The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pleural Effusions and is brought to you by Gabriela Rivera Camacho, MD and Emily Griffith, NP-C.

1. Pleural Effusion Case Studies
Gabriela Rivera Camacho, MD & Emily Griffith, NP-C
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Charlotte, North Carolina
Michael Gibbs, MD, Faculty Editor
The Chest X-Ray Mastery Project™

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: PLEURAL EFFUSION.

4. Visit our website
www.EMGuidewire.com
for a complete archive of chest x-ray presentations and much more!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 63-year-old with
metastatic breast
cancer

8. Malignant Left Pleural Effusion
63-year-old with
metastatic breast
cancer

9. 60-Year-Old With
Metastatic Ovarian
Cancer

10. 60-Year-Old With
Metastatic Ovarian
Cancer
Metastases To RUL + Bilateral Malignant Left Pleural Effusions

11. 28-year-old with progressive dyspnea

12. 28-year-old with progressive dyspnea
LLL Pleural Effusion – The lateral view helps define the size of the effusion

13. 13-month-old
being treated for
pneumonia in the
setting of recent
influenza.
He developed
worsening
dyspnea.

14. Parapneumonic effusion with left to right mediastinal shift
13-month-old
being treated for
pneumonia in the
setting of recent
influenza.
He developed
worsening
dyspnea.

15. Chest tube
placed with
500 ml of
purulent output
13-month-old
being treated for
pneumonia in the
setting of recent
influenza.
He developed
worsening
dyspnea.
Parapneumonic effusion with left to right mediastinal shift resolving

17. Bilateral Pleural Effusions
Loss of the normal
costophrenic angles Flattened Effusion
well seen on lateral

18. 60-year-old with advanced cirrhosis and encephalopathy

19. 60-year-old with advanced cirrhosis and encephalopathy
Right Pleural Effusion

20. 72-year-old with metastatic breast cancer

21. 72-year-old with metastatic breast cancer
Malignant Right Pleural Effusion

22. 43-year-old with metastatic breast cancer

23. 43-year-old with metastatic breast cancer
Bilateral Malignant Pleural Effusions

24. 65-Year-Old With Dyspnea

25. Hazy Left Hemithorax – Pleural Effusion
Mediastinal
Shift
65-Year-Old With Dyspnea

26. ED Bedside Ultrasound confirms the effusion
65-Year-Old With Dyspnea

27. ED Bedside Ultrasound confirms the effusion
Left Pleural
Effusion
65-year-old
with dyspnea
The relationship of the
effusion with the aorta
distinguished the
pleural space from the
pericardial space
Pericardial Effusion

29. Right Pleural Effusion

30. after pleural drainage

31. 68-year-old with a history of breast cancer presents with dyspnea
Today One year prior

32. 68-year-old with
a history of
breast cancer
presents with
dyspnea
Malignant Pleural Effusion

34. Light’s Criteria
Transudate Versus Exudate1,2
Pleural Fluid Protein/Plasma Protein >0.5
Pleural Fluid LDH/Plasma LDH >0.6
Pleural Fluid LDH >200 IU
1In patients with heart failure on diuretics, Light’s Criteria may misclassify a
transudate as an exudate up to 25% of the time.
2In heart failure patients, a serum protein 3.1 g/dl higher than the pleural fluid,
or a serum albumin 1.2 g/dl higher than the pleural fluid will help correctly
identify a transudate.

37. Parapneumonic Effusions
• The most common exudative effusions are those associated with
underlying pneumonia.
• Mortality is higher among pneumonia patients who have a
parapneumonic effusion, compared with those with pneumonia and
no effusion.
• With the aging of the population, the incidence and mortality due to
parapneumonic effusion and empyema continues to rise.

38. Right Parapneumonic Effusion

40. Malignant Effusions
• The second most common exudative effusions are those associated
with underlying malignancy.
• Most malignant pleural effusions arise from lung cancer, breast
cancer, and lymphoma.
• The presence of a malignant pleural effusion is associated with higher
mortality and significantly shorter survival.

41. Lung mass with malignant effusion

42. Lung mass after effusion drainage

44. If you have interesting cases of Pleural Effusion, we invite you
to send a set of digital PDF images and a brief descriptive clinical history to:
michael.gibbs@atriumhealth.org
Your de-identified case(s) will be posted on our education website and you
and your institution will be recognized!