Chest Radiography Treatment

After the initial stabilization of the patient, clinical suspicion for pleural effusion should be confirmed with appropriate radiographic evaluation. The most frequently ordered studies are chest radiography, ultrasonography, and computed tomography (CT) scanning. Chest radiography is the primary diagnostic tool because of its availability, accuracy, and low cost. It may confirm the presence of effusion and suggest the underlying etiology.

Pleural fluid typically collects in the most dependent portion of the pleural space on an upright chest radiograph, primarily the posterior costophrenic recess, followed by the lateral recess. As little as 50 mL of fluid will cause blunting of the posterior costophrenic recess on a lateral upright film, whereas 200 mL are required to cause blunting of the lateral recess on a posteroanterior (PA) film.

Posteroanterior upright chest radiograph shows isolated left sided pleural effusion and loss of left lateral costophrenic

A lateral decubitus chest radiograph may detect as little as 5 mL of fluid.Additional findings suggestive of pleural effusion include homogenous opacification or diffuse haziness with a ground-glass appearance, visibility of pulmonary vessels through the haziness, and an absence of air bronchograms.

A massive effusion is often attributable to an underlying malignancy. Other conditions that must be considered include the following:

• Congestive heart failure
• Tuberculosis (TB)
• Cirrhosis with ascites
• Transdiaphragmatic rupture of a liver abscess into the pleural space (>90% right-sided)
• Paragonimiasis (usually unilateral)
• Peritoneal dialysis (90% right sided)
• Cryptococcosis
• Pancreatic pseudocyst
• Chronic pancreatitis
• Meigs syndrome
• Uremic pleuritis
• Yellow nail syndrome
• Effects of medications