Pleural Effusion & Pneumothorax radiology made simple by Anish Dhakal (Aryan)

Radiographs of Pleural Pathologies

1. Radiography of Pleural Pathologies Presented by: Anish Dhakal September 16 th , 2018

2. Normal Anatomy & Physiology Parietal pleural lines the inside of thoracic cage, visceral pleura adheres to the lung surface Enfolded visceral pleura forms the interlobar fissures Potential space: 2 to 5 mL pleural fluid Hundreds of milliliters fluid produced and reabsorbed each day Fluid produced primarily at the parietal pleura Reabsorbed at the visceral pleura and by lymphatic drainage through the parietal pleura

3. Transudates or Exudates? Transudate Exudate Congestive Heart Failure Malignancy Hypoalbuminemia Empyema Cirrhosis Hemothorax Nephrotic syndrome Chylothorax

4. Side specificity: Usually bilateral Usually unilateral Left sided Right sided Congestive Heart Failure (usually same amount on either side) Tuberculosis Pancreatitis Meigs syndrome Lupus Pulmonary thromboembolic disease Distal thoracic duct obstruction Rheumatoid arthritis Trauma Dressler syndrome Proximal thoracic duct obstruction

5. Opacified Hemithorax

6. Decubitus film for Pleural Effusion: Confirm the presence of pleural effusion Determine whether a pleural effusion flows freely, important factor before draining the fluid “Uncover” a portion of the underlying lung hidden by effusion

7. Patterns of Pleural Effusion on Chest X-Rays: Subpulmonic effusion: Between the parietal pleura lining the superior surface of diaphragm and visceral pleura under the lower lung lobe

8. The Meniscus Sign:

9. Loculated Pleural Effusions: Absence of pleural adhesions: effusions flow freely with change in patient position Adhesions, commonly caused by old infections or hemothorax causes effusions in the same location irrespective of change in position Unusual shape and unusual location Therapeutic importance: collections traversed by multiple adhesions making it difficult to drain the noncommunicating pockets of fluid in a single pleural drainage

10. Fissural Pseudotumors: Also called vanishing tumors Sharply marginated collections of pleural fluid either between the layers of interlobar fissure or beneath the fissure in subpleural location Transudates, most commonly in CHF patients Lenticular in shape , mostly in minor fissure, no free flow, usually with pointed ends on both sides

11. Laminar effusions: Thin, bandlike density along the lateral chest wall near costophrenic angle but doesn’t obliterate it) CHF or lymphangitic spread of malignancy

12. Hydropneumothorax/ Hemopneumothorax :

13. Pneumothorax : Air in the pleural cavity Visceral pleura visible as thin white line , outlined by air on both sides Curvature of visceral pleural line is parallel to that of chest wall In supine radiograph, pneumothorax air displaces costophrenic sulcus inferiorly and increases lucency of that costophrenic sulcus ( Deep sulcus sign ) Decubitus chest x-rays or expiratory chest x-rays might sometimes be useful

14. Deep Sulcus Sign:

15. Conditions Mimicking Pneumothorax: Absence of lung markings: Bullous diseases of lung Large cysts of lung Pulmonary embolism (lack of perfusion in particular part of lung: Westermark’s sign of oligemia ) P aradoxically i nsertion of chest tube into bulla might cause pneumothorax Look for visceral pleural line convex outwards

16. Mistaking a skinfold for pneumothorax: Fold of skin between patient’s back and cassette Edge of skinfold might be mistaken for visceral pleural line Parallel to the chest wall just like pneumothorax Usually thick band of density rather than thin pleural line

17. Mistaking medial border of scapula for pneumothorax Supine radiographs: scapula are not retracted to the outer margin of the rib cage Medial border of scapula superimpose on upper lung border and mimic pleural white line

18. Volume Calculation in Pneumothorax: How large it is?

19. Example of Calculation: Light’s Equation A pneumothorax of 2 cm (distance between visceral plural line and parietal pleura) HT= 10 cm L= 8 cm Volume of pneumothorax= 1- 8 3 /10 3 = 1 – 512/1000 = 49% of total hemithorax volume