Normal Physiology

 Normally there are 2-10 cc of fluid in the

pleural space
 Each hour, as much as 100cc of fluid is
produced, mostly at parietal pleura
 Fluid drains mostly to visceral pleura and
via lymphatics
 Abnormal Physiology

 Pleural effusions may form when

  hydrostatic pressure
  colloid osmotic pressure
  capillary permeability
  absorption of fluid by lymphatics
  pressure in pleural space
 Transport of peritoneal fluid through diaphragm or via
lymphatics
Pleural Effusion-Types

 Transudate
 Exudate
 Empyema
 Hemothorax
 Chylothorax
 Subpulmonic Effusion

 Usually less than 300-350cc

 Accumulates at base of lung between visceral and parietal
pleura
 Causes apparent lateral displacement of highest part of
hemidiaphragm
 Flat-edge sign on lateral
 Increased 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

 Normally there are 2-10cc of fluid in the

pleural space
 When >75cc accumulate, the posterior
costophrenic (CP) sulci, seen on the lateral
film, become blunted
 When 200-300cc accumulate, the CP sulci on
the frontal film become blunted
 Normal R costophrenic angle Blunted L costophrenic angle

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)
 Meniscus Sign

 Pleural fluid tends to rise higher along its edge

producing a meniscus shape medially and laterally
 Usually only lateral meniscus can be seen
 The meniscus is a good indicator of the presence of
a pleural effusion
Fluid rises higher
along the edge of
a pleural effusion
producing an
upside down “U”
or meniscus
shape

Meniscus Sign
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

 If both a pneumothorax and a pleural effusion

occur together, it is called a
hydropneumothorax
 A hydropneumothorax is usually due to trauma,
surgery, bronchopleural fistula
 It 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

 Pleural effusions are transudates or exudates

 It takes from 200-300cc to blunt the costophrenic
sulcus on the frontal view
 The meniscus is the classic shape of an effusion on
a frontal film
 Pleural effusions shift the mediastinal structures
away from the side opacified
Congratulations, You
Graduate

You know your

effusions when you
see them

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