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Recognizing A

Pleural Effusion

Normal Anatomy
lVisceral pleura is adherent to the lung
lSpace between visceral and parietal
pleura is a potential space
lInfoldings of visceral pleura form
fissures
lLoose connective tissue beneath
visceral pleura = subpleural space
Normal Physiology
lNormally there are 2-10 cc of fluid
in
the pleural space
lEach hour, as much as 100cc of fluid is
produced, mostly at parietal pleura
lFluid drains mostly to visceral pleura
and via lymphatics

Abnormal Physiology
lPleural effusions may form when
^hydrostatic pressure
v colloid osmotic pressure
^ capillary permeability
v absorption of fluid by lymphatics
v pressure in pleural space
Transport of peritoneal fluid through
diaphragm
or via lymphatics

Pleural Effusion-Types
lTransudate
lExudate
nEmpyema
nHemothorax
nChylothorax

Transudate^ capillary hydrostatic
pressure or v osmostic pressure
nCHF
nHypoalbuminemia
nCirrhosis
nNephrotic syndrome

Exudate
lUsually 2
0
neoplastic or
inflammatory
dzs involving pleura
l[Fluid Protein] : [serum protein] > 0.5
l[Fluid LDH] : [serum LDH] >0.6
lFluid LDH > 2/3 highest normal serum
LDH

Specific Types of Effusions
lHemothorax
nFluid hematocrit > 50% blood
hematocrit
lEmpyema = exudate containing pus
lChylothorax = ^ triglycerides or
cholesterol
nObstruction or rupture of lymphatic
vessels
Side-specificity
lMostly left-sided
nPancreatitis
nDresslers syndrome
nDistal thoracic duct obstruction
lMostly right-sided
nHeart failure
nAbdominal disease related to liver or ovary
nProximal thoracic duct obstruction

Appearances of Pleural Effusions
lSubpulmonic effusion
lBlunting of Costophrenic angle
lMeniscus sign
lLayering
lLoculated
lLaminar effusion
lOpacified hemithorax
lAir-fluid levels

Subpulmonic Effusion
lUsually less than 300-350cc
lAccumulates at base of lung between
visceral and parietal pleura
lCauses apparent lateral displacement of
highest part of hemidiaphragm
lFlat-edge sign on lateral
lIncreased distance between stomach
bubble and base of lung

Subpulmonic Pleural Effusion
On the frontal film, the highest point of the apparent right hemidiaphragm
is displaced laterally (it is usually in the center). On the lateral film, there
is a flat edge where the effusion meets the major fissure

Blunting of the CP Angle
lNormally there are 2-10cc of fluid
in the
pleural space
lWhen >75cc accumulate, the posterior
costophrenic (CP) sulci, seen on the
lateral film, become blunted
lWhen 200-300cc accumulate, the CP
sulci on the frontal film become blunted

When 200-300cc of fluid accumulate in pleural space, the usually
acute
costophrenic angle (sulcus), as seen on the right in this person,
becomes blunted (as seen on the left in this person)
Normal R costophrenic angle Blunted L costophrenic
angle

Meniscus Sign
lPleural fluid tends to rise higher along
its
edge producing a meniscus shape
medially and laterally
lUsually only lateral meniscus can be seen
lThe meniscus is a good indicator of the
presence of a pleural effusion

Effect of Position - Layering
Supine
Erect
In the supine position, the fluid layers out posteriorly and produces a
haziness, especially near the bases (since the patient is actually semi-
recumbent). In the erect position, the fluid falls even more to the
bases.

Loculated Effusion
Occurs 2 adhesions which form
between visceral and parietal pleura
lAdhesions more common with blood
(hemothorax) and pus (empyema)
lLoculated effusions have unusual
shapes or positions in thorax
nE.g. remain at apex on erect films
A loculated effusion
has an unusual
shape (lentiform) or
position in the
thoracic cavity
This is a loculated
empyema

Loculated Effusion
Laminar Effusion
lA laminar effusion collects in the
loose
connective tissue between the lung and
the visceral pleura
lIt is not usually free-flowing
lIt usually occurs with CHF or
lymphangitic spread of malignancy
A laminar effusion
collects
between the lung and
the
visceral pleura in the
loose
connective tissue of the
subpleural space
Laminar effusions are
usually seen with CHF
or
lymphangitic spread of
tumor

Laminar Effusion
Opacified Hemithorax
lIf an effusion fills the entire hemithorax,
it acts like a mass
lThere is displacement of the heart and
trachea away from the side of opacification
lIn atelectasis of an entire lung, the heart
and trachea are pulled toward the side of
opacification

The right
hemithorax is
opaque
There is a shift of
the heart and
trachea away from
the side of
opacification
This is
characteristic of a
pleural effusion
Large Right Pleural Effusion
Hydropneumothorax
lIf both a pneumothorax and a pleural
effusion occur together, it is called a
hydropneumothorax
lA hydropneumothorax is usually due to
trauma, surgery, bronchopleural fistula
lIt is characterized by an air-fluid level in
the hemithorax

A straight edge,
indicative of a fluid
interface, in this
case an air-fluid
interface, is seen on
the right.
In order to have an
air-fluid level in the
pleural space, there
must be a
pneumothorax
present.

Hydropneumothorax
Important Points
lPleural effusions are transudates or
exudates
lIt takes from 200-300cc to blunt the
costophrenic sulcus on the frontal view
lThe meniscus is the classic shape of an
effusion on a frontal film
lPleural effusions shift the mediastinal
structures away from the side opacified
http://learningradiology.com/medstudents/r
ecognizingseries/recognizingeffusionsppt_
files/v3_document.htm
DRY PLEURISY

Definisi Radang pleura tanpa Efusi Pleura
- Gejala: nyeri pleuritik ( akhir inspirasi ),
febris, batuk non produktif
- Pemeriksaan Fisik: tampak sakit, suara napas
menurun, Pleural friction rub
- Laboratorium : smear/kultur sputum BTA / gram
- Radiologi : perselubungan dengan air
bronkhogram positif ~ pneumonia
- Terapi : Antibiotika broad spectrum
Antibiotika ~ hasil smear

http://learningradiology.com/lectures/chestlectures/pleuralef
fusionppt_files/v3_document.htm
Efusi pleura
Pleural Fluid
Normal Physiology

Produced at parietal and resorbed at
visceral pleura
Amount depends on
Colloid osmotic pressure
Capillary pressure

Pleural Effusion
Types of

Subpulmonic
Free-flowing
Laminar
Loculated
Fissural (pseudotumor)

Pleural Effusion
General

Requires 250-300cc to be visible on
frontal film

Pleural Effusion
X-ray Appearance

Blunting of posterior costophrenic
sulci
Blunting of lateral costophrenic sulci
Meniscus sign
Opacification of hemithorax
Fluid in the fissures

Subpulmonic
Effusion

Subpulmonic Effusion
General

All pleural effusions begin
subpulmonic
Between base of lung and
hemidiaphragm
Requires less fluid to cause blunting
of
posterior costophrenic angle
Than lateral CP angle
Subpulmonic Effusion
X-Ray Appearance

Displaces highest point of
hemidiaphragm laterally
Ski-slope appearance to effusion on
lateral at major fissure
Increased distance between stomach
bubble and air in base of left lung
Laminar
Effusion

Laminar Effusion
General

Collection of fluid in the sub-pleural
space
Loose connective tissue beneath
visceral
pleura
Sign of increased L atrial pressure or
lymphangitic spread

Laminar Effusion
X-Ray Appearance

Often thin white density paralleling
chest wall at CP angle
May extend far up lateral chest wall
before producing meniscus
Hemothorax vs. Pleural Effusion
Hemothorax loculates early
2 fibrinous adhesions
Higher density measurements on CT
for
blood

Loculated
Effusion

Loculated Pleural Effusion
General

Loculation occurs 2 pleural adhesions
Blood and empyema tend to loculate
Pre-existing pleural disease causes
loculation
Asbestosis

Loculated Pleural Effusion
X-ray Appearance

No change in position of effusion with
change in position of chest