Angelia V, Jahya AN, Hilman LP, Kusumaningrum VF, et al. Incidence of acute kidney injury and use of renal replacement therapy in intensive care unit patients in Indonesia. BMC Nephrol. 2020;21:191.
  6. Hidayat H, Pradian E, Kestriani ND. Angka Kejadian, lama rawat, dan mortalitas pasien acute kidney injury di ICU RSUP Dr. Hasan Sadikin Bandung. Jurnal Anestesi Perioperatif. 2020;8:108–18.
  7. Goepfert MS, Richter HP, Zu Eulenburg C, Gruetzmacher J, Rafflenbeul E, Roeher K, et al. Individually optimized hemodynamic therapy reduces complications and length of stay in the intensive care unit: A prospective, randomized controlled trial. Anesthesiology. 2013;119:824–36.
  8. Komiya K, Akaba T, Kozaki Y, Kadota JI, Rubin BK. A systematic review of diagnostic methods to differentiate acute lung injury/acute respiratory distress syndrome from cardiogenic pulmonary edema. Crit Care. 2017;21:228.
  9. Assaad S, Kratzert WB, Shelley B, Friedman MB, Perrino A Jr. Assessment of pulmonary edema: Principles and practice. J Cardiothorac Vasc Anesth. 2018;32:901–14.
  10. Meade MO, Guyatt GH, Cook RJ, Groll R, Kachura JR, Wigg M, et al. Agreement between alternative classifications of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2001;163:490–3.
  11. Kwok T, Mak P, Rainer T, Graham C. Treatment and outcome of acute cardiogenic pulmonary oedema presenting to an emergency department in Hong Kong: Retrospective cohort study. Hong Kong J Emerg Med. 2006;13:148–54.
  12. Herring W. Learning radiology: Recognizing the basics. 4th ed. Philadelphia: Elsevier Health Sciences Division; 2020. p.8–13.
  13. Zunera R, Afifi R, Madjid AS, Prihartono J, Wulani V, Prasetyo M. Nilai rerata vascular pedicle width, vascular pedicle-cardiac ratio vascular pedicle-thoracic ratio orang dewasa normal Indonesia studi di RS dr. Cipto Mangunkusomo. eJournal Kedokteran Indonesia. 2015;3:169–76.
  14. Wichansawakul S, Vilaichone W, Tongyoo S, Permpikul C, Wonglaksanapimol S, Daengnim K, et al. Evaluation of correlation between vascular pedicle width and intravascular volume status in Thai critically ill patients. J Med Assoc Thai. 2011;94 Suppl 1:S181–7.
  15. Thomason JW, Ely EW, Chiles C, Ferretti G, Freimanis RI, Haponik EF. Appraising pulmonary edema using supine chest roentgenograms in ventilated patients. Am J Respir Crit Care Med. 1998;157:1600–8.
  16. Milne EN, Pistolesi M, Miniati M, Giuntini C. The vascular pedicle of the heart and the vena azygos. Part I: The normal subject. Radiology. 1984;152:1–8.
  17. Danzer CS. The cardiothoracic ratio. Am J Med Sci. 1919;157:13–554.
  18. Truszkiewicz K, Poręba R, Gać P. Radiological cardiothoracic ratio in evidence-based medicine. J Clin Med. 2021;10:2016.
  19. Simkus P, Gutierrez Gimeno M, Banisauskaite A, Noreikaite J, McCreavy D, Penha D, et al. Limitations of cardiothoracic ratio derived from chest radiographs to predict real heart size: Comparison with magnetic resonance imaging. Insights Imaging. 2021;12:158.
  20. Ely EW, Smith AC, Chiles C, Aquino SL, Harle TS, Evans GW, et al. Radiologic determination of intravascular volume status using portable, digital chest radiography: A prospective investigation in 100 patients. Crit Care Med. 2001;29:1502–12.
  21. Ely EW, Haponik EF. Using the chest radiograph to determine intravascular volume status: the role of vascular pedicle width. Chest. 2002;121:942–50.
  22. Martin GS, Ely EW, Carroll FE, Bernard GR. Findings on the portable chest radiograph correlate with fluid balance in critically ill patients. Chest. 2002;122:2087–95.
  23. Haponik EF, Adelman M, Munster AM, Bleecker ER. Increased vascular pedicle width preceding burn-related pulmonary edema. Chest. 1986;90:649–55.
  24. Ronco C, Kaushik M, Valle R, Aspromonte N, Peacock WF 4th. Diagnosis and management of fluid overload in heart failure and cardio-renal syndrome: The "5B" approach. Semin Nephrol. 2012;32:129–41.

Creative Commons License

Creative Commons Attribution-Share Alike 3.0 License
This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License.



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.