Mayshia Prazitya Shakti

1410029050

Pembimbing :

Dr. Freddy Yoedyanto, Sp. Rad

DIAGNOSTIC IMAGING OF SMALL AMOUNTS OF PLEURAL FLUID : PLEURAL EFFUSION VS PHYSIOLOGIC PLEURAL FLUID

INTRODUCTION

• Pleural space is only potential space between the parietal and visceral pleura and it is covered by a thin fluid layer.

• The data on the smallest amount of pleural fluid detectable by imaging methods vary considerably >> lateral decubitus and usg

• There is no clear consensus definition of small pleural effusion on chest radiography and on sonography

• There are no fixed boundaries between the amount of pleural fluid detected by imaging methods in physiologic and pathologic conditions

CHEST RADIOGRAPHY

Upright position PF accumulate in infrapulmonary space forming the “infra or sub pulmonary effusion”The amount of 175 to 500 mL could be hidden in pleural space on erect PA views radiographs >> Small PE = meniscus sign

Lateral erect + injected saline 25 mL to PF could be detected as a subpulmonic accumulation (1)LESS RELIABLE >> HIGH RISK

Lateral erect Junction of the major fissure with the diaphragm straight triangular shadow at anterior diaphragmatic contourHard to interpret the sign without previous lateral chest x-rays and in the cases of superimposing fat in anterior mediastinum (2)

Lateral Decubitus + expiration Facilitates distinction between small PE and artefacts (skin folds, sheets and subcutaneous fat) and the amount of PF detectable with this technique was as little as 5 mL

New criteria : fluid density form 3 mm to 15 mm in thickness, with horizontal air-fluid level at lateral dependent chest wall

(1) Collins et al (2) Hessen et al; Peterson et al

CHEST ULTRASONOGRAPHY (US)

US of pleural spaces from behind, with the patient sitting positionUSG of pleural spaces from behind, with the patient sitting position + elbow position

Patient placed in lateral decubitus position for 5 minutes first, then US examination while he/she leaning on the elbow

IMAGING PHYSIOLOGIC PLEURAL FLUID

• In 1951 reported that four percents of physiologic pleural fluid was detected by lateral decubitus chest radiography in 300 healthy persons and in 22% of healthy women after childbirth (3)

• In this study (using the same techniques in more than 100 health individual >> didn’t find

• Four recent studies showed that physiologic pleural fluid is easy to detect by chest sonography in about to 25 to 30 oercent of healthy individual using elbow position. In healthy pregnant woman the percentage is raised up to 60%

(3) Hessen et al

CONCLUSION

• There is a “dry Pleural Space” and “Wet Pleural Space” in healthy individual

• The term PE >> pleural illness

• In spite of all those investigations clear border between physiologic PF and PE remains stil indeterminate.

Lateral Decubitus + expiration and US with elbow Position

THANK YOU!!