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Kitazono et al.
Chest Radiography of Pleural Effusions
Cardiopulmonary Imaging
Original Research
P
leural effusions are exceedingly the English language literature on the accu-
common, occurring in an esti- racy of supine radiography in the diagnosis
mated 1 million patients each of pleural effusion have had highly variable
year in the United States, many results, likely because of small sample siz-
of whom are critically ill in an ICU [1]. Bed- es, the use of only known positive [5] or sus-
side supine and semierect chest radiography pected [6] findings of effusion, and the meth-
is logistically easier to perform in the care of ods used to verify pleural fluid, which ranged
critically ill patients and often is the primary from posteroanterior and lateral upright radi-
Keywords: bedside, pleural effusion, semierect, supine imaging technique used in the ICU. Howev- ography, lateral decubitus chest radiography,
er, bedside imaging often is suboptimal, and and ultrasound imaging [5–7]. Furthermore,
DOI:10.2214/AJR.09.2950
numerous pitfalls of supine imaging of the without the use of cross-sectional imaging as
Received April 22, 2009; accepted after revision chest have been identified [2–4]. the reference standard, the nature of false-
August 8, 2009. Basilar opacities are among the most com- positive findings was not investigated.
1
mon imaging findings in ICU patients and are We undertook this study to determine,
All authors: Department of Radiology, Hospital of the
often a result of pleural effusion, parenchy- with CT as the reference standard, the accu-
University of Pennsylvania, 3400 Spruce St., Philadelphia,
PA 19104. Address correspondence to mal lung disease, or a combination of these racy of routine bedside radiography in the di-
M. T. Kitazono (Mary.Kitazono@uphs.upenn.edu). conditions. Despite the frequent detection of agnosis of pleural effusions in critically ill
basilar lung opacities in our everyday prac- patients. We hypothesized that bedside chest
AJR 2010; 194:407–412 tice, accuracy in detecting and differentiat- radiography in the ICU is moderately accu-
ing pleural fluid from parenchymal opacities rate in the detection of pleural effusions and
0361–803X/10/1942–407
on bedside supine and semierect chest ra- in differentiating them from other causes of
© American Roentgen Ray Society diographs is not known. Previous studies in basilar pulmonary opacity.
Materials and Methods TABLE 1: Definition of Terms Used to Characterize Opacities
After institutional review board approval and Opacity Characteristic Definition
in accordance with HIPAA regulations, the cas-
Apical capping Sharply marginated curvilinear opacity between aerated apical lung and the
es of 100 patients in the surgical ICU who con-
apical ribs (Fig. 1)
secutively underwent CT of the chest less than 24
Lateral band Sharply marginated linear opacity between aerated lateral border of lung and
hours after undergoing chest radiography were
medial border of the lateral aspects of the ribs (Fig. 1)
retrospectively selected for review. Informed con-
sent was not required. The exclusion criteria in- Meniscus Sharply marginated curvilinear opacity that obscures the lateral costophrenic
angle
cluded complete omission of the lung bases, in-
terval thoracentesis, and chest tube placement or Subpulmonic opacity Apparent elevation of the hemidiaphragm
a related procedure. Layering opacity Homogeneous opacity overlying the hemithorax with vascular markings
apparent through the opacity (Fig. 2); expected appearance of effusion on
Chest Radiography supine image
The chest radiographs were reviewed by four Gradient opacity Homogeneous opacity overlying hemithorax that becomes progressively more
readers: a thoracic imaging attending radiologist radiodense from cephalic to caudal aspect with vascular markings apparent
through the opacity (Fig. 3); expected appearance of effusion on a semierect
with more than 18 years of experience, a thoracic
image
imaging fellow, a fourth-year radiology resident,
Air bronchograms Air-filled tubular or branching structures visible within an opacity
and a second-year radiology resident. No special
training was given before interpretation. Uniformity of opacity Homogeneous, heterogeneous, or both homogeneous and heterogeneous
Each hemithorax was separately evaluated for components
the presence of basilar opacities. If an opacity was
present, the characteristics were recorded (Table
1, Figs. 1–3). The imaging features of pleural ef-
fusions on supine and semierect radiographs can
be divided into two main categories. The first is
extrapulmonary signs, which identify an opacity
as being between the lung and chest wall or dia-
phragm; these signs include meniscus, apical cap,
lateral band, and subpulmonic opacity. The sec-
ond category is homogeneous densities overlying
the hemithorax; these signs include layering and
gradient opacities.
The readers independently determined the
likelihood of the presence of pleural effusion and
parenchymal opacity on a 5-point scale (5, defi- A B
nitely present; 4, probably present; 3, possibly Fig. 1—55-year-old woman with pleural effusions appearing as gradient opacities with apical caps and right-
sided lateral band.
present; 2, probably not present; 1, definitely not A, Bedside anteroposterior semierect radiograph shows bilateral gradient opacities that become progressively
present). The finding of a meniscus, apical cap, or more radiopaque from lung apices to lung bases. Vascular markings are apparent through opacity. Prominent
lateral band was interpreted as certain evidence right-sided lateral band and bilateral apical caps are evident. Bilateral pleural effusions with associated
of the presence of an effusion (typical score, 5). passive atelectasis were predicted.
B, Unenhanced axial CT scan of chest at level of main pulmonary artery confirms diagnosis of bilateral pleural
The finding of a gradient opacity, layering opaci- effusions with effusion-related atelectasis.
ty, or subpulmonic opacity was interpreted as high
likelihood of the presence of an effusion (typical eral mediastinal shift indicated probable pleural ed. Pleural effusion was diagnosed if low-attenu-
score, 4). effusion, and an unshifted mediastinum indicat- ation (0–20 HU) material was visualized between
Air bronchograms were interpreted as certain ed both possible effusion and possible parenchy- the lung parenchyma and the chest wall. The effu-
evidence of parenchymal opacities (typical score, mal opacity. sion was considered loculated if it was clearly di-
5), and heterogeneity was interpreted as high likeli- All chest radiographs were obtained in the an- vided into more than one compartment. There were
hood of a parenchymal opacity (typical score, 4 or teroposterior projection with a mobile radiogra- no cases of high-attenuation pleural effusion or he-
5). If imaging findings were indicative of moderate phy unit (AMX-4+, GE Healthcare). According mothorax in our patient sample. The quantity of
or large pleural effusion, it was assumed that as- to the position indicators, no radiograph was ob- pleural fluid was semiquantitatively scored on CT
sociated passive atelectasis was present. Therefore, tained in the erect position, 28 were semierect, scans as small, moderate, or large. The quantity
the presence of a parenchymal opacity also was and eight were supine. The position of 64 radio- depended on the maximum anteroposterior depth
predicted (typical score, 4 or 5) even in the absence graphs was not indicated. of pleural fluid (measured at the maximum effusion
of any other signs of parenchymal opacification. depth, which varied by patient): less than 15% (≈ 75
When an opaque hemithorax was encountered, CT mL), 15–30%, or greater than 30% (≈ 350 mL) of
the location of the mediastinum was the principle All CT scans were reviewed by the same thorac- the diameter of the hemithorax [8].
differentiating criterion: an ipsilateral mediastinal ic imaging attending radiologist during a separate Although many patients had diffuse airspace
shift indicated a parenchymal opacity, a contralat- session after all radiographs had been interpret- disease, such as pulmonary edema, an opacity was
A B
Fig. 2—57-year-old man with pleural effusions appearing as layering opacities. Fig. 3—52-year-old man with pleural effusions
A, Supine chest radiograph shows homogeneously increased opacification of right hemithorax typical of appearing as gradient opacities. Semierect chest
layering opacity, typically scored 4 for probable pleural effusion. Right hemithorax also was typically scored 4 radiograph shows bilateral homogeneous opacities
for pulmonary opacity because readers were predicting presence of atelectasis independent of effusion. Most at lung bases interpreted as gradient opacities and
readers scored left lung base 4 for opacity and 2 for effusion. scored 5 for pleural effusions by all readers. Probable
B, CT scan confirms presence of moderate right pleural effusion and associated passive atelectasis in adjacent associated bibasilar passive atelectasis was inferred
right lower lobe. from moderate size of pleural effusions. Pleural
effusions and passive atelectasis were confirmed at
CT (not shown).
diagnosed only when a discrete region of alveolar ficity, and areas under the ROC curve in the de- at different positions on similar ROC curves
opacification was found, either alone or superim- tection of parenchymal opacities on bedside chest (Fig. 4). With the results for all readers aver-
posed on a diffuse alveolar process. For the pur- radiographs also were calculated for each reader. aged, the overall sensitivity in the diagnosis of
poses of this study, we made no distinction between We considered scores of 3 and higher positive pre- pleural effusion on bedside chest radiographs
opacification due to volume loss (atelectasis) and dictions of effusion or opacity. was 66%. The specificity was 89% with a fit-
opacification due to alveolar filling (e.g., pneumo- ted area under the ROC curve of 0.852 (Table
nia, contusion, infarction). Results 2). Exclusion of the 15 loculated effusions did
Various CT scanners were used, including a CT of the chest was performed on 117 not change the diagnostic accuracy.
single-detector scanner (CTi, GE Healthcare), consecutively registered ICU patients with- Because the four readers had similar diag-
4-MDCT scanners (LightSpeed QXI, GE Health- in the 2-month period October and Novem- nostic accuracy in diagnosing effusion, the
care; Volume Zoom, Siemens Healthcare), a 16- ber 2007. Thirteen of the patients were ex- composite results for all readers were used
MDCT scanner (Sensation 16, Siemens Health- cluded because they had not undergone chest to determine overall accuracy in the detec-
care), a 64-MDCT scanner (Sensation 64, Siemens radiography within 24 hours before CT. Two tion of effusion on the basis of the size of the
Healthcare), and a dual-source 64-MDCT scanner patients were excluded because overlying effusion and to analyze the accuracy of in-
(Somatom Definition, Siemens Healthcare). Sev- structures completely obscured the lung bas- dividual radiographic characteristics of effu-
eral imaging techniques were used. Sixty-one ex- es; one patient, because the lung bases were sion. Overall, 53% of the small pleural ef-
aminations were performed with IV contrast en- completely omitted; and one patient, because fusions, 71% of the moderate effusions, and
hancement: 47 with 100 mL of iohexol 300 mg I/ a chest tube was inserted between the imag- almost all (92%) of the large pleural effu-
mL (Omnipaque 300, GE Healthcare) and 14 with ing studies. The other 100 ICU patients (200 sions were correctly diagnosed. The speci-
100 mL of iohexol 350 mg I/mL (Omnipaque 350, hemithoraces; 60 men and boys, 40 women ficity was high, approximately 89%, for all
GE Healthcare) at injection rates of 1.5–4.0 mL/s. and girls; mean age, 54.3 years; range, 14–91 pleural effusions (Table 3).
Various collimations and pitches were used de- years) formed the final study group. Diffuse
pending on the type of scanner and imaging proto- airspace disease was present in 40 patients. False-Negative Findings of Effusion
col. Images were reviewed on a PACS workstation Chest CT depicted 117 cases of pleural ef- On average, 34% (161/468, the denomina-
(RadWorks, GE Healthcare) at a slice thickness of fusion: 16 large, 46 medium, and 55 small. tor being the total number of effusions mul-
1, 3, or 5 mm. Eight isolated right pleural effusions, 11 iso- tiplied by four readers) of the pleural effu-
lated left pleural effusions, and 49 bilateral sions were missed on chest radiographs. Most
Statistics pleural effusions were found. Fifteen cases (64%) of the missed effusions were small,
The sensitivity, specificity, and receiver operat- of effusion were loculated. 33% were moderate, and 3% were large. For-
ing characteristic (ROC) curves in the detection ty-five percent (73/161) of the missed effu-
of pleural effusion on bedside chest radiographs Sensitivity and Specificity sions were interpreted as parenchymal opaci-
were calculated with CT as the reference standard. All readers had similar accuracy in detect- ties rather than effusions, and the other 55%
Area under the ROC curves was calculated with a ing effusions without a significant difference (88/161) were interpreted as not basilar opaci-
Web-based calculator [9]. Separate analyses were according to level of experience. The read- ties. In 59% (95/161) of the cases of false-neg-
conducted for each reader and for small, moderate, ers with the highest sensitivity had the lowest ative findings of effusions interpreted as not
and large pleural effusions. The sensitivity, speci- specificity, and thus all readers’ results were basilar opacity, evidence of diffuse alveolar
0.4
Parenchymal Opacities
CT showed 146 pulmonary opacities, 65%
0.3 (381/584) of which were predicted by the read-
Attending
0.2 Fellow
ers on chest radiographs with a specificity of
0.1
4th-year Resident 89% (193/216) for all readers combined. Indi-
2nd-year Resident
vidual readers had sensitivities varying from
0.0
56% to 77% and specificities varying from
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
False-Positive Fraction
81% to 96% with no significant trend based on
level of experience. The area under the ROC
TABLE 2: Reader Accuracy in Diagnosis of Pleural Effusion curve varied from 0.815 (second-year resi-
dent) to 0.872 (fourth-year resident) (Table 5).
Reader Sensitivity (%) Specificity (%) Area Under ROC Curve
Most of the misdiagnosed pulmonary opaci-
Attending 59 (69/117) 95 (79/83) 0.844 ties (93%, 150/161) on chest radiographs were
Fellow 62 (72/117) 90 (75/83) 0.843 erroneously predicted to be normal lung bases
Fourth-year resident 76 (89/117) 86 (71/83) 0.878 with no effusion or discrete opacity.
Second-year resident 66 (77/117) 93 (77/83) 0.855
Discussion
Average 66 (309/468)a 89 (295/332)a 0.852 Bedside supine and semierect chest radiog-
Note—Values in parentheses are raw numbers. ROC = receiver operating characteristic. raphy of ICU patients has low and interme-
aTotal number of effusions multiplied by four readers.
diate sensitivity in the detection of small and
moderate effusions (53% and 71%, respective-
TABLE 3: Average Reader Accuracy for Detecting Pleural Effusions ly) but is highly sensitive and specific in the
of Different Sizes With Bedside Chest Radiography
detection of large effusions (92% and 89%).
Size of Effusion Sensitivity (%) Specificity (%) Accordingly, large effusions usually can be
Small 53 (117/220) 89 (295/332) excluded with high confidence, but small and
Moderate 71 (131/184) 89 (295/332) medium effusions often are not identified be-
cause they are misdiagnosed as parenchymal
Large 92 (59/64) 89 (295/332)
opacities (45%) or are not seen (55%).
Total (n = 117) 66 (309/468)a 89 (295/332)a The 66% overall sensitivity for all pleural
Note—Values in parentheses are raw numbers. effusions in our study is slightly lower than
aTotal number of effusions multiplied by four readers.
previously reported sensitivities ranging from
67% to 82% [6, 7]. However, the previous
lung disease was seen on chest radiographs, Characteristics of Pleural Effusion studies may have shown falsely elevated sen-
but the presence of an independent basilar Meniscus, apical cap, lateral band, sub- sitivities due to the methods of verifying ef-
opacity was not predicted. pulmonic opacity, layering opacity, and gra- fusion, including decubitus radiography and
dient opacity all were highly specific but not ultrasound, which are not as sensitive as CT
False-Positive Findings of Effusion sensitive signs of pleural effusion (Table 4). in the detection of small effusions. Exclud-
Eleven percent (36/327) of the suspected In total, 73% (342/468) of all patients with ing the small effusions in our study increases
effusions were false-positive findings, most pleural effusions had at least one of the high- the sensitivity to 78% (190/244) in the detec-
of which (64%, 209/327) were homogeneous ly specific signs on chest radiographs (apical tion of effusion, and this rate is comparable
opacities on chest radiographs that proved to cap, lateral band, meniscus, layering opac- with previously reported values.
be atelectasis on CT scans. Approximately ity, gradient opacity, or subpulmonic opac- Diagnostic accuracy for effusion did not
one of three (31%, 11/36) false-positive find- ity). Complete opacification of a hemitho- differ significantly between readers, whose
ings of effusion had a false meniscus sign, rax with ipsilateral mediastinal shift was levels of experience varied. Although there
which was usually caused by pleural thick- found in only three patients, and CT showed was only one reader in each category, our re-
ening or a large pericardial fat pad (Fig. 5). that all three of these patients had ipsilater- sults suggest that the ability to diagnose pleu-
The attending radiologist made one false- al effusions and atelectasis. Homogeneous ral effusions on bedside radiographs is a basic
positive finding of meniscus, and each of the opacity was the single most sensitive find- skill that can be learned quickly during resi-
other readers made three or four false-posi- ing of pleural effusion on bedside chest ra- dency. The results also suggest that because
tive findings of meniscus. diographs, 68% (319/468) of effusions ex- of suboptimal visualization on bedside radio-
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