William Herring, M.D.

© 2002

Differentiating the
Causes of an Opacified
Hemithorax

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Three Major Causes + 1

 Atelectasis of an entire lung

 A large pleural effusion
 Pneumonia of an entire lung
 And a fourth cause:
 Post-pneumonectomy – removal of
an entire lung
Atelectasis of the Lung

 Atelectasis of an entire lung = loss of volume

of the affected lung
 Visceral and parietal pleura do NOT separate
from each other
 There is a shift of heart and hemidiaphragm
toward side of opacification (toward side of
volume loss)
The right
hemithorax
is opaque

There is a shift
of the heart and
trachea toward
the side of the
opacification

Atelectasis of the Right Lung

Pleural Effusion

 If an effusion (whatever the fluid is) fills the

entire hemithorax
 It acts like a mass
 Pushing the heart and trachea away from the
side of opacification
The right
hemithorax
is opaque

There is a shift
of the heart and
trachea away
from the side of
opacification

Large Right Pleural Effusion

Pneumonia

 The hemithorax is opaque and there is no

shift of the heart or trachea
 There may be an air bronchogram sign
present

Hyperlink
The left
hemithorax
is opaque

There is no shift
of the heart or
trachea

The opacified
hemithorax
contains air
bronchograms

Pneumonia of the LUL

Post-Pneumonectomy

 When the entire lung is removed, there is

volume loss on the pneumonectomized side
 The hemithorax eventually fibroses and
becomes opaque
 Clues: There is frequently a resected fifth rib
and/or surgical clips
The left
hemithorax
is opaque

There is a shift
of the heart and
trachea toward
that side
indicating
volume loss

The left 5th rib

has been
resected

Pneumonectomy on the left

Important Points

 In atelectasis, there is s shift toward the

side of the opacification
 In pleural effusion, there is a shift away
from the side of the opacification
 In pneumonia, there is no shift
 In pneumonectomy, the 5th rib is usually
absent
Which is this?

Atelectasis

Pneumonia

Effusion
Which is this?

Atelectasis

Pneumonia

Effusion
Which is this?

Atelectasis

Pneumonia

Effusion
Correct
This is Atelectasis

 There is
opacification of
the right
hemithorax with
shift toward that
side
Correct
This is Pneumonia

 There is
opacification
of the left
hemithorax
with no shift
 There are air
bronchograms
on the right
Correct
This is a Large Pleural Effusion
 There is
opacification of
the left
hemithorax with
shift away from
that side
Wrong
Look Again

 In atelectasis, there is s shift toward the

side of the opacification
 In pleural effusion, there is a shift away
from the side of the opacification
 In pneumonia, there is no shift
 In pneumonectomy, the 5th rib is usually
absent
Congratulations, You
Graduate

You know how to

tell pneumonia,
atelectasis and
pleural effusion
apart
 Air Bronchogram

 Bronchi not visible since their walls are thin,

they contain air, are surrounded by air
 When something of fluid density fills alveoli,
air in bronchus becomes visible
 Pulmonary edema fluid
 Blood
 Gastric aspirate
 Inflammatory exudate