CHEST Postgraduate Education Corner

CHEST IMAGING FOR CLINICIANS: REVIEW

Diagnostic Utility and Clinical Application of

Imaging for Pleural Space Infections
John E. Heffner, MD, FCCP; Jeffrey S. Klein, MD, FCCP; and Christopher Hampson, MD

Timely diagnosis of pleural space infections and rapid initiation of effective pleural drainage
for those patients with complicated parapneumonic effusions or empyema represent keystone
principles for managing patients with pneumonia. Advances in chest imaging provide oppor-
tunities to detect parapneumonic effusions with high sensitivity in patients hospitalized for
pneumonia and to guide interventional therapy. Standard radiographs retain their primary role
for screening patients with pneumonia for the presence of an effusion to determine the need
for thoracentesis. Ultrasonography and CT scanning, however, have greater sensitivity for fluid
detection and provide additional information for determining the extent and nature of pleural
infection. MRI and PET scan can image pleural disease, but their role in managing parapneu-
monic effusions is not yet clearly defined. Effective application of chest images for patients
at risk for pleural infection, however, requires a comprehensive understanding of the unique
features of each modality and relative value. This review presents the diagnostic usefulness and
clinical application of chest imaging studies for evaluating and managing pleural space infec-
tions in patients hospitalized for pneumonia. CHEST 2010; 137(2):467–479

Abbreviations: FDG-PET 5 2-[18F]-fluoro-2-deoxy-glucose positron emission tomography; PAL 5 pyothorax-associated

lymphoma; VATS 5 video-assisted thoracoscopic surgery

Because of the considerable morbidity and mor-

tality of empyema, all patients hospitalized with
pneumonia should undergo a careful evaluation to
identify the presence of a parapneumonic effusion
and determine whether pleural fluid needs to be
drained.1 Thoracic imaging represents an important
component of this evaluation.1,2 Recent advances in
imaging techniques have revolutionized the manage-
ment of pleural infections by improving the detection
of infected fluid and guiding and monitoring thera-
peutic interventions. The present review compares
Manuscript received December 20, 2008; revision accepted May
8, 2009.
Affiliations: From the Department of Medical Education (Dr
Heffner), Providence Portland Medical Center, Oregon Health
and Science Center, Portland, OR; and the Department of Tho-
racic Radiology (Drs Klein and Hampson), Fletcher Allen Health
Care, University of Vermont College of Medicine, Burlington,
VT.
Correspondence to: John E. Heffner, MD, FCCP, Providence
Portland Medical Center, 5050 NE Hoyt St, Suite 540, Portland,
OR 97213; e-mail: John_heffner@mac.com
© 2010 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians (www.chestjournal.orgⲐ
siteⲐmiscⲐreprints.xhtml).
DOI: 10.1378Ⲑchest.08-3002
the diagnostic usefulness of imaging modalities and
how they can contribute to management decisions
for patients with pneumonia complicated by parap-
neumonic effusions.
Normal Pleural Membranes
In health, imaging studies cannot visualize the
pleural space against the diaphragm and chest wall3
because pleural membranes are only 0.2 to 0.4 mm
thick and physiologic volumes (4 to 18 mL)4 of pleu-
ral fluid form a thin 5- to 10-mm layer.5 The invagina-
tions of visceral pleura composing the interlobar and
accessory fissures appear as linear or curvilinear lines.
Interlobar loculated fluid may simulate parenchymal
or intrapleural neoplasms (pseudotumors) (Fig 1).
The peripheral pleural surfaces adjacent to the chest
wall include the costal pleurae that compose the
majority of the pleural surface in contact with the ribs,
the mediastinal pleurae, and the diaphragmatic pleurae
situated medially and inferiorly, respectively. What may
appear to represent costal pleural membranes on CT
images is actually a combination of visceral and pari-
etal pleurae, physiologic pleural fluid, fascia, and the
innermost intercostal muscles (Fig 1C).

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Figure 1. The frontal radiograph (A) shows right-sided subpul-
monic and loculated lateral pleural effusion and a pseudotumor
in the medial, mid-lung field. The lateral projection (B) local-
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Standard Radiographs
Standard chest radiographs survey the entire pleu-
ral space, underlying lung, mediastinum, chest wall,
and spine for potential causes and complications
of the pleural process. The presence of a lung cavity
situated medial to pleural fluid collections, for instance,
identifies a lung abscess (Fig 2).
The radiographic appearance of infected pleural
fluid collections depends on the volume and viscosity
of pleural fluid, the patient’s position, and presence of
pleural loculations. Of special note are difficulties
of detecting and assessing subpulmonic effusions
(Fig 3),6 nondependent loculations that simulate masses
or airspace densities on frontal projections (Fig 4),
loculated collections along mediastinal pleural reflec-
tions (Fig 5), and effusions on portable radiographs
(Figs 5-7).
Chest Ultrasonography
For ultrasonographic chest examination, a narrow
footprint linear or sector transducer is typically
used. A high-frequency linear transducer (5-7.5 MHz)
provides high-resolution intercostal scanning, but is
limited in penetration for patients with thick chest
walls and does not provide a large field of view for
visualization of the pleural space and underlying
lung.7 For most patients, a convex or sector transducer
of intermediate frequency (3-4 MHz) provides the
best compromise between near-field resolution of
the lung-pleura interface, a wider evaluation of large
effusions, and assessment of the parietal pleura and
lung parenchyma.8-10
Normal pleural membranes are too thin to be visu-
alized even by high-resolution ultrasonography. The
interface between the normal visceral pleura and under-
lying lung produces the “pleural stripe,” which is a thin
echogenic line projecting internal to the ribs (Fig 8).
It moves craniocaudally with respiration on ultrasono-
graph.7 Another ultrasonography finding in normal
patients is the comet-tail artifact, which is seen deep
to the pleural stripe and results from subpleural inter-
lobular septae in normally aerated lung at its interface
with the pleural surface. In patients with underlying
consolidation or atelectasis of the lung, particularly in
the presence of pleural effusion, the visceral pleura is
visible as an echogenic line thinner than the previously
mentioned pleural interface. Focal pleural masses
izes the pseudotumor to the upper major fissure. The pseudotu-
mor appears more rounded than the usual lenticular appearance.
A contrast-enhanced chest CT slice (C) confirms the pseudotumor
to be a loculated pleural effusion within the major fissure (arrow),
with additional lateral and posterior locules. The CT scan does not
visualize costal pleural membranes in the left hemithorax; what
appear to be pleural membranes (arrowheads) actually represent
a combination of visceral and parietal pleurae, physiologic pleural
fluid, fascia, and the innermost intercostal muscles.
Postgraduate Education Corner
Figure 2. Frontal chest radiograph that demonstrates an air-
fluid level within rounded density (arrow) that suggested a lung
abscess in a patient with multiloculated empyema involving the
right apex and paramediastinal pleurae. Contrast-enhanced CT
scan (B) through the lower thorax showed fluid collections in the
major fissure (F) and posteriorly with a cavitary abscess in the
right lower lobe (arrow). The hilum is poorly defined on the fron-
tal radiograph because of a paramediastinal fluid collection con-
firmed by CT scan (CT image not shown).
associated with an effusion are readily seen and biop-
sied with ultrasonography guidance.11,12 Ultrasonogra-
phy allows characterization of pleural fluid collections
with septations and loculations being better appreci-
ated than on CT scan, but pleural thickening and the
extent of pleural disease throughout the thorax are
more difficult to assess.
Ultrasonography is more sensitive (5 mL fluid detect-
able) than decubitus radiography.13-18 Pleural effusions
typically appear as triangular anechoic collections
immediately above the diaphragm (Fig 9) that change
shape with respiration and outline the underlying echo-
genic, airless posterior costophrenic sulcus. Portable
chest ultrasonograph examination is particularly useful
to detect and quantify pleural fluid collections in supine
critically ill patients.19
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Figure 3. Frontal (A) and lateral (B) radiographs demonstrate
a subpulmonic effusion with apparent elevation of the right dia-
phragm with a laterally displaced apex (arrow in A). In B, note
the sloping interface (white arrows) between the effusion (*)
and the middle lobe anterior to the major fissure (solid arrow).
This appearance results from the oblique interface between
the subpulmonic effusion and the middle lobe anterior to the
major fissure, as the lung-fluid interface fails to create a sharp
tangent to the lateral x-ray beam and therefore is not evident
radiographically.
Chest ultrasonography can also suggest the nature
of fluid collections. Four typical internal echogenicity
patterns of pleural effusion on sonography have been
described: (1) homogeneously anechoic (Fig 10A),
(2) complex nonseptated with internal echogenic foci
(Fig 10B), (3) complex septated (Fig 10C), and (4)
homogeneously echogenic (Fig 10D).20 Although
transudative pleural effusions are typically anechoic, as
many as 55% of proven transudative pleural effusions will
have a complex nonseptated appearance.21 Conversely,
CHEST / 137 / 2 / FEBRUARY, 2010 469

Figure 4. Frontal radiograph (A) of a patient with multilocular
empyema demonstrating obscuration of the left hemidiaphragm by
lung consolidation and pleural fluid and an ill-defined density in the
medial, midlung field (arrow). The lateral view (B) demonstrates a
nondependent loculated empyema (arrows) with the “d-sign.”
although most complicated parapneumonic effu-
sions and empyemas contain internal echoes or
appear entirely echogenic, up to 27% of exudative
effusions are anechoic.20
Uniformly echogenic collections typically contain
blood or debris and almost invariably indicate the
presence of an empyema in patients who appear clini-
cally infected.22 Large, discrete, primary loculations of
pleural fluid establish the presence of visceral to parietal
pleural adhesions and suggest empyema in appropriate
settings.23 Evidence by ultrasonography of secondary
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Figure 5. Supine portable radiograph (A) in a patient with large
posterior bilateral pleural effusions that demonstrates increased
density over both lung fields. The CT scan (B) shows the large
effusions layering posteriorly. Passive atelectasis of the left and
right lung (arrows) is demonstrated in this contrast-enhanced
study. The homogeneity of the atelectatic lung on all sections
excludes lung necrosis or abscess There is no evidence of parietal
pleural thickening or enhancement on this CT level.
loculations or septations within pleural fluid collections
(honeycomb appearance) has no diagnostic value.
CT Scan
Multidetector CT scan allows acquisition of contigu-
ous 1- to 3-mm sections through the chest during
one breath hold and provides high-resolution imaging
of the pleura with multiplanar coronal and sagittal
reconstructions that assist the evaluation of complex
pleural abnormalities adjacent to lung, mediastinal,
and chest wall lesions (Fig 11).24 Intravenous contrast
Postgraduate Education Corner
 Figure 7. Frontal radiograph of a patient with a pleural effusion
that collects within an incomplete right major fissure, which cre-
ates a perihilar lucency outlined peripherally by a circumscribed
concave opacity.

sion. An exception to this rule exists along the right and

Figure 6. Portable radiograph (A) of a large left pleural effu-
sion in a patient with mediastinal lymphoma (note mediastinal
widening and obscuration of aortic arch) that demonstrates
crescentic fluid density (arrow) over the lung apex. A contrast-
enhanced CT scan (B) shows the left pleural effusion with
the enhancing atelectatic left lung sharply delineated from the
effusion.
left parasternal portions of the costal pleural surfaces,
where the transversus thoracis muscles are seen as
symmetric thin soft-tissue densities, and along the lower
posterior costal pleural surface, where the subcostalis
muscles are variably seen as thin linear opacities inter-
nal to the lower posterior ribs. These densities are eas-
ily distinguished from pleural thickening (Fig 12).
Chest CT scan is more sensitive than chest radio-
graphy for detecting small pleural effusions.7 Because
CT scan provides an unimpeded view of the entire
pleural surface, the underlying lung parenchyma, and the
adjacent mediastinum and chest wall, it is the ideal
modality for determining the extent of pleural infec-
tion and the nature of fluid collections.

allows differentiation of pleural membranes from

parenchymal processes for patients with empyema
and associated pulmonary infections or neoplasms.7
Obtaining images 20 to 60 s after contrast infusion
allows the best visualization of pulmonary vasculature
and separation of lung from pleural abnormalities.7
CT scan cannot visualize normal pleura against the
chest wall because pleural membranes blend in with
endothoracic fascia and intercostal muscles.3 In the
paravertebral regions, a thin line representing the pleu-
ral layers and pleural space may be visible because the
innermost intercostal muscle is absent in this region.
The interlobar and accessory fissures are visible in
cross section as curvilinear opacities on thin-section
axial, sagittal, and coronal reformatted images. Visual-
ization of a thin layer of tissue along the internal mar-
Figure 8. Sonogram of a normal patient shows a thin echogenic
gin of the inner cortices of the ribs is abnormal and interface between the normal visceral pleura and underlying lung
indicates the presence of pleural thickening or effu- deep to the ribs that produces the normal pleural stripe (arrows).

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Figure 9. The frontal radiograph (A) suggests a right parap-
neumonic effusion, which is confirmed by sonographic evi-
dence (B) of a characteristic triangular anechoic fluid collection
immediately above the diaphragm. Eff 5 effusion; L 5 lung;
Li 5 liver.
The signs of pleural fluid on CT scan parallel those
observed on conventional radiography. Small, free-
flowing effusions appear as meniscoid collections of
water attenuation along the posterior pleural surfaces.
Small effusions form a sharp interface with the lower
lobe. Large effusions cause passive atelectasis of
adjacent lung and produce on non-contrasted studies
an irregular interface with aerated lung. With contrast,
the atelectatic lung undergoes enhancement and
becomes sharply delineated from the effusion (Fig 6B).
As effusions increase in volume, they extend farther
cranially up the posterior pleural surface, eventually
extending over the lung apex. They also extend along
the lateral margins of the lung and into interlobar
fissures. Large effusions produce extensive passive
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atelectasis of the lung and often produce contralateral
shift of the heart and mediastinum.
Loculated effusions appear as lenticular masses of
fluid attenuation, most often situated in the depen-
dent portions of the costal pleural space along the lower
posterior pleural surface. Medially situated fluid col-
lections adjacent to the mediastinum are easily delin-
eated on CT scan. Loculated fluid collections within
the major or minor fissures produce pseudotumors,
which can simulate underlying lung cancer or abscess
on standard radiographs (Fig 1C).5
The attenuation of pleural fluid collections pro-
vides some diagnostic information but does not allow
definite distinction between infected and uninfected
effusions. Most infected pleural fluid collections have
attenuation similar to water (ie, 0 Hounsfield units),
whereas collections with high protein content and
bloody effusions may have attenuations of soft tissue
(ie, 30-50 Hounsfield units) (Fig 13). The detection
of air in the pleural space, in the absence of recent
thoracentesis, chest tube placement, or surgical
intervention, almost invariably indicates pleural
infection, most often a necrotizing pneumonia or
abscess with rupture into the pleural space. Sponta-
neous or posttraumatic rupture of the esophagus or
central airways can likewise produce a hydropneu-
mothorax. The detection of small air bubbles within a
pleural collection is specific for an infected pleural
fluid collection.
Conditions that thicken the pleura render them visi-
ble on CT scan. Parietal pleural thickening almost always
indicates the presence of a pleural exudate, although
this finding is not specific for infection.25 Even without
contrast, thickening of the parietal pleura in a patient
with pleural infection is easily detected by CT scan.
Pleural infection typically produces smooth, uniform
pleural thickening almost always limited to the costal
and diaphragmatic pleural surfaces. The detection
of mediastinal pleural thickening or nodules along
thickened parietal pleural surfaces on CT scan suggests
pleural malignancy. Although thickening of the parietal
pleura underlying the ribs is relatively specific for an
exudative pleural effusion, patients with transudative
effusions and preexisting underlying pleural fibrosis or
pleural malignancy will also demonstrate this finding.
In patients with infected pleural fluid collections, the
identification of a thickened, enhancing rim of parietal
and visceral pleura surrounding a loculated pleural
fluid collection on contrast-enhanced CT scan (split
pleura sign) (Fig 14) is reliable evidence of empyema.25
Increased attenuation of extrapleural fat and
thickening of the fat layer ⱖ 3 mm is seen in 60%
of empyemas.25,26 Patients with transudates have
normal-appearing extrapleural tissue.26 Although simi-
lar extrapleural changes are noted in 27% of patients
with malignant pleural processes, the majority of
Postgraduate Education Corner
Figure 10. Sonographic appearance of parapneumonic effusions with the patterns of homogeneously anechoic (asterisk denotes fluid)
(A), complex nonseptated with internal echogenic foci (B), complex septated (C), and homogeneously echogenic (D). Most complicated
parapneumonic effusions and empyemas have internal echoes or appear entirely echogenic. “L” denotes lung and curved arrow identifies
the diaphragm.

such patients have a complicating pleural infection
or a history of prior pleurodesis.27
CT scan evaluates the underlying lung, adjacent chest
wall including ribs and spine, the diaphragm, and
the subphrenic space. Pneumonia, lung abscess, or
obstructing malignancy are readily evident on contrast-
enhanced studies. In patients with fibrinopurulent
pleural infections, the underlying lung often shows
multiple alternating outpouchings and indentations
due to fibrin strands that produce intrapleural adhe-
sions. Septations within an infected effusion are less
readily imaged as compared with ultrasonography.28
Pleural-based lung abscesses may be difficult to dis-
tinguish from loculated empyemas. On CT scan, lung
abscesses tend to be round rather than lenticular in
shape like empyemas and also have thick, irregular
walls and do not displace adjacent lung.29
If ineffectively treated, empyemas can progress
to a fibrothorax with pleural peels that appear as
uniform smooth thickenings of the pleurae with
hypertrophy of the extrapleural fat and reduced vol-
ume of the affected hemothorax with narrowing of
the intercostal spaces and shift of the mediastinum
to the affected side. Chest CT scan cannot predict
the likelihood that pleural thickening during the fibrin-
opurulent phase of pleural infections will progress to
fibrothorax.30
MRI
MRI plays a limited role in evaluating suspected
pleural infections. The ability of MRI to provide a
global view of the pleural space in axial, sagittal, and
coronal planes without ionizing radiation suggests
possible advantages. Chest MRI provides similar
accuracy as CT scan in differentiating loculated pleu-
ral effusions from underlying lung. But difficulties in
performing motion-free high-quality MRI studies for
seriously ill patients and the superior spatial resolu-
tion of multidetector CT scan in evaluating the
underlying lung have limited the application of MRI
for evaluating the pleural space. Its use is limited to
assessing patients with known pleural infection who
have suspected spinal or rib involvement.

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Figure 11. Pyopneumothorax due to bronchopleural fistula
complicating lung abscess. (A) Upright chest radiograph shows
a large right hydropneumothorax with small air-fluid level in
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PET Scan
Chest imaging with positron emission tomography
using 2-[18F]-fluoro-2-deoxy-glucose (FDG-PET) has
a limited role for evaluating pleural infections. It may
contribute in special circumstances when more con-
ventional techniques cannot discriminate between
pleural infections and malignancies (see later discus-
sion) because FDG-PET scan may demonstrate dif-
ferent uptake characteristics in pleural membranes in
these two conditions.31,32
Application of Imaging Modalities in
Suspected Pleural Infection
As reviewed in the previous sections, existing chest
imaging provides information about the presence,
nature, and extent of pleural infection. Application
of various modalities to individual patients, however,
requires an understanding of the comparative value of
each modality in addressing specific clinical questions
faced in managing pneumonia. The following sections
review evidence that assists clinicians in applying
chest imaging studies and interpreting their results
when evaluating suspected pleural infections.
Detection of Pleural Effusions in Patients at Risk
Standard chest radiographs remain the initial study
to screen patients with pneumonia for pleural fluid.7
Free-flowing or loculated moderate-to-large effusions
may present obvious evidence of pleural fluid and
justify in most circumstances proceeding to image-
guided thoracentesis. Lower lung zone lung consoli-
dation may obscure radiographic evidence of pleural
fluid and require additional imaging studies. Decubitus
views represent the traditional follow-up study when
standard radiographs cannot exclude pleural fluid.33
Chest ultrasonography has replaced decubitus views
because it is fast, effective, more sensitive,13-18,34
and portable.35
The utility of portable ultrasonography for detecting
effusions has been demonstrated in the ED13 and in
the ICU.22,36 Also, Tu and coworkers22 demonstrated
in critically ill patients that the ultrasonographic fea-
tures of pleural fluid predict the probability of pleural
infection and need for diagnostic thoracentesis. Patients
with anechoic or complex nonseptated and relatively
consolidated right mid lung (arrow). (B) Contrast-enhanced CT
shows a cavity with air-fluid level (white arrow) reflecting an
abscess within the consolidated middle lobe. There is a large
right hydropneumothorax with thickening and enhancement of
the parietal pleura (black arrow). (C) Sagittal reformatted image
through the middle lobe abscess shows a large bronchopleural
fistula (white arrows) extending posterosuperiorly from the abscess
cavity to the posterior hydropneumothorax. Purulent material
was recovered at surgery.
Postgraduate Education Corner
Figure 12. A patient with two chest tubes in the right hemithorax
that drain a parapneumonic effusion. There is asymmetric thicken-
ing of the right posterolateral chest wall and expansion of the extra-
pleural fat (black straight arrow) due to edema, findings commonly
observed with empyemas. A small amount of pleural fluid remains
posteriorly (curved arrow). The left hemithorax demonstrates the
normal appearance of the inner cortices of the ribs wherein no tis-
sue can be visualized adjacent to the lung (arrowhead). In contrast,
the finding of even a thin layer of tissue along the inner rib cortices
establishes pleural thickening or effusion (white arrow).
nonhyperechoic fluid had low risk for empyema and
thoracentesis could be deferred, whereas patients
with complex septated, homogenously echogenic, or
complex nonseptated and relatively hyperechoic
patterns required immediate thoracentesis.
Chest CT scan is not used routinely as the initial
imaging study for detecting pleural fluid. Exceptions
include patients suspected of having fluid loculated
in interlobar fissures or paramediastinal locations
beyond the range of ultrasonography detection.
Also, in centers with ready access to CT scanning on
an urgent basis, contrast-enhanced CT scan may be
the preferred initial imaging study rather than ultra-
sonography if the standard radiograph demonstrates
Figure 13. CT image of a patient with a subpleural lung abscess
(upper short arrow) and an adjacent region (lower short arrow) of
either loculated pleural fluid of high attenuation or pleural thick-
ening. Additional high-attenuation pleural fluid or thickening is
seen posteriorly (long arrow).
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Figure 14. A CT image of a patient with empyema demonstrat-
ing enhancing rims of parietal and visceral pleurae (short arrows)
surrounding a loculated pleural fluid collection (split pleura sign).
Note the hypertrophied extrapleural fat (long arrows) due to the
chronic thickening and retraction of the pleural layers, which are
commonly associated with empyemas.
pulmonary parenchymal lesions suggestive of can-
cer, septic emboli, or cavitation. Additionally, chest
CT scan can better distinguish between a loculated
empyema or subpleural lung abscess.
Imaging for Guiding Thoracentesis
Experts have deemed thoracentesis guided by chest
percussion and auscultation as safe and feasible if
standard radiographs demonstrate large effusions or if
small effusions layer to a depth of . 1 cm on decubitus
views.37 These approaches, however, have a pneu-
mothorax rate of 10% to 39%38-42 and a 12% to 15% rate
for a dry tap.43 Thoracentesis guided by ultrasonogra-
phy decreases complications38,40,41 and improves fluid
collection rates.43-45 Diacon and coworkers46 demon-
strated the superiority of US as compared with stan-
dard radiographs combined with the physical examina-
tion to identify appropriate needle insertion sites.
Ultrasonography is rapidly emerging as a standard of
care in guiding thoracentesis for parapneumonic effu-
sions, especially in the critical care setting.22,36 For guid-
ing thoracentesis, chest CT scan is reserved for patients
with pleural fluid loculations in locations that do not
allow safe access by ultrasonographic guidance.47
Using Imaging Studies for Selecting Therapeutic
Interventions
Pleural space infections that progress to empyema
are categorized in three phases: exudative, fibrinopu-
rulent, and organized.1 Each phase has management
implications, with more advanced phases requiring
increasingly invasive drainage interventions. Ideally,
CHEST / 137 / 2 / FEBRUARY, 2010 475
findings from imaging studies would assist clinicians
in identifying the phase of empyema formation and
selecting patients for initial chest tube drainage, fibrin-
olytic therapy, thoracoscopy, or thoracotomy.
The American College of Chest Physicians clinical
practice guideline for empyema management recom-
mends initial imaging findings for guiding therapeutic
decisions.1 Large effusions that occupy greater than
50% of the hemithorax, the presence of pleural locula-
tions, and signs of pleural thickening are stated to indi-
cate a poor prognosis with medical management and
require surgical drainage.1 Unfortunately, limited evi-
dence exists to support these recommendations.
The standard radiograph provides minimal infor-
mation for guiding therapeutic interventions. The
presence of intrapleural air-fluid levels indicative of
a bronchopleural fistula establishes a need for surgery.
Otherwise, the size, location, or distribution of pleu-
ral fluid on standard radiographs has limited thera-
peutic implications.
Expert opinion advises that demonstration of locu-
lations and pleural thickening by CT scan or ultra-
sonography identifies patients with late-stage empye-
mas who will fail chest tube drainage and require
fibrinolytic therapy or surgical interventions.48 Studies
have conflicted, however, in supporting this impres-
sion. For determining success of image-guided chest
tube drainage, Akhan and coworkers47 reported that
the presence of nonloculated anechoic collections
without septae on ultrasonograph had a high likelihood
of successful treatment with image-guided catheter
drainage. Otherwise, no other ultrasonography findings
were associated with chest tube success or failure.
Another study examined all patients with ultrasonog-
raphy before image-guided catheter drainage and
noted success rates of 92% with anechoic effusions, 81%
with complex nonseptated effusions, and 63% with
complex septated effusions.49 In contrast, Keeling and
coworkers50 found no relationship between ultrasono-
graphy or CT scan appearances of the pleural space
and the phase of empyema or efficacy of small-bore
chest tube drainage. In the absence of appropriately
designed blinded prospective studies, it remains unclear
whether scan CT scan or ultrasonography findings
predict outcome of image-guided chest tube drainage.
Despite the absence of data, Chen and coworkers51 noted
that evidence of sonographic septae indicated that
clinicians would be more likely to proceed to intra-
pleural fibrinolytic therapy (63.8% vs 38.8%) or surgical
intervention (24.3% vs 7.5%) in an unblinded study.
Regarding the ability of imaging studies to predict
the success or failure of fibrinolytic therapy, Gervais
and colleagues52 reported that CT scan features of
number of loculations, degree of pleural thickening
(range 1-15 mm), or pleural heterogeneity did not
predict ultimate outcome for patients treated with intra-
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pleural recombinant tissue plasminogen activator.
Similarly, Levinson and Pennington53 noted no dif-
ferences in outcomes between patients with single
or multiple loculations treated with intrapleural uroki-
nase or recombinant tissue plasminogen activator.
For selecting patients for initial video-assisted tho-
racoscopic surgery (VATS) vs proceeding directly to
thoracotomy, CT scan and ultrasonography provide
only general guidance. Among patients with empyema
taken to VATS, 30% were under-staged by preopera-
tive CT scanning and subsequently required drainage
by thoracotomy.54 Similarly, Roberts55 demonstrated
that CT scan did not identify patients who failed VATS
and required conversion to thoracotomy. Evidence on
CT scan of mediastinitis, severe tissue trauma, bron-
chopleural fistula, esophageal perforation, or other
serious intrathoracic lesions may indicate a need for
thoracotomy.54 Because multiloculated empyema can
be treated by medical thoracoscopy as well as VATS,56
preoperative CT scanning assists patient selection for
VATS only by detecting loculations beyond the reach
of the medical thoracoscope or demonstrating definite
evidence of fibrothorax. Most surgeons, however, rec-
ommend a preoperative CT scan before taking patients
to VATS or thoracotomy.57
Although chest CT scan and ultrasonography may
provide some guidance for selecting a therapeutic
approach, their accuracies should not be overestimated.
Prognostication from the results of imaging studies is
difficult because multiple clinical factors, such as
duration of illness, severity of illness, comorbid con-
ditions, and operability, often determine the response
to therapy and clinical course.2,58 Up to 70% of patients
admitted with pneumonia and parapneumonic effu-
sions have serious associated conditions.58-60 The clin-
ical approach is as much driven by these factors as by
the imaging appearance of the pleural space.
Imaging for Guiding Chest Tube Placement and
Fibrinolytic Therapy
The success of chest tube drainage with or without
fibrinolytic therapy depends on accurately placing
the catheter into dependent regions of free-flowing
or loculated effusions. Imaging by fluoroscopy, ultra-
sonography, or CT scan has been used for placement of
small-bore catheters with good clinical results.47,50,52,61-65
Many centers use real-time ultrasonography imaging
as their primary modality for placing catheters,49,66
although some interventional radiologists insert cath-
eters without real-time imaging if the standard radio-
graph shows a large free-flowing effusion or if a recent
CT scan or ultrasonograph is available.52 Advantages
of real-time imaging include the ability to determine
the need for multiple pigtail catheters during the
procedure.47
Postgraduate Education Corner
 Chest CT scan for catheter guidance is preferred when
effusions are loculated and no safe access route can be
identified by ultrasonography47 and when coexisting
parenchymal lesions require imaging during catheter
insertion.25-27,67 It is not the primary imaging modality
for guiding catheter insertion, however, because of
its cost, radiation exposure, and the need to transport
patients.
Chest CT scan and ultrasonography have usefulness
for directing drainage by thoracoscopy and thoraco-
tomy. For medical thoracoscopy, it is advisable to select
a site by ultrasonography for insertion of the trocar
where loculated pleural fluid collections are the larg-
est and a position distant from the diaphragm, which
may be elevated.48 Most surgeons who perform drainage
by VATS or thoracotomy perform a preoperative CT
scan to determine the extent of pleural fluid collection
to guide initial inspection of the pleural space.
Imaging for Monitoring Adequacy of Drainage
No outcome studies exist to guide the selection of
post-drainage image studies to ensure adequacy of
drainage and to time periodic imaging assessments
efficiently. Depending on the location and nature of
the initial pleural effusion at the time of drainage,
periodic standard radiographs, ultrasonography studies,
or repeat CT scans may be indicated. Standard radio-
graphs are most useful for patients with free-flowing
effusions that appear to drain well after catheter
insertion with evidence on a postprocedure radiograph
that complete drainage has occurred. For patients
with more complicated pleural effusions with locula-
tions, follow-up real-time ultrasonography provides
opportunities to reposition the chest catheter, insert
additional catheters if residual fluid appears unlikely
to drain, and perform thoracentesis for loculations dis-
tant from the chest catheter.47 Chest CT scan may be
necessary for patients with loculated effusions in
interlobar fissures or adjacent to the mediastinum.53
Judgment is necessary for determining when
to initiate additional drainage interventions when
follow-up imaging identifies residual pleural fluid after
catheter insertion. Levinson and coworkers53 recom-
mend observing residual fluid collections less than 3 to
4 cm in diameter or containing less than 50 to 75 mL.
Additional drainage procedures were recommended
for larger fluid collections. Clinical signs of ongoing
infection or sepsis, however, should also determine
the need for additional efforts to drain residual fluid.
Special Circumstances
Empyema Necessitans: If left untreated, chronic
empyemas may progress to empyema necessitans,
which develop when intrapleural suppuration dis-
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© 2010 American College of Chest Physicians
sects into the chest wall.47,68,69 Common pathogens
include TB, Actinomycosis, and Nocardia, although
this complication can also occur with mixed anaerobic
species.68 Patients classically present with a pain-
ful chest wall mass typically between the second and
sixth intercostal spaces.69 Empyema necessitans can
also present as fistula tracts into the bronchi, esopha-
gus, breast, diaphragm, retroperitoneum, and groin.69
Chest CT scan provides the most sensitive technique
for detecting empyema necessitans and character-
izing the extent of chest wall and adjacent structure
invasion.69,70
Coexisting Malignancies or Extrapulmonary
Infections: Empyemas may occur in association with
lung cancer, endobronchial metastases, and primary
pleural malignancies. Endobronchial lung cancer and
cancers metastatic to bronchi may cause postobstruc-
tive pneumonia with secondary empyema. In such set-
tings, loculated empyemas may obscure radiographic
evidence of the underlying malignancy. Patients with
chronic empyemas, most notably tuberculous empy-
emas, can develop pyothorax-associated lymphoma
(PAL), which is a body cavity primary lymphoma.71,72
Most of these tumors are non-Hodgkin lymphomas,
which have been reported in 2.2% of patients with
chronic empyemas in Japan.73
The standard chest radiograph has poor sensitivity
for detecting malignancies because mediastinal
lymphadenopathy, pleural thickening, cavitary lung
lesions, and airway obstruction may result from the
underlying lung and pleural infection. Chest ultra-
sonography may identify evidence of focal pleural
masses and guide needle biopsy.11,12 Ultrasonography
has advantages over chest CT scan in imaging the
pleura overlying the diaphragms with the ability to
guide successful biopsy of pleural nodules as small as
0.5 cm.12
Chest CT scan provides the most global information
for detecting coexisting malignancies. CT scans
may detect obstructing airway tumors and evidence of
lung and pleural masses. Chest CT scan is also helpful
in patients at risk for PAL. Evidence of increased opac-
ity in the pleural space compared with the rest of the
empyema cavity, soft tissue bulging, reduced sharp-
ness of the fat planes in the chest wall, destruction of
bone near the empyema, extensive medial deviation
of calcified pleurae, and new onset of an air-fluid level
in an empyema cavity have high sensitivity but low
specificity for PAL.74,75 A single case report suggests
that FDG-PET scan allows early detection of local
recurrence of PAL in patients who responded to
chemotherapy.76
Small studies suggest that FDG-PET scan can
assist the discrimination of pleural infection from
malignancy. In one study of 98 patients, only two of
CHEST / 137 / 2 / FEBRUARY, 2010 477
12 patients with parapneumonic effusions had moder-
ate or intense FDG uptake as compared with 52 of
the 54 patients with cancer.31 Larger studies are
needed, however, to establish the value of PET scan
in this setting.
Chest CT scan or MRI may also demonstrate evi-
dence of coexisting osteomyelitis of the vertebral col-
umn or rib with demonstration of bone destruction,
periosteal reaction, or disc space destruction. An
intraabdominal origin of pleural infection is demon-
strated by CT scan detection of subphrenic fluid
collections.
Summary and Conclusions
Modern imaging modalities have advanced the diag-
nosis and management of pleural infections. Standard
radiographs remain the initial screening examination
for most patients at risk, but ultrasonography and CT
scan have emerged as important techniques, each
with its unique value and application. The uniqueness
of each patient who presents with pleural infection
requires a clear understanding of the relative value of
existing modalities in different settings. Unfortunately,
the evidence base for the operating characteristics of
imaging in pleural infections remains insufficient for
developing high-grade clinical recommendations.
Acknowledgments
FinancialⲐnonfinancial disclosures: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companiesⲐorganizations whose products or services may be dis-
cussed in this article.
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