Cardiopulmonar y Imaging Original Research

Kitazono et al.
Chest Radiography of Pleural Effusions

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Cardiopulmonary Imaging
Original Research

Differentiation of Pleural Effusions

From Parenchymal Opacities:
Accuracy of Bedside Chest
Radiography
Mary T. Kitazono1
Charles T. Lau
Andrea N. Parada
Pooja Renjen
Wallace T. Miller, Jr.
Kitazono MT, Lau CT, Parada AN, Renjen P,
Miller WT Jr

OBJECTIVE. The purpose of this study was to determine, with CT as the reference standard, the ability of radiologists to detect pleural effusions on bedside chest radiographs.
MATERIALS AND METHODS. Images of 200 hemithoraces in 100 ICU patients undergoing chest radiography and CT within 24 hours were reviewed. Four readers with varying
levels of experience reviewed the chest radiographs and predicted the likelihood of the presence of an effusion or parenchymal opacity on independent 5-point scales. The results were
compared with the CT findings.
RESULTS. All readers regardless of experience had similar accuracy in detecting pleural
effusions. Among 117 pleural effusions, 66% were detected on chest radiographs (53%, 71%,
and 92% of small, moderate, and large effusions) with 89% specificity. Similarly, 65% of all
parenchymal opacities were detected on chest radiographs, also with 89% specificity. Most
(93%) of the misdiagnosed pulmonary opacities were simply not seen. Meniscus, apical cap,
lateral band, and subpulmonic opacity were highly specific findings but had low individual
sensitivity for effusions. The finding of homogeneous opacity, including both layering and
gradient opacities, was the most sensitive sign of effusion. Atelectasis can occasionally mimic
the pleural veil sign of effusion, accounting for most false-positive findings.
CONCLUSION. Radiologists interpreting bedside chest radiographs of ICU patients
detect large pleural effusions 92% of the time and can exclude large effusions with high confidence. However, small and medium effusions often are misdiagnosed as parenchymal opacities (45%) or are not seen (55%). Pulmonary opacities often are missed (34%) but are rarely
misdiagnosed as pleural effusions (7%).

Keywords: bedside, pleural effusion, semierect, supine

DOI:10.2214/AJR.09.2950
Received April 22, 2009; accepted after revision
August 8, 2009.
1

All authors: Department of Radiology, Hospital of the

University of Pennsylvania, 3400 Spruce St., Philadelphia,
PA 19104. Address correspondence to
M. T. Kitazono (Mary.Kitazono@uphs.upenn.edu).

AJR 2010; 194:407412

0361803X/10/1942407
American Roentgen Ray Society

AJR:194, February 2010

leural effusions are exceedingly

common, occurring in an estimated 1 million patients each
year in the United States, many
of whom are critically ill in an ICU [1]. Bedside supine and semierect chest radiography
is logistically easier to perform in the care of
critically ill patients and often is the primary
imaging technique used in the ICU. However, bedside imaging often is suboptimal, and
numerous pitfalls of supine imaging of the
chest have been identified [24].
Basilar opacities are among the most common imaging findings in ICU patients and are
often a result of pleural effusion, parenchymal lung disease, or a combination of these
conditions. Despite the frequent detection of
basilar lung opacities in our everyday practice, accuracy in detecting and differentiating pleural fluid from parenchymal opacities
on bedside supine and semierect chest radiographs is not known. Previous studies in

the English language literature on the accuracy of supine radiography in the diagnosis
of pleural effusion have had highly variable
results, likely because of small sample sizes, the use of only known positive [5] or suspected [6] findings of effusion, and the methods used to verify pleural fluid, which ranged
from posteroanterior and lateral upright radiography, lateral decubitus chest radiography,
and ultrasound imaging [57]. Furthermore,
without the use of cross-sectional imaging as
the reference standard, the nature of falsepositive findings was not investigated.
We undertook this study to determine,
with CT as the reference standard, the accuracy of routine bedside radiography in the diagnosis of pleural effusions in critically ill
patients. We hypothesized that bedside chest
radiography in the ICU is moderately accurate in the detection of pleural effusions and
in differentiating them from other causes of
basilar pulmonary opacity.

407

Kitazono et al.

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Materials and Methods

After institutional review board approval and
in accordance with HIPAA regulations, the cases of 100 patients in the surgical ICU who consecutively underwent CT of the chest less than 24
hours after undergoing chest radiography were
retrospectively selected for review. Informed consent was not required. The exclusion criteria included complete omission of the lung bases, interval thoracentesis, and chest tube placement or
a related procedure.

TABLE 1: Definition of Terms Used to Characterize Opacities

Opacity Characteristic

Sharply marginated curvilinear opacity between aerated apical lung and the
apical ribs (Fig. 1)

Lateral band

Sharply marginated linear opacity between aerated lateral border of lung and
medial border of the lateral aspects of the ribs (Fig. 1)

Meniscus

Sharply marginated curvilinear opacity that obscures the lateral costophrenic

angle

Subpulmonic opacity

Apparent elevation of the hemidiaphragm

Layering opacity

Homogeneous opacity overlying the hemithorax with vascular markings

apparent through the opacity (Fig. 2); expected appearance of effusion on
supine image

Gradient opacity

Homogeneous opacity overlying hemithorax that becomes progressively more

radiodense from cephalic to caudal aspect with vascular markings apparent
through the opacity (Fig. 3); expected appearance of effusion on a semierect
image

Air bronchograms

Air-filled tubular or branching structures visible within an opacity

Uniformity of opacity

Homogeneous, heterogeneous, or both homogeneous and heterogeneous

components

Chest Radiography
The chest radiographs were reviewed by four
readers: a thoracic imaging attending radiologist
with more than 18 years of experience, a thoracic
imaging fellow, a fourth-year radiology resident,
and a second-year radiology resident. No special
training was given before interpretation.
Each hemithorax was separately evaluated for
the presence of basilar opacities. If an opacity was
present, the characteristics were recorded (Table
1, Figs. 13). The imaging features of pleural effusions on supine and semierect radiographs can
be divided into two main categories. The first is
extrapulmonary signs, which identify an opacity
as being between the lung and chest wall or diaphragm; these signs include meniscus, apical cap,
lateral band, and subpulmonic opacity. The second category is homogeneous densities overlying
the hemithorax; these signs include layering and
gradient opacities.
The readers independently determined the
likelihood of the presence of pleural effusion and
parenchymal opacity on a 5-point scale (5, definitely present; 4, probably present; 3, possibly
present; 2, probably not present; 1, definitely not
present). The finding of a meniscus, apical cap, or
lateral band was interpreted as certain evidence
of the presence of an effusion (typical score, 5).
The finding of a gradient opacity, layering opacity, or subpulmonic opacity was interpreted as high
likelihood of the presence of an effusion (typical
score, 4).
Air bronchograms were interpreted as certain
evidence of parenchymal opacities (typical score,
5), and heterogeneity was interpreted as high likelihood of a parenchymal opacity (typical score, 4 or
5). If imaging findings were indicative of moderate
or large pleural effusion, it was assumed that associated passive atelectasis was present. Therefore,
the presence of a parenchymal opacity also was
predicted (typical score, 4 or 5) even in the absence
of any other signs of parenchymal opacification.
When an opaque hemithorax was encountered,
the location of the mediastinum was the principle
differentiating criterion: an ipsilateral mediastinal
shift indicated a parenchymal opacity, a contralat-

408

Definition

Apical capping

Fig. 155-year-old woman with pleural effusions appearing as gradient opacities with apical caps and rightsided lateral band.
A, Bedside anteroposterior semierect radiograph shows bilateral gradient opacities that become progressively
more radiopaque from lung apices to lung bases. Vascular markings are apparent through opacity. Prominent
right-sided lateral band and bilateral apical caps are evident. Bilateral pleural effusions with associated
passive atelectasis were predicted.
B, Unenhanced axial CT scan of chest at level of main pulmonary artery confirms diagnosis of bilateral pleural
effusions with effusion-related atelectasis.

eral mediastinal shift indicated probable pleural

effusion, and an unshifted mediastinum indicated both possible effusion and possible parenchymal opacity.
All chest radiographs were obtained in the anteroposterior projection with a mobile radiography unit (AMX-4+, GE Healthcare). According
to the position indicators, no radiograph was obtained in the erect position, 28 were semierect,
and eight were supine. The position of 64 radiographs was not indicated.

CT
All CT scans were reviewed by the same thoracic imaging attending radiologist during a separate
session after all radiographs had been interpret-

ed. Pleural effusion was diagnosed if low-attenuation (020 HU) material was visualized between
the lung parenchyma and the chest wall. The effusion was considered loculated if it was clearly divided into more than one compartment. There were
no cases of high-attenuation pleural effusion or hemothorax in our patient sample. The quantity of
pleural fluid was semiquantitatively scored on CT
scans as small, moderate, or large. The quantity
depended on the maximum anteroposterior depth
of pleural fluid (measured at the maximum effusion
depth, which varied by patient): less than 15% ( 75
mL), 1530%, or greater than 30% ( 350 mL) of
the diameter of the hemithorax [8].
Although many patients had diffuse airspace
disease, such as pulmonary edema, an opacity was

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Chest Radiography of Pleural Effusions

Fig. 257-year-old man with pleural effusions appearing as layering opacities.

A, Supine chest radiograph shows homogeneously increased opacification of right hemithorax typical of
layering opacity, typically scored 4 for probable pleural effusion. Right hemithorax also was typically scored 4
for pulmonary opacity because readers were predicting presence of atelectasis independent of effusion. Most
readers scored left lung base 4 for opacity and 2 for effusion.
B, CT scan confirms presence of moderate right pleural effusion and associated passive atelectasis in adjacent
right lower lobe.

Fig. 352-year-old man with pleural effusions

appearing as gradient opacities. Semierect chest
radiograph shows bilateral homogeneous opacities
at lung bases interpreted as gradient opacities and
scored 5 for pleural effusions by all readers. Probable
associated bibasilar passive atelectasis was inferred
from moderate size of pleural effusions. Pleural
effusions and passive atelectasis were confirmed at
CT (not shown).

ficity, and areas under the ROC curve in the detection of parenchymal opacities on bedside chest
radiographs also were calculated for each reader.
We considered scores of 3 and higher positive predictions of effusion or opacity.

at different positions on similar ROC curves

(Fig. 4). With the results for all readers averaged, the overall sensitivity in the diagnosis of
pleural effusion on bedside chest radiographs
was 66%. The specificity was 89% with a fitted area under the ROC curve of 0.852 (Table
2). Exclusion of the 15 loculated effusions did
not change the diagnostic accuracy.
Because the four readers had similar diagnostic accuracy in diagnosing effusion, the
composite results for all readers were used
to determine overall accuracy in the detection of effusion on the basis of the size of the
effusion and to analyze the accuracy of individual radiographic characteristics of effusion. Overall, 53% of the small pleural effusions, 71% of the moderate effusions, and
almost all (92%) of the large pleural effusions were correctly diagnosed. The specificity was high, approximately 89%, for all
pleural effusions (Table 3).

diagnosed only when a discrete region of alveolar

opacification was found, either alone or superimposed on a diffuse alveolar process. For the purposes of this study, we made no distinction between
opacification due to volume loss (atelectasis) and
opacification due to alveolar filling (e.g., pneumonia, contusion, infarction).
Various CT scanners were used, including a
single-detector scanner (CTi, GE Healthcare),
4-MDCT scanners (LightSpeed QXI, GE Healthcare; Volume Zoom, Siemens Healthcare), a 16MDCT scanner (Sensation 16, Siemens Healthcare), a 64-MDCT scanner (Sensation 64, Siemens
Healthcare), and a dual-source 64-MDCT scanner
(Somatom Definition, Siemens Healthcare). Several imaging techniques were used. Sixty-one examinations were performed with IV contrast enhancement: 47 with 100 mL of iohexol 300 mg I/
mL (Omnipaque 300, GE Healthcare) and 14 with
100 mL of iohexol 350 mg I/mL (Omnipaque 350,
GE Healthcare) at injection rates of 1.54.0 mL/s.
Various collimations and pitches were used depending on the type of scanner and imaging protocol. Images were reviewed on a PACS workstation
(RadWorks, GE Healthcare) at a slice thickness of
1, 3, or 5 mm.

Statistics
The sensitivity, specificity, and receiver operating characteristic (ROC) curves in the detection
of pleural effusion on bedside chest radiographs
were calculated with CT as the reference standard.
Area under the ROC curves was calculated with a
Web-based calculator [9]. Separate analyses were
conducted for each reader and for small, moderate,
and large pleural effusions. The sensitivity, speci-

AJR:194, February 2010

Results
CT of the chest was performed on 117
consecutively registered ICU patients within the 2-month period October and November 2007. Thirteen of the patients were excluded because they had not undergone chest
radiography within 24 hours before CT. Two
patients were excluded because overlying
structures completely obscured the lung bases; one patient, because the lung bases were
completely omitted; and one patient, because
a chest tube was inserted between the imaging studies. The other 100 ICU patients (200
hemithoraces; 60 men and boys, 40 women
and girls; mean age, 54.3 years; range, 1491
years) formed the final study group. Diffuse
airspace disease was present in 40 patients.
Chest CT depicted 117 cases of pleural effusion: 16 large, 46 medium, and 55 small.
Eight isolated right pleural effusions, 11 isolated left pleural effusions, and 49 bilateral
pleural effusions were found. Fifteen cases
of effusion were loculated.
Sensitivity and Specificity
All readers had similar accuracy in detecting effusions without a significant difference
according to level of experience. The readers with the highest sensitivity had the lowest
specificity, and thus all readers results were

False-Negative Findings of Effusion

On average, 34% (161/468, the denominator being the total number of effusions multiplied by four readers) of the pleural effusions were missed on chest radiographs. Most
(64%) of the missed effusions were small,
33% were moderate, and 3% were large. Forty-five percent (73/161) of the missed effusions were interpreted as parenchymal opacities rather than effusions, and the other 55%
(88/161) were interpreted as not basilar opacities. In 59% (95/161) of the cases of false-negative findings of effusions interpreted as not
basilar opacity, evidence of diffuse alveolar

409

Kitazono et al.
Fig. 4Graph shows
receiver operating
characteristic curves
for detection of pleural
effusions of all sizes by
readers with varying
levels of experience.

1.0
0.9

True-Positive Fraction

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0.8
0.7
0.6
0.5
0.4
0.3
Attending

0.2

Fellow
4th-year Resident

0.1

2nd-year Resident

0.0
0.0

0.1

0.2

0.3
0.4
0.5
0.6
0.7
False-Positive Fraction

0.8

1.0

0.9

TABLE 2: Reader Accuracy in Diagnosis of Pleural Effusion

Reader

Sensitivity (%)

Specificity (%)

Area Under ROC Curve

Attending

59 (69/117)

95 (79/83)

0.844

Fellow

62 (72/117)

90 (75/83)

0.843

Fourth-year resident

76 (89/117)

86 (71/83)

0.878

Second-year resident

66 (77/117)

93 (77/83)

0.855

Average

66 (309/468)a

89 (295/332)a

0.852

NoteValues in parentheses are raw numbers. ROC = receiver operating characteristic.

aTotal number of effusions multiplied by four readers.

TABLE 3: Average Reader Accuracy for Detecting Pleural Effusions

of Different Sizes With Bedside Chest Radiography
Size of Effusion
Small

Sensitivity (%)

Specificity (%)

53 (117/220)

89 (295/332)

Moderate

71 (131/184)

89 (295/332)

Large

92 (59/64)

89 (295/332)

Total (n = 117)

66 (309/468)a

89 (295/332)a

NoteValues in parentheses are raw numbers.

aTotal number of effusions multiplied by four readers.

lung disease was seen on chest radiographs,

but the presence of an independent basilar
opacity was not predicted.
False-Positive Findings of Effusion
Eleven percent (36/327) of the suspected
effusions were false-positive findings, most
of which (64%, 209/327) were homogeneous
opacities on chest radiographs that proved to
be atelectasis on CT scans. Approximately
one of three (31%, 11/36) false-positive findings of effusion had a false meniscus sign,
which was usually caused by pleural thickening or a large pericardial fat pad (Fig. 5).
The attending radiologist made one falsepositive finding of meniscus, and each of the
other readers made three or four false-positive findings of meniscus.

410

hibiting some kind of homogeneous opacity,

and was the finding most likely to indicate
the presence of small and moderate-sized effusions (Table 4). Atelectasis, however, can
occasionally mimic the pleural veil sign on
chest radiographs, accounting for most of the
false-positive findings in this study.

Characteristics of Pleural Effusion

Meniscus, apical cap, lateral band, subpulmonic opacity, layering opacity, and gradient opacity all were highly specific but not
sensitive signs of pleural effusion (Table 4).
In total, 73% (342/468) of all patients with
pleural effusions had at least one of the highly specific signs on chest radiographs (apical
cap, lateral band, meniscus, layering opacity, gradient opacity, or subpulmonic opacity). Complete opacification of a hemithorax with ipsilateral mediastinal shift was
found in only three patients, and CT showed
that all three of these patients had ipsilateral effusions and atelectasis. Homogeneous
opacity was the single most sensitive finding of pleural effusion on bedside chest radiographs, 68% (319/468) of effusions ex-

Parenchymal Opacities
CT showed 146 pulmonary opacities, 65%
(381/584) of which were predicted by the readers on chest radiographs with a specificity of
89% (193/216) for all readers combined. Individual readers had sensitivities varying from
56% to 77% and specificities varying from
81% to 96% with no significant trend based on
level of experience. The area under the ROC
curve varied from 0.815 (second-year resident) to 0.872 (fourth-year resident) (Table 5).
Most of the misdiagnosed pulmonary opacities (93%, 150/161) on chest radiographs were
erroneously predicted to be normal lung bases
with no effusion or discrete opacity.
Discussion
Bedside supine and semierect chest radiography of ICU patients has low and intermediate sensitivity in the detection of small and
moderate effusions (53% and 71%, respectively) but is highly sensitive and specific in the
detection of large effusions (92% and 89%).
Accordingly, large effusions usually can be
excluded with high confidence, but small and
medium effusions often are not identified because they are misdiagnosed as parenchymal
opacities (45%) or are not seen (55%).
The 66% overall sensitivity for all pleural
effusions in our study is slightly lower than
previously reported sensitivities ranging from
67% to 82% [6, 7]. However, the previous
studies may have shown falsely elevated sensitivities due to the methods of verifying effusion, including decubitus radiography and
ultrasound, which are not as sensitive as CT
in the detection of small effusions. Excluding the small effusions in our study increases
the sensitivity to 78% (190/244) in the detection of effusion, and this rate is comparable
with previously reported values.
Diagnostic accuracy for effusion did not
differ significantly between readers, whose
levels of experience varied. Although there
was only one reader in each category, our results suggest that the ability to diagnose pleural effusions on bedside radiographs is a basic
skill that can be learned quickly during residency. The results also suggest that because
of suboptimal visualization on bedside radio-

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Chest Radiography of Pleural Effusions

Fig. 575-year-old woman with false-positive finding of pleural effusion.

A, Bedside chest radiograph shows apparent meniscus sign at left costophrenic angle, typically scored 4 or 5
for probable or definite pleural effusion. Heterogeneous opacity at left lung base also was predicted.
B, CT scan shows large pericardial fat pad curving up lateral margin of chest wall, producing false appearance
of meniscus. Parenchymal infiltrate and dependent atelectasis are evident at left lung base.

TABLE 4: Reader Accuracy in Identifying Features of Pleural Effusion

Frequency (%)
Finding

Small
Effusion

Moderate
Effusion

Large
Effusion

Apical capping

2 (4/220) 8 (14/184) 9 (6/64)

Lateral band

4 (9/220)

Sensitivity
(%)

Specificity
(%)

5 (24/468) 100 (24/24)

12 (22/184) 31 (20/64) 11 (52/468) 100 (52/52)

Subpulmonic opacity

2 (4/220) 2 (4/184)

Meniscus

13 (28/220) 16 (29/184) 41 (26/64) 18 (83/468) 89 (83/94)

9 (6/64)

3 (14/468) 88 (14/16)

Layering opacity

9 (19/220) 22 (41/184) 23 (15/64) 16 (75/468) 95 (75/79)

Gradient opacity

19 (41/220) 32 (58/184) 55 (35/64) 29 (134/468) 91 (134/147)

Any kind of homogeneous opacity 43 (94/319) 67 (123/184) 91 (58/64) 59 (275/468) 86 (275/319)

TABLE 5: Reader Accuracy in Diagnosing Pulmonary Opacities

Reader

Sensitivity (%)

Specificity (%)

Area Under ROC

Curve

Attending

61 (89/146)

94 (51/54)

0.842

Fellow

56 (82/146)

96 (52/54)

0.852

Fourth-year resident

77 (112/146)

85 (46/54)

0.872

Second-year resident

67 (98/146)

81 (44/54)

0.815

Average

65 (381/584)

89 (193/216)

0.863

graphs, there is a limit to diagnostic accuracy

that is difficult to overcome, even for the most
experienced readers.
All six characteristic findings of effusion
were highly specific for the presence of effusion. However, the extrapulmonary signs,
including meniscus, apical cap, lateral band,
and subpulmonic opacity, are uncommon
findings. Only 27% of effusions had at least
one of these signs, and most of these effusions were moderate or large.
The homogeneously increased attenuation
caused by pleural fluid often differentiates
pleural effusion from conditions such as

AJR:194, February 2010

pneumonia, atelectasis, and contusion, which

cause parenchymal opacities and often contain a mixture of aerated and unaerated lung
that causes heterogeneously increased attenuation. In this study, the presence of a homogeneous opacity seen in isolation or superimposed on a heterogeneous opacity was a
moderately specific indicator of the presence
of pleural fluid, having 86% specificity. This
finding was the most sensitive (68%) for
pleural effusion on bedside chest radiographs
and was the finding most likely to indicate
the presence of small and moderate-sized effusions. However, atelectasis occasionally

causes homogeneously increased attenuation

indistinguishable from that of pleural fluid on
chest radiographs. It accounted for most of the
false-positive findings (73%) in this study.
The readers accuracy in detecting parenchymal opacities was rather low, only 65%
of the opacities being correctly predicted on
chest radiographs. Most of these misdiagnosed opacities (93%) were simply not seen
and were interpreted as a normal lung base
with no effusion or focal opacity. On CT
scans, however, many of these missed opacities were visualized as small areas of subsegmental atelectasis or focal ground-glass opacities, which are findings of dubious clinical
significance. In a small percentage of cases
(7%), the opacity was mistaken for effusion.
Several limitations to our study should
be noted. The retrospective design in which
only patients undergoing chest CT were selected as participants may have biased the
sample to include patients who are the most
ill and more likely to have pleural effusions.
The high prevalence of both pleural effusion
and pulmonary opacity in this ICU sample
prevents generalization of these results to
populations of patients who are not critically
ill. However, patients who are not critically
ill can undergo standard upright radiography.
In addition, the 200 hemithoraces were treated as separate entities, and the radiographic
findings of large ipsilateral pleural effusion
might have biased the readers toward predicting the presence of a small contralateral
effusion in equivocal cases.
Bedside supine and semierect chest radiography of ICU patients is reliable for differentiating large pleural effusions from pulmonary
opacities. Small and medium effusions, however, often are misdiagnosed as parenchymal
opacities (45% in this study) or are not seen
(55% of cases in this study). Pleural effusion is
present in most ICU patients in whom effusion
is suspected (89% specificity in this study).
Large effusions can be excluded with high
confidence on supine and semierect chest radiographs. A considerable portion of pulmonary opacities are misdiagnosed (34% in this
study), most of which are simply not seen.
An opacity is infrequently mistaken for an effusion (7% of cases in this study).
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