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3. Evaluate for Pneumothorax – Mediastinal Shift
Large pleural effusions may cause a mass effect, shifting the mediastinum and trachea to the opposite side, and/or causing atelectasis of the adjacent lung.
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1. Evaulate for Pneumothorax – Lung/Air Contrast
A pneumothorax allows visualization of the viscerla pleura as a curvilinear line, paralleling the chest wall, separating the partially collapsed lung from pleural air.
Left Image: Pneumothorax on inspiration.
Right Image: Pneumothorax on expiration.
Identify: Parietal & Visceral Pleura
The Pleura lubricates and prevents friction during respiration.
The partial pleura lines the chest wall, mediastinal and diaphragmatic surfaces, while the visceral pleura lines the lungs and fissures.
Evaluate for Appearance – Thickening
Thickening of the pleura is usually a result of inflammation.
Evaluate for Appearance – Calcifications
Calcification is a result of a previous emphysema or pneumothorax.
Evaluate for Appearance – Mass
Pleural and extra pleural masses form an obtuse angle with adjacent pleura, while parenchymal and pulmonary masses usually form an actue angle
4. Evaluate for Effusion Mediastinal Shift
A mediastinal shift can occur if there is tension. In this image, notice the collapsed right lung. This patient requires a chest tube to relieve the pressure.
1. Evaulate for Effusion – Meniscus
In an uncomplicated effusion, fluid is usually higher laterally than medially, thus forming a meniscus with the pleura. A horizontal fluid line will be seen only with a mixture of air and water in the pleura space (hydropneumothorax).
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3. Evaluate for Effusion – Fluid Pooling
Pooling of fluid can first be seen posteriorly. If there is enough it will then move laterally.
This is why the lateral film is most sensitive for pleural effusion. A lateral decubitis view will show the effusion in a dependent position if it is not loculated.
Right image depicts a lateral decubitis view with a small effusion
2. Evaluate for Effusion – Blunted Angles/Thickening
Blunting of the costophrenic angles (see normal sharp angles) generally indicates a pleural effusion. Blunting can also indicate thickening of the pleura.
4. Evaluate for Diaphragm – Free Air
Free air under the diaphragm suggests pneumonperitoneum (i.e. bowel perforation). Right image indicates where free air is located.
2. Evaluate for Diaphragm – Elevation
An elevated hemidiaphragm can be caused by a diaphragm paralysis, lung resection/pneumectomy, atelectasis and pregnancy. A pleural effusion may also result in an apparent elevation.
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