|IMAGES IN ACADEMIC MEDICINE: REPUBLICATION
|Year : 2017 | Volume
| Issue : 3 | Page : 193-195
Diagnosis of pleural effusion with ultrasound
Laura A Wallace1, Eric J Adkins1, David P Bahner2
1 Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
2 OPUS 12 Foundation, Columbus Chapter, OH, USA
|Date of Web Publication||21-Apr-2017|
David P Bahner
Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH 43210
Source of Support: None, Conflict of Interest: None
We describe a case of a middle-aged male with end-stage renal disease who presented with dyspnea after a recent mycoplasma infection.
The following core competencies are addressed in this article: Medical knowledge, Patient care.
Republished with permission from: Wallace LA, Adkins EJ, Bahner DP. Bedside sonography primer: diagnosis of pleural effusion with ultrasound. OPUS 12 Scientist 2012;6(1):12-13.
Keywords: Bedside sonography, diagnostic imaging, emergency department, pleural effusion
|How to cite this article:|
Wallace LA, Adkins EJ, Bahner DP. Diagnosis of pleural effusion with ultrasound. Int J Acad Med 2017;3, Suppl S1:193-5
| Introduction and Case Report|| |
A 56-year-old male kidney transplant patient presented to the emergency department (ED) after recent hospital discharge for “walking pneumonia.” He complained of ongoing shortness of breath with productive cough worse than on discharge. On presentation, his oxygen saturation was 93% on room air. His physical examination was remarkable for absent breath sounds, dullness to percussion, and egophony in the lower left lung fields. Laboratories were notable for a white blood cell count of 5.1 with a left shift.
A chest X-ray [Figure 1] was read as “left pleural effusion with adjacent consolidation (which) may just represent atelectasis, though overlying infection cannot be excluded.”
Thoracic ultrasound was performed at the bedside, which demonstrated the fluid present in the left lung space, with atelectasis of the left lung.
TTo rule out pleural effusion by ultrasound, an anechoic area of fluid must be visible between the parietal and visceral pleura. In addition, an area of atelectatic lung tissue may be visible in large effusions. There will be a lack of pleural sliding with inspiration as no aerated lung tissue crosses the near field of the ultrasound picture over the diaphragm and liver. In addition, vertebral bodies will be visible in the posterior chest as the pleural fluid provides an acoustic window for visualization [Figure 2] and [Figure 3].
|Figure 2: Left upper quadrant view including the pleural cavity, diaphragm, and spleen. A large anechoic pleural effusion is visible in the center of the image, with the costodiaphragmatic recess is being visible in the near field and atelectatic lung tissue visible along the leading edge|
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|Figure 3: Left upper quadrant image demonstrating splenic anatomy, vertebral bodies visible posterior to the lung fields, and effusion|
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For patients with suspected pulmonary pathology, ultrasound may be a faster and more cost-effective method of evaluating lung fields. X-ray evaluation of lungs is limited, and computed tomography (CT) is expensive and time-consuming. Literature supporting thoracic ultrasound for both diagnostic and therapeutic purposes is becoming more persuasive. Although CT is still considered the criterion standard for pleural effusion, ultrasound has been shown to be comparable to CT scanning and superior to chest X-ray. In one prospective observational study, ED thoracic ultrasound was reported to have changed patient management in 41% of pleural effusion cases. In 2008, “thoracic ultrasound for the detection of pleural effusion and pneumothorax” was added to the American College of Emergency Physicians core emergency ultrasound application guidelines.
In addition, thoracentesis is an important procedure in emergency medicine for both diagnostic and therapeutic purposes. One prospective study  concluded that “the complication rate with thoracentesis performed by interventional radiologists under ultrasound guidance is lower than that reported for nonimage-guided thoracentesis.”
In this case, ultrasound was additionally used to guide a diagnostic thoracentesis performed in the ED before inpatient admission. The patient was started on broad-spectrum antibiotics while pleural fluid cultures were pending and admitted to the hospital for close clinical monitoring. Fluid studies and cultures demonstrated a transudative effusion and no culture growth, so the antibiotics were discontinued. As the effusion recurred after therapeutic thoracentesis, the patient underwent surgical drainage and pleurodesis before hospital discharge.
Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Maslove DM, Chen BT, Wang H, Kuschner WG. The diagnosis and management of pleural effusions in the ICU. J Intensive Care Med 2013;28:24-36.
Tayal VS, Nicks BA, Norton HJ. Emergency ultrasound evaluation of symptomatic nontraumatic pleural effusions. Am J Emerg Med 2006;24:782-6.
American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med 2009;53:550-70.
Jones PW, Moyers JP, Rogers JT, Rodriguez RM, Lee YC, Light RW. Ultrasound-guided thoracentesis: Is it a safer method? Chest 2003;123:418-23.
[Figure 1], [Figure 2], [Figure 3]