Ultrasound in the diagnosis and management of pleural effusions

Abstract

We review the literature on the use of point-of-care ultrasound to evaluate and manage pleural effusions. Point-of-care ultrasound is more sensitive than physical exam and chest radiography to detect pleural effusions, and avoids many negative aspects of computerized tomography. Additionally, point-of-care ultrasound can assess pleural fluid volume and character, revealing possible underlying pathologies and guiding management. Thoracentesis performed with ultrasound guidance has lower risk of pneumothorax and bleeding complications. Future research should focus on the clinical effectiveness of point-of-care ultrasound in the routine management of pleural effusions and how new technologies may expand its clinical utility.

Conflict of interest statement

Conflicts of Interest: None

© 2015 Society of Hospital Medicine.

Figures

Figure 1

Transducer position. In supine or semi-recumbent patients, the transducer is placed longitudinally on the posterior axillary line at the level of the diaphragm. The transducer should be wedged in between the patient and the bed to visualize the most dependent pleural space.

Figure 2

A) Small pleural effusion (right chest). A small pleural effusion is shown with adjacent structures that should be definitively identified, including the liver, diaphragm, lung, and chest wall. B) Large pleural effusion (left chest). Large pleural effusions cause compressive atelectasis of adjacent lung, giving the lung a tissue-like echogenicity. Note the heart is often visualized in the far field with large left-sided pleural effusions.

Figure 3

A) Free-flowing pleural effusion. Color flow Doppler demonstrates movement of pleural fluid in the costophrenic recess with respiration. B) Pleural mass. Absence of flow by color Doppler is demonstrated with a hypoechoic pleural mass that could be mistaken for a pleural effusion.

Figure 4

A) Loculated pleural effusion. A complex pleural effusion with loculations between the lung, diaphragm, and a diaphragmatic metastasis is demonstrated. B) Empyema. The echogenic, speckled appearance of a large empyema with underlying consolidated lung is shown in a transverse view.

Figure 5

Measurement of pleural fluid depth. The distance between the skin and parietal and visceral pleura can be measured prior to thoracentesis to determine the minimum and maximum depths to safely insert a needle.