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| Version | User | Scope of changes |
|---|---|---|
| Jul 4 2008, 9:42 PM EDT | M.J.Fuller | 2 photos added, 2 photos deleted |
| Jul 4 2008, 9:34 PM EDT | M.J.Fuller | 9 words added, 2 words deleted |
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Key: Additions Deletions
Introduction
Case 1
Case 2
Discussion
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A pleural effusion is an abnormal condition in which fluid has accumulated in the pleural space. The plain film signs of pleural effusion are commonly seen and readily identified on plain film chest images.
Pleural fluid can accumulate in isolation between the lung base and diaphragm. This is known as a subpulmonic effusion and presents a more difficult diagnostic challenge. When a chest X-ray is reported by a radiologist as "normal" there is potential for embarrassment when that slightly elevated-looking diaphragm turns out to be a large subpulmonic effusion. The radiographer can help prevent such embarrassment with the selective application of the decubitus chest projection on patients with suspected subpulmonic effusion.
Case 1
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This is a PA chest image. The radiographer has positioned the patient with the shoulders rolled well forward affording a good view of the lungfields. The linear opacity above the right hemidiaphragm is subsegmental atelectasis (lower white arrow). The horizontal fissure is not horizontal, suggesting some lower lobe collapse which is likely to be associated with the atelectasis identified. There are multiple pleural plaques associated with previous asbestos exposure (black arrow). The grey arrows identify the normal space between the fundus of the stomach and the diaphragm. |
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This is a PA chest image on the same patient taken after cardiac surgery. Note the increased distance between the fundus of the stomach (black arrow) and the diaphragm (white arrow). The appearance is complicated somewhat by the apparent air fluid level, suggesting that there is air as well as fluid in the pleural space. Where it is clinically indicated, the presence of a subpulmonic effusion can be proven with the aid of a left lateral decubitus view. |
Case 2
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This is a PA chest image. The patient is post cardiac surgery. Note the increased distance between the air-filled fundus of the stomach and the left hemidiaphragm (arrowed). The radiographer noted this finding and suspected a subpulmonic effusion. He/she performed a left lateral decubitus view to see if the pleural fluid would track along the left chest wall within the pleural space. |
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The left lateral decubitus chest image demonstrates fluid in the pleural space (arrow). Note that this is termed a left lateral decubitus view even though it is marked "R decubitus". |
Discussion
I do not think that it is unreasonable for senior/experienced radiographers to be on the look-out for subpulmonic effusions. (and subpulmonic pneumothorax ) Importantly, not every patient who has a subpulmonic effusion warrants a lateral decubitus view. It would not be unexpected for a patient to have a subpulmonic effusion post thoracic surgery. Subjecting a patient to the rigors of adopting the decubitus position unnecessarily is undesirable for a variety of reasons. Where a subpulmonic effusion is suspected and likely to be a significant finding, a lateral decubitus chest view may assist the radiologist, referring doctor and ultimately the patient.
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