SONOGRAPHIC EVALUATION OF PLEURAL EFFUSION

1. SONOGRAPHIC EVALUATION
OF PLEURAL EFFUSION
DR V N PUTTANNA GOWDA
CHIEF RADIOLOGIST
RADNEST RADIOLOGY SERVICES
BANGALORE

2. WHY ULTRASOUND?
 Ultrasound allows the detection of small amounts -as
small as 3 to 5 ml.
 Contrary to the conventional radiological method,
ultrasound allows an easy differentiation of loculated
pleural fluid and thickened pleura.
 Useful in guiding thoracentesis even in small fluid
collections .
 The ability of chest US to detect underlying disease
was comparable to that of CT in pleural effusions.

3. WHY ULTRASOUND?
 Immediate bed side availability/ portable
 Safe – no radiation
 Easy to perform
 Repeatability
 Guides procedures

4. BED SIDE USG
 EASE OF IMMEDIATE APPLICATION.
 INTERGRATED WITH PHYSICAL EXAM AND
CLINICAL IMPRESSION.
 AWARE OF ALL ASPECTS OF CLINICAL
SITUATION.
 NO TIME DELAY WHICH IS MOST COMMON
WITH CONVENTIONAL RADIOGRAPHIC
TECHNIQUES.

5. Basics
 Case Selection
 Look at CXR/CT
 Difficult in the presence of gas/air
 Position the patient
 The machine
 Switch it on
 Use the right probe
 Understand the gain and focus button
 Location
 Identify the spleen or liver and work up
 Fluid or Solid
 Is there fluid and how much?
 Nature of fluid?
 Mark, aim and fire

6. Knobology – know the machine
 Patient details – OP/ IP
 Mode -
 Gain - Controls the degree of echo amplification
or brightness of image
 Zoom – Enlarges the image
 Depth- Tissue depth till you want to see
 Calipers – Used fro measurements
 Save/ acquire/ print-

7. Technique
 It is important to review the patient's chest xray to localize
the area of interest
 Maximum visualization of the lung and pleural space is
achieved by scanning along the intercostal spaces
 Scanning should be performed during quiet respiration, to
allow for assessment of normal lung movement
 On gray-scale images, the echogenicity of a lesion can be
compared with that of the liver and characterized as
hypoechoic, isoechoic, or hyperechoic.
 In supine,sitting and decubitus positions when ever
possible

8.  3.5- to 10-MHz linear, convex, and sector transducers.
 High-frequency linear probe can exam the detailed
signs of pleura and provide assessment of superficial
lesions.
 3.5–5 MHz probe -suitable for imaging adequate
depth of penetration of lung.
 Probe is moved along the intercostals space to avoid
interference by ribs or sternum.

11. Physiology of the pleural space

12. Sonographic images of normal pleura and chest wall using a
5- to 10-MHz linear scanner

13. PL EFFUSION ECHOGENICITY
 The strength of ultrasound lies in demonstrating characteristics of
the pleural fluid itself.
 Four basic ultrasounds patterns of internal echogenicity of pleural
effusion
A-Anechoic,
B-Complex nonseptated,
C-Complex septated,
D-Homogenously echogenic.

14. Purely anechoic collection is found in exudates and transudates
with equal frequency.
However, internal echoes in the form of septations or focal
areas of debris are due invariably to exudates.
US presentations in transudative pleural effusions are not
always in an anechoic pattern. Transudative pleural effusions
may have a complex nonseptated pattern.
There was no transudative pleural effusion with complex
septated or homogenously echogenic pattern .
The ability of chest US to detect underlying disease was
comparable to that of computed tomography (CT) in pleural
effusions.

15. The applications of sonographic appearances in effusions of
febrile patients in the intensive care unit (ICU) can determine
the necessity of thoracentesis in high risk patients with effusion
in ICU .
Complex nonseptated and relatively hyperechoic, complex
septated and homogenously echogenic pleural effusion patterns
might predict the possibility of empyema in febrile patients in
the ICU.
The sonographic septation in lymphocyte-rich exudative pleural
effusions can help us differentiate tuberculosis pleurisy from
malignant pleural effusion
Ultrasound Diagnosis of Chest Diseaseses
By Wei-Chih Liao, Chih-Yen Tu, Chuen-Ming Shih, Chia-Hung Chen, Hung-Jen Chen and Hsu Wu-Huei
DOI: 10.5772/55419

16. Congestive heart failure
Pericardial disease
Hepatic hydrothorax
Nephrotic syndrome
Myxedema
Pulmonary embolism
(sometimes)
Transudative Pleural Effusions
Parapneumonic effusions
Tuberculous
Fungal
Viral
Parasitic
Pulmonary embolism
Abdominal disease
Collagen vascular disease
Post cardiac injury
Post CABG
Asbestos
Exudative Pleural Effusions

18. CAUSES OF PLEURAL EFFUSION
Inflammatory pleural effusion
Due to inflammation in lung (tuberculosis, pneumonia, infarct,
abscess, bronchiectasis), collagen vascular disease (rheumatoid
arthritis, systemic lupus erythematosis, uremia) or radiation therapy
Empyema: pus in pleural cavity; due to bacteria or fungal seeding
of pleural space; often from lung infection;
Noninflammatory pleural effusion
Hydrothorax: clear/straw colored fluid; usually due to
congestive heart failure
Hemothorax: usually due to rupture of aneurysm or vascular
trauma; associated with large clots
Chylothorax: accumulation of milky white fluid, usually lymph,
contains fat (DD: turbid serous fluid); usually left sided, caused by
thoracic duct trauma/obstruction due to malignancy
Malignant pleural effusion

19. Transudates
< 0.5
< 0.6
< 2/3 the upper
limit for serum
Pleural Fluid
Pleural/serum
Protein
Pleural/serum
LDH
Pleural
LDH
Exudates
> 0.5
0.6
>2/3 the upper
limit for serum
Differentiation of transudates and exudates

20.  Pleural fluid hematocrit greater that 50% that of
peripheral blood
 Causes
- Traumatic (penetrating or non- penetrating)
- Iatrogenic (thoracic surgery or line
placement)
- Non traumatic (from metastatic pleural
disease),
- spontaneous rupture of an intrathoracic
vessel, bleeding disorders
- Complication of anticoagulant therapy
HEMOTHORAX
>Retention of clotted blood in the thorax (causing restriction)
> Infection
> Effusion (usually self limited)
>Fibrothorax (occurs in less that 1% of hemothoraces.
Decortication is necessary)
 Complications of Hemothorax

21.  Defined by the presence of chyle (lymph) in the pleural
space.
 Diagnosis
- Appearance often milky. Must differentiate chylous from
chyliform effusion
- Chemical confirmation
Triglyceride > 110 mg/ dL
If triglyceride is between 50-110 mg/dL , send fluid for
lipoprotein electrophoresis. Chylomicrons confirms a
chylothorax
If triglyceride is < 50 , it is not chylous
- Chyliform effusion has elevated cholesterol and occurs in
long standing effusions.
Chylous pleural effusion

22.  Tumor 54%
- Lymphoma
 Trauma 25%
- Surgical
- Other
 Idiopathic 15%
 Miscellaneous 6%
CAUSES OF CHYLOUS EFFUSION

23.  Milky pleural fluid due to elevated
cholesterol of lecithin-globulin complexes
 Most commonly associated with
- tuberculosis,
- rheumatoid arthritis,
- therapeutic pneumothorax
CHYLIFORM EFFUSIONS

24. Sonographic appearance of
pleural effusion

32. Bil PLEURAL EFFUSION clear

33. loculated PLEURAL EFFUSION

34. Para pneumonic PLEURAL
EFFUSION

35. Sept PLEURAL EFFUSION LL
coll

36. Right septated PE with dense lower
lobar consol

39. Empyema neccesitans

41. Associated findings
 Evaluation of pneumothorax
 Evaluation of pleural effusion and opacified
hemithorax
 Evaluation of chest wall
 Evaluation of diaphragmatic mobility
 Differentiation between subpulmonic effusion,
subphrenic collection or elevated hemidiaphragm
 Others (lung edema, fibrosis, etc.)

42. Take home message
 This tool is very beneficial
 Know the basics
 Know the device
 Appropriate machine and probe
 Pleural effusion echogenicity to classify
 Marking for thoracentesis /thoracentesis
 Look for associated findings
 Beware of artefact

43. Ultrasound Diagnosis of Chest Diseaseses
Wei-Chih Liao1, 2, Chih-Yen Tu1, 2, 3, Chuen-Ming Shih1, 2, Chia-Hung Chen1, 2, Hung-Jen
Chen1, 2 and Hsu Wu-Huei1, 2
https://radiopaedia.org/articles/pleural-effusion

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