Radiographic features of simple pneumothorax
Plain radiograph
A pneumothorax is, when looked for, usually easily appreciated on erect chest radiographs.
Typically they demonstrate:
● visible visceral pleural edge is seen as a very thin, sharp white line
● no lung markings are seen peripheral to this line
● peripheral space is radiolucent compared to the adjacent lung
● lung may completely collapse
● mediastinum should not shift away from the pneumothorax unless a tension
pneumothorax is present (discussed separately)
● subcutaneous emphysema and pneumomediastinum may also be present
Radiographic features of Tension pneumothorax
The diagnosis is a clinical one. Radiographic features do not measure actual intrapleural pressure or
cardiorespiratory compromise. Radiographic features of increasing intrapleural pressure are:
● ipsilateral hypertransradiancy with absence of lung marking
● ipsilateral collapsed lung (Airin the pleural space breaks the water seal that sticks thetwo
layers of pleura together allowing thelung to collapsethroughits inherent elasticity.)
● ipsilateral depressed diaphragm
● contralateral mediastinal shift
In the rare instance of bilateral tension pneumothoraces, there may be no cardiomediastinal shift
Effusion
"Pleural effusion" is commonly used as a catch-all term to describe any abnormal accumulation of fluid in the pleural cavity. The
lack of specificity is mainly due to the limitations of the imaging modality. Given that most effusions are detected by x-ray, which
generally cannot distinguish between fluid types,
If simple fluid, then the term hydrothorax may be employed, although this is rarely used (other than in combination terms e.g.
hydropneumothorax).
Plain radiograph
Chest radiographs are the most commonly used examination to assess for the presence of pleural
effusion; however, it should be noted that on a routine erect chest x-ray as much as 250-600 mL of fluid is
required before it becomes evident 6. A lateral decubitus projection is most sensitive, able to identify even
a small amount of fluid. At the other extreme, supine projections can mask large quantities of fluid.
Chest radiograph (lateral decubitus)
A lateral decubitus film (obtained with the patient lying on their side, effusion side down, with a cross table
shoot through technique) can visualise small amounts of fluid layering against the dependent parietal
pleura.
Chest radiograph (erect)
Both PA and AP erect films are insensitive to small amounts of fluid. Features include:
● blunting of the costophrenic angle
● blunting of the cardiophrenic angle
● fluid within the horizontal or oblique fissures
● eventually, a meniscus will be seen, on frontal films seen laterally and gently sloping medially
(note: if a hydropneumothorax is present, no such meniscus will be visible)
● with large volume effusions, mediastinal shift occurs away from the effusion (note: if coexistent
collapse dominates then mediastinal shift may occur towards the effusion)
Chest radiograph (semi erect)
When the patient is semi-erect, the fluid will collect preferentially in the posterior costophrenic
recess and posterior pleural space.
• The result is a vague increase in opacity in the lower zones with preservation of the
diaphragmatic silhouette, no meniscus and even a normal costophrenic angle. Lobar collapse
does not have the same dependence on patient position (Fig 10.9)."
Chest radiograph (supine)
Large amounts of fluid can be present on supine films with minimal imaging changes, as the fluid is
dependent and collects posteriorly. There is no meniscus, and only There is an overall increase in
shadowing of the hemithorax, which can be easily overlooked.. It is therefore especially difficult to identify
similar sized bilateral effusions as the density of the lungs will be similar.
"If the effusion is large enough, there is apparent thickening of the pleura at the edges due to the
displacement of lung from the chest wall by the fluid (Fig 10.8)."
Subpulmonic pleural effusion
• Typically subpulmonic effusions are simple in nature and therefore the fluid is free flowing and becomes
apparent when the patient is X-rayed in the supine position.
Complex pleural effusion
• When the contour of the effusion is not meniscal as described above but straight or convex, this implies
that the effusion is complex in nature containing viscous fluid and/or septations.
• Complex effusions do not necessarily occupy the dependent spaces and may therefore occur in
isolation anywhere in the pleural space.
• A complex pleural collection raises the possibility of an empyema or haematoma, but chronic simple
effusions can become complex without a supervening infection, and a simple pleural effusion in a
complex pleural space may mimic these appearances, i.e. after previous surgical intervention or infection
(Fig 10.11).
Empyema
● An empyema is an infection in the pleural space. The fluid may vary from turbid to thick
pus and can be very difficult to drain
● The presence of pleural opacity that fails to conform to the meniscal appearance
characteristic of a simple pleural effusion should alert the reader to the possibility of an
empyema or pleural tumour.
● • Extension of an empyema outside the chest wall may mimic an invasive soft tissue
mass."
● Generally, empyemas form an obtuse angle with the chest wall,
MESOTHELIOMA
