Recognizing A

Pleural Effusion

• Normal AnatomylVisceral pleura is adherent to the lunglSpace between visceral and parietalpleura is a potential spacelInfoldings of visceral pleura formfissureslLoose connective tissue beneathvisceral pleura = subpleural space

• Normal Physiology lNormally there are 2-10 cc of fluid inthe pleural spacelEach hour, as much as 100cc of fluid isproduced, mostly at parietal pleuralFluid drains mostly to visceral pleuraand via lymphatics

• Abnormal Physiology lPleural effusions may form when^hydrostatic pressurev colloid osmotic pressure^ capillary permeabilityv absorption of fluid by lymphaticsv pressure in pleural spaceTransport of peritoneal fluid through diaphragmor via lymphatics

• Pleural Effusion-Types lTransudatelExudatenEmpyemanHemothoraxnChylothorax

• Transudate^ capillary hydrostatic pressure or v osmostic pressurenCHFnHypoalbuminemianCirrhosisnNephrotic syndrome

• Exudate lUsually 20 neoplastic or inflammatorydzs involving pleural[Fluid Protein] : [serum protein] > 0.5l[Fluid LDH] : [serum LDH] >0.6lFluid LDH > 2/3 highest normal serumLDH

• Specific Types of Effusions lHemothoraxnFluid hematocrit > 50% blood hematocritlEmpyema = exudate containing puslChylothorax = ^ triglycerides orcholesterolnObstruction or rupture of lymphatic vessels

• Side-specificity lMostly left-sidednPancreatitisnDressler’s syndromenDistal thoracic duct obstructionlMostly right-sidednHeart failurenAbdominal disease related to liver or ovarynProximal thoracic duct obstruction

• Appearances of Pleural Effusions lSubpulmonic effusionlBlunting of Costophrenic anglelMeniscus signlLayeringlLoculatedlLaminar effusionlOpacified hemithoraxlAir-fluid levels

• Subpulmonic Effusion lUsually less than 300-350cclAccumulates at base of lung betweenvisceral and parietal pleuralCauses apparent lateral displacement ofhighest part of hemidiaphragmlFlat-edge sign on laterallIncreased distance between stomachbubble and base of lung

Subpulmonic Pleural EffusionOn the frontal film, the highest point of the apparent right hemidiaphragmis 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 thepleural spacelWhen >75cc accumulate, the posteriorcostophrenic (CP) sulci, seen on thelateral film, become bluntedlWhen 200-300cc accumulate, the CPsulci 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 itsedge producing a meniscus shapemedially and laterallylUsually only lateral meniscus can be seenlThe meniscus is a good indicator of thepresence of a pleural effusion

Effect of Position - Layering

Supine Erect

• In the supine position, the fluid layers out posteriorly and produces ahaziness, 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 formbetween visceral and parietal pleuralAdhesions more common with blood(hemothorax) and pus (empyema)lLoculated effusions have unusualshapes or positions in thoraxnE.g. remain at apex on erect films

• A loculated effusionhas an unusualshape (lentiform) orposition in thethoracic cavityThis is a loculatedempyema

Loculated Effusion

• Laminar Effusion lA laminar effusion collects in the looseconnective tissue between the lung andthe visceral pleuralIt is not usually free-flowinglIt usually occurs with CHF orlymphangitic spread of malignancy

• A laminar effusion collectsbetween the lung and thevisceral pleura in the looseconnective tissue of thesubpleural spaceLaminar effusions areusually seen with CHF orlymphangitic spread oftumor

Laminar Effusion

• Opacified Hemithorax lIf an effusion fills the entire hemithorax, it acts like a masslThere is displacement of the heart andtrachea away from the side of opacificationlIn atelectasis of an entire lung, the heartand trachea are pulled toward the side ofopacification

• The righthemithorax isopaqueThere is a shift ofthe heart andtrachea away fromthe side ofopacificationThis ischaracteristic of apleural effusion

Large Right Pleural Effusion

Hydropneumothorax lIf both a pneumothorax and a pleuraleffusion occur together, it is called ahydropneumothoraxlA hydropneumothorax is usually due totrauma, surgery, bronchopleural fistulalIt is characterized by an air-fluid level inthe hemithorax

• A straight edge,indicative of a fluidinterface, in thiscase an air-fluidinterface, is seen onthe right.In order to have anair-fluid level in thepleural space, theremust be apneumothoraxpresent.

Hydropneumothorax

• Important Points lPleural effusions are transudates orexudateslIt takes from 200-300cc to blunt thecostophrenic sulcus on the frontal viewlThe meniscus is the classic shape of aneffusion on a frontal filmlPleural effusions shift the mediastinalstructures away from the side opacified

• http://learningradiology.com/medstudents/recognizingseries/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/pleuraleffusionppt_files/v3_document.htm

• Efusi pleura

Pleural FluidNormal Physiology

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

Pleural EffusionTypes of

• Subpulmonic•Free-flowing•Laminar•Loculated•Fissural (pseudotumor)

Pleural EffusionGeneral

• Requires 250-300cc to be visible onfrontal film

Pleural EffusionX-ray Appearance

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

SubpulmonicEffusion

Subpulmonic EffusionGeneral

• All pleural effusions begin subpulmonic•Between base of lung and hemidiaphragm•Requires less fluid to cause blunting ofposterior costophrenic angle•Than lateral CP angle

Subpulmonic EffusionX-Ray Appearance

• Displaces highest point of“hemidiaphragm” laterally•Ski-slope appearance to effusion onlateral at major fissure•Increased distance between stomachbubble and air in base of left lung

• LaminarEffusion

Laminar EffusionGeneral

• Collection of fluid in the sub-pleuralspace•Loose connective tissue beneath visceralpleura•Sign of increased L atrial pressure orlymphangitic spread

Laminar EffusionX-Ray Appearance

• Often thin white density parallelingchest wall at CP angle•May extend far up lateral chest wallbefore producing meniscus

Hemothorax vs. Pleural Effusion

• Hemothorax loculates early•2° fibrinous adhesions•Higher density measurements on CT forblood

• LoculatedEffusion

Loculated Pleural EffusionGeneral

• Loculation occurs 2° pleural adhesions•Blood and empyema tend to loculate•Pre-existing pleural disease causesloculation•Asbestosis

Loculated Pleural EffusionX-ray Appearance

• No change in position of effusion withchange in position of chest