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