SONOGRAPHIC EVALUATION OF PLEURAL

EFFUSIONDR V N PUTTANNA GOWDA

CHIEF RADIOLOGISTRADNEST RADIOLOGY SERVICES

BANGALORE

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.

WHY ULTRASOUND? Immediate bed side availability/

portable Safe – no radiation Easy to perform Repeatability Guides procedures

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.

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

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-

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

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.

Physiology of the pleural space

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

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. 

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.

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 DiseasesesBy Wei-Chih Liao, Chih-Yen Tu, Chuen-Ming Shih, Chia-Hung Chen, Hung-Jen Chen and Hsu Wu-Huei DOI: 10.5772/55419

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 diseaseCollagen vascular diseasePost cardiac injuryPost CABGAsbestos

Exudative Pleural Effusions

CAUSES OF PLEURAL EFFUSIONInflammatory 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

Transudates

< 0.5

< 0.6

< 2/3 the upperlimit for serum

Pleural Fluid

Pleural/serumProtein

Pleural/serumLDH

Pleural LDH

Exudates

> 0.5

0.6

>2/3 the upper limit for serum

Differentiation of transudates and exudates

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

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

Tumor 54% - Lymphoma

Trauma 25% - Surgical - Other

Idiopathic 15%

Miscellaneous 6%

CAUSES OF CHYLOUS EFFUSION

Milky pleural fluid due to elevated cholesterol of lecithin-globulin complexes

Most commonly associated with - tuberculosis, - rheumatoid arthritis, - therapeutic pneumothorax

CHYLIFORM EFFUSIONS

Sonographic appearance of pleural effusion

Bil PLEURAL EFFUSION clear

loculated PLEURAL EFFUSION

Para pneumonic PLEURAL EFFUSION

Sept PLEURAL EFFUSION LL coll

Right septated PE with dense lower lobar consol

Empyema neccesitans

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.)

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

Ultrasound Diagnosis of Chest DiseasesesWei-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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