William Herring, M.D.

© 2003

Recognizing A
Pleural Effusion

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Normal Anatomy

 Visceral pleura is adherent to the lung

 Space between visceral and parietal
pleura is a potential space
 Infoldings of visceral pleura form fissures
 Loose connective tissue beneath visceral
pleura = subpleural space
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
Transudate

  capillary hydrostatic pressure or 

osmostic pressure
 CHF
 Hypoalbuminemia
 Cirrhosis
 Nephrotic syndrome
Exudate

 Usually 2 neoplastic or inflammatory dzs

involving pleura
 [Fluid Protein]  [serum protein] > 0.5
 [Fluid LDH]  [serum LDH] >0.6
 Fluid LDH > 2/3 highest normal serum LDH
Specific Types of Effusions

 Hemothorax
 Fluid hematocrit > 50% blood hematocrit
 Empyema = exudate containing pus
 Chylothorax =  triglycerides or cholesterol
 Obstruction or rupture of lymphatic vessels
Side-specificity

 Mostly left-sided
 Pancreatitis
 Dressler’s syndrome
 Distal thoracic duct obstruction
 Mostly right-sided
 Heart failure
 Abdominal disease related to liver or ovary
 Proximal thoracic duct obstruction
Appearances of Pleural
Effusions
 Subpulmonic effusion
 Blunting of Costophrenic angle
 Meniscus sign
 Layering
 Loculated
 Laminar effusion
 Opacified hemithorax
 Air-fluid levels
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
 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
 Adhesions more common with blood
(hemothorax) and pus (empyema)
 Loculated effusions have unusual shapes or
positions in thorax
 E.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

 A laminar effusion collects in the loose

connective tissue between the lung and the
visceral pleura
 It is not usually free-flowing
 It 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

 If an effusion fills the entire hemithorax, it acts

like a mass
 There is displacement of the heart and trachea
away from the side of opacification
 In 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

 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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