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Pleural Diseases

  1. Pleural effusion
    1. A small amount of free fluid may be undetectable on an erect PA chest film, as it tends initially to collect under the lower lobes of lung. Such small subpulmonary effusions can be demonstrated on lateral decubitus chest radiograph, which has largely been replaced now by newer techniques like USG or CT.
    2. Chest Radiograph Frontal projection reveal: Homogenous opacity in right lower zone with concavity upwards and apparently higher appearing laterally than medially – classical Pleural meniscus – in early pleural effusion.

  1. Bilateral Lateral decubitus views show spread out pleural fluid along the dependant chest wall.

  1. Lateral decubitus view with affected side dependent provides a sensitive means of detecting small quantities of pleural fluid (50–100 mL).
  2. The posterior and then  the lateral costophrenic angles become blunted as the amount of effusion increases, by which time a 200—500 mL effusion is present.
  3. Following this classical signs develop.

QLateral decubitus views may demonstrate small amount of pleural fluid (as small as 25 mL).

  1. Loculated pleural effusion
    1. Fluid can loculate between visceral pleural layers in fissures or between visceral and parietal layers, usually against the chest wall. Fissural interlobar loculation is seen particularly in heart failure and may produce the so-called phantom tumor/vanishing tumor.Q
    2. On lateral view it is sharply marginated and biconvex and has a tail passing along fissure. A common problem is to differentiate encysted fluid in lower right oblique fissure from middle lobe collapse.
    3. Factors, which favour a collapsed and consolidated middle lobe rather than an effusion, include nonhomogeneity, a straight or concave border in lateral view, wedge-like outline with base reaching the sternum and absence of minor fissure.
    4. Chest Radiograph Frontal and Lateral projections reveal: Well defined homogenous radio-opacities in Right midzone, fusiform in shape with long axis lying along the horizontal fissure – Loculated pleural effusion along horizontal fissure.

  1. Pneumothorax
    1. Spontaneous pneumothorax is most common, and occurs most commonly due to rupture of subpleural blebs. Q
  1. Sharp white visceral pleural line
  2. Radiolucent pleural space devoid of lung markings
  3. Underlying collapse of lung
  4. A large pneumothorax may sometime lead to complete relaxation and retraction of the lung, with some mediastinal shift towards the normal side, which increases on inspiration.
  5. Chest Xray Frontal radiograph reveals: Hyperluscent avascular area in left hemithorax with a visceral pleural line visible paralleling the left thoracic wall suggestive of Pneumothorax. No significant Diaphragmatic depression/mediastinal shift is noted.

  1. Tension pneumothorax:
    1. Massive displacement of mediastinum
    2. Kinking of the great vessels
    3. Ipsilateral lung squashed against the mediastinum, or herniated across the midline
    4. Depressed or inverted ipsilateral dome of diaphragmQ
    5. Chest Xray Frontal View reveals: Massive left pneumothorax with avascular zone, visceral pleural line, ipsilateral diaphragmatic flattening, mediastinal shift suggestive of Tension Pneumothorax.

  1. Mediastinal Shift
    1. Towards the abnormal side
      1. Lobar collapse (mucus plug, foreign body)
      2. Pulmonary agenesis or hypoplasia (primary or secondary)
      3. Scimitar syndrome (hypogenetic lung)
      4. Bronchopulmonary sequestration (basal)
      5. Swyer James (MacLeod) syndrome
    2. Away from the abnormal side
      1. Pneumothorax
      2. Pleural effusion (without collapse)
      3. Air trapping: foreign body, congenital lobar emyphsema (apical), bronchial atresia
      4. Cystic congenital adenomatoid malformation
      5. Diaphragmatic hernia​

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