RADIOLOGY OF CHEST

PLEURAL EFFUSION

PLEURAL EFFUSION
• This is the presence of fluid in pleural cavity.

TYPES OF PLEURAL FLUID:
• • • • • Transudate. Exudate. Sanguinous. (Blood) Empyema. Chylous.

CAUSES OF PLEURAL EFFUSION:
• TRANSUDATE:
– Heart failure – Renal failure – Hepatic failure – Hypoproteinemia – Meigs syndrome

CAUSES OF PLEURAL EFFUSION:
• EXUDATE:
– Inflammatory
• • • • Bacterial pneumonia Viral Tuberculosis Pancreatitis

– Neoplastic – Pulmonary infraction – Subpherenic / liver abscess

CAUSES OF PLEURAL EFFUSION:
• SANGUINOUS (Haemothorax)
– – – – – Traumatic Infection Neoplastic Bleeding disorders Infarction

CAUSES OF PLEURAL EFFUSION:
• EMPYEMA (Pyothorax).
– Pneumonia – Liver/subpherenic/lung abscess – Tuberculosis

CHYLOUS (Chylothorax) Traumatic rupture/Obstruction of thoracic duct

RADIOLOGIC SIGNS OF PLEURAL EFFUSION
FREE FLUID • Homogenous basal opacity in erect film starting in costopherenic angle with miniscus, curved upper margin extending along lateral chest wall, may extend into a fissure. • Change in appearance as posture changes • Transudate, exudate, Haemorrhagic or chylous effusion requires aspiration for distinction.

RADIOLOGIC SIGNS OF PLEURAL EFFUSION
• Exudates, haemorrhagic effusion or empyema can lead to pleural thickening, altering diaphragmatic contour. • Can later calcify esp. in tuberculosis • Lateral decubitus view is needed for distinction between small effusion and pleural thickening. But ultrasound is more sensitive.

RADIOLOGIC SIGNS OF PLEURAL EFFUSION
• More than 200 cc of fluid is needed to obscure lateral costophernic angle. • Massive effusion cause homogeneously opaque hemithorax with shifting of mediastinum towards opposite side. Diaphragm can be depressed or even inverted. • HYDROPNEUMOTHORAX provides air fluid level.

LOCAULATED PLEURAL EFFUSION
• IN-FISSURES: – – – – In oblique or horizontal fissure Ovoid in shape Usually in heart failure Disappears as fluid state is corrected (vanishing tumour).

• •

SUBPULMONARY. LOCULATED EFFUSION ALONG CHEST WALL.

Pleural Effusion

Upright…Meniscus Supine…Unilateral increased density Decubitus…Effusion layered on downside

Pleural Effusion Supine patient

Pleural Effusion

Semiupright…..Lung base opacity fades superiorly

Pleural Effusion

63-year-old man recovering from congestive heart failure…Effusion loculated in fissure

Massive Pleural Effusion or Total Lung Atelectasis
Massive pleural effusion Heart and mediastinum shifted away from whited out hemithorax

Massive Pleural Effusion or Total Lung Atelectasis

Total Atelectasis Heart and mediastinum shifted toward whited out hemithorax

PNEUMOTHORAX

PNEUMOTHORAX
• It is the air in the pleural space with relaxation of lung tissue. RADIOLOGICALLY • There is white line of lung margin and no pulmonary marking beyond. • More obvious on expiratory film esp. when it is small.

TYPES OF PNEUMOTHORAX
• • • • • Simple/Spontaneous pneumothorax. Open pneumothorax. Tension pneumothorax. Bronchopleural fistula. Hydropneumothorax.

CAUSES OF PNEUMOTHORAX
IDIOPATHIC
• Most common type, usually in tall thin males • Rupture of small bleb/bulla

TRAUMATIC
• • • • • • Rib fracture esp 1st or 2nd --- associated with haemothorax, surgical emphysema. Surgical --- CVP line complication. Accidental --- stab Ventilator pressure Pleural aspiration Perforated oesophagus

CAUSES OF PNEUMOTHORAX
• • MEDIASTINAL/SUBCUTANEUS EMPHYSEMA Status-asthmaticus Oesophageal tear. RUPTURED BULLAE In COPD CONNECTIVE TISSUE DISORDER Rheumatoid arthritis NECROTIC TUMOUR Ca. Bronchus Metastasis esp. Osteosarcoma HYALINE MEMBRANE DISEASE

• •

Trace the lung vascular markings out to the border of the rib cage. When the lung markings stop short of the rib cage and there is increased radiolucency in the pleural space, the patient has a pneumothorax.

Tension Pneumothorax

PNEUMOTHORAX ** Examine patient * Look for deviated heart and mediastinum, depressed

Supine Patient Medial Pneumothorax

Is there a pneumothorax or isn’t there?

Order a Lateral Decubitus chest radiograph With the side of the chest in question as the upside Possible left pneumothorax get right lateral decubitus chest Look for displaced visceral pleura along upside lateral chest wall Order Upright Expiratory chest radiograph Look for pneumothorax at lung apex

Pneumopericardium

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