Is the Lateral Decubitus Radiograph Necessary

for the Management of a Parapneumonic

Pleural Effusion?*
Mark L. Metersky

Chest 2003;124;1129-1132
DOI 10.1378/chest.124.3.1129

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Is the Lateral Decubitus Radiograph
Necessary for the Management of a
Parapneumonic Pleural Effusion?*
Mark L. Metersky, MD, FCCP
(CHEST 2003; 124:1129 –1132)
Key words: pleural effusion; pneumonia; radiography; thoracic
A pproximately 50% of patients who are admitted
to the hospital with community-acquired pneu-
monia will develop a pleural effusion.1,2 While most
parapneumonic effusions will resolve without specific
therapy, approximately 10% will become complicated
or progress to empyema.3 Because delays in the drain-
age of these clinically significant effusions have been
associated with increased morbidity and mortality,4
prompt detection and accurate characterization of a
parapneumonic effusion are important. Guidelines5
based on a consensus conference have comprehen-
sively summarized the literature regarding parapneu-
monic effusions and have made specific recommenda-
tions for their management. Although this document
reflects the “state of the art,” as the authors noted, most
studies of parapneumonic effusions have been obser-
vational, often with a limited numbers of patients.
One of the recommendations in the guidelines was
that all patients with a parapneumonic effusion
should have a chest radiograph performed with a
lateral decubitus view.5 This recommendation also
was incorporated into the American Thoracic Society
guidelines6 for the care of adults with community-
acquired pneumonia. The rationale is that if the
thickness of the effusion on the lateral decubitus
view is ⬍ 1 cm, the effusion is small enough so that
no further intervention is needed.1 While there is
good evidence that small effusions resolve without
specific therapy,1 the suggestion that a lateral decu-
bitus radiograph is required to determine the appro-
priate course of action with respect to a parapneu-
monic effusion appears to have been made without
sufficient supporting data. The purpose of this article is
to review the indications and usage of the lateral
*From the Pulmonary Division, University of Connecticut School
of Medicine, Farmington, CT.
Manuscript received July 16, 2002; revision accepted December
6, 2002.
Reproduction of this article is prohibited without written permis-
sion from the American College of Chest Physicians (e-mail:
permissions@chestnet.org).
Correspondence to: Mark L. Metersky, MD, FCCP, Pulmonary
Division, University of Connecticut Health Center, 263 Farming-
ton Ave, Farmington, CT 06030-1225; e-mail: metersky@nso.
uchc.edu
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© 2003 American College of Chest Physicians
decubitus chest radiograph and demonstrate its limited
value in the setting of parapneumonic pleural effusions.
Radiographs of the chest made with the patient in
the standard erect position usually will not reveal the
presence of a pleural effusion ⬍ 300 to 500 mL in
size, as the fluid usually pools in the posterior
costophrenic sulcus.7,8 The varying volumes reported
may be due to differences in patient size, as a larger
individual probably can “hide” a larger volume of
fluid than can a smaller individual. The lateral
decubitus view was first described by Merlo Gomez
and Heidenreich,9 in 1924, as a technique to identify
the presence of small pleural effusions. Its first
English-language description was by Rigler,7 in
1931, who used this technique to confirm the pres-
ence of pleural effusions in a small series of patients
despite the absence of a visible effusion using the
standard erect views. Subsequently, other investiga-
tors demonstrated that the sensitivity of this view can
be increased by placing a pillow under the patient’s
pelvis, so that the thorax slopes downward away from
the lung base.10 By injecting known amounts of fluid
into cadavers, in 1973 Moskowitz et al8 demon-
strated that effusions as small as 5 to 10 mL could be
detected using the lateral decubitus view.
What Are the Potential Indications for
Performing a Lateral Decubitus
Radiograph in the Setting of Pneumonia?
To Identify a Parapneumonic Effusion That Is Not
Visible on Erect Chest Radiographs
While the lateral decubitus view will often reveal
very small effusions that have not been identified by
erect chest radiographs, there generally is no reason
that such a small parapneumonic effusion needs to
be diagnosed. Light et al1 reported that small para-
pneumonic effusions always resolved without any
specific intervention. Difficulty in diagnosing a
larger pleural effusion should be rare when a lateral
erect radiograph is obtained. Taryle et al2 found that
16 of 20 parapneumonic effusions (80%) were iden-
tifiable by radiographs obtained with posteroanterior
and/or lateral erect views, while 4 effusions were
identified on the lateral decubitus view only. One of
CHEST / 124 / 3 / SEPTEMBER, 2003 1129
these was a very small parapneumonic effusion that
was probably not clinically significant, although it
could be determined from the article how large the
other three effusions were. In a multicenter study of
empyemas,11 difficulty in identifying the presence of
pleural fluid was thought most often to be due to the
lack of a lateral erect chest radiograph. Occasionally,
a larger pleural effusion may be difficult to identify,
if it is in a subpulmonic distribution or if there is a
superimposed dense alveolar infiltrate. In such cases,
the lateral decubitus radiograph may confirm the
presence of a clinically significant effusion, although
often a CT scan of the chest will provide more
clinically useful information.
To Determine Whether the Fluid Is Loculated
While the lateral decubitus view often can identify
loculations, they can usually be ascertained by a
standard erect view.3 The fundamental question is,
“Is it necessary to know whether the fluid is loculated
prior to performing a thoracentesis?” Although many
loculated effusions resolve without drainage,4 the
presence of loculations correlates with the develop-
ment of a complicated pleural effusion or empy-
ema.11–13 The drainage of loculated effusions is
sometimes necessary even in the face of the results
of pleural fluid chemistry testing that do not suggest
the need for tube thoracostomy.12 However, since
loculations occur more frequently with larger effu-
sions,12 it is not clear that the presence of loculations
provides any more prognostic information than does
the semiquantitative estimate of fluid volume based
on chest radiographs obtained with the patient in the
erect position.4 Even if the presence of loculations
provides prognostic information, a thoracentesis
would ordinarily be performed before deciding on
the need for more aggressive therapy. If the thora-
centesis is successful in removing all of the radio-
graphically visible fluid, or if the fluid clearly shows
the need for tube thoracostomy, the lateral decubitus
view will yield no clinically useful information. In the
case of an effusion that cannot be completely re-
moved by thoracentesis, the presence of loculations
can be presumed, and the subsequent management
will be directed by the fluid characteristics. In some
cases, the performance of tube thoracostomy may be
difficult due to the presence of multiple and/or small
loculations, and a CT scan of the chest will yield
much more useful information than will radiograph
made with a lateral decubitus view. Support for this
line of thought (although not for omitting the lateral
decubitus view) can be inferred from a published
treatment algorithm14 that recommended the perfor-
mance of a radiograph with the lateral decubitus
view and then thoracentesis, whether or not the fluid
1130
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© 2003 American College of Chest Physicians
is loculated. Interestingly, when one queries house
officers about why they ordered a lateral decubitus
radiograph, the invariable answer is to “see whether
the fluid is loculated, because loculated fluid cannot
be tapped without radiographic guidance.” I could
find no support in the literature for this idea but have
encountered it at several institutions. If a large
pleural effusion is identifiable by the standard erect
view chest radiographs and a physical examination,
there should be little risk in performing a “blind”
thoracentesis, whether the fluid is loculated or not.
In the specific setting of multiloculated empyema,
radiographic guidance by either CT scan or ultra-
sound can be invaluable in guiding the placement of
small-bore drainage tubes.
To Determine the Volume of the Effusion Based on
the Thickness of the Fluid Layer
This is the major reason that the lateral decubitus
radiograph is recommended.1,5 What data support
this? In 1980, Light et al1 reported that all pleural
effusions resulting in a ⬍ 1-cm layer seen on a
radiograph with a lateral decubitus view resolved
with antibiotic therapy only. This knowledge, com-
bined with their experience that an effusion of this
size could usually be tapped easily,15 resulted in a
recommendation that a lateral decubitus radiograph
be performed in all cases of suspected parapneumo-
nic effusion.1 However, clinically relevant estimates
of the size of pleural effusions can be made without
the use of the lateral decubitus radiograph.11 Also,
estimated fluid volume based on the lateral decubi-
tus radiograph correlates poorly with the true vol-
ume. In a study comparing the accuracy of ultra-
sound and the lateral decubitus view predicting the
volume of a pleural effusion, Eibenberger et al16
found that the mean prediction error using the
lateral decubitus radiograph was 465 mL, compared
to 224 mL using ultrasound. The actual fluid volume
in three patients with an effusion that was 1.2 cm
thick on the lateral decubitus radiograph ranged
from approximately 350 to 1,400 mL.
A New Recommendation
Since empyemas that occupy only 20% of the
hemithorax occur commonly,11 it is clear that a
lateral decubitus radiograph is not required to deter-
mine the need for sampling effusions of this size or
larger. For smaller effusions, the work of Light et al1
provides strong evidence that thoracentesis is not
necessary for effusions that are ⬍ 1 cm thick on the
lateral decubitus view. They also suggested that it
may be difficult to perform a blind thoracentesis
when the effusion is smaller than this.1 Therefore, if
Opinions/Hypotheses
the smallest effusion that can be easily tapped could
be identified by radiographs with the standard pos-
teroanterior and lateral views, then that size will
correspond to the size that current recommendations
suggest should be tapped.
In my experience, a blind thoracentesis is almost
always easily performed if the column of fluid is ⬎ 5
cm in height at the posterior costophrenic sulcus.
Smaller effusions leave little room for error. This is a
more logical measurement to rely on than one
obtained from the lateral decubitus radiograph, since
it shows exactly how much fluid is present in the
location where the needle usually will be placed. Of
course, the height of the effusion cannot be mea-
sured directly since the inferior recess of the poste-
rior costophrenic sulcus is obscured by the fluid.
However, it can be estimated by comparing the
height of the fluid above the contralateral posterior
costophrenic sulcus. Unlike the domes of the dia-
phragm, the two sulci are usually at similar levels.
In order to assess the validity of this method, I
compared the appearance of effusions imaged by
radiographs with both lateral erect and lateral decu-
bitus views in 20 patients (see “Appendix”). As can be
seen by the linear regression (Fig 1), the measure-
ments obtained by both methods are closely corre-
lated (p ⬍ 0.001; r2 ⫽ 0.51), albeit with some scat-
ter, presumably due to inexact quantification of the
amount of fluid associated with both views. The
regression line also demonstrates that 1 cm fluid on
the lateral decubitus view correlates with approxi-
mately 5 cm fluid on the lateral erect view. While
the two methods give similar results, the use of the
standard lateral erect view obviates the need for the
subsequent lateral decubitus view.
Despite the lack of evidence supporting the ne-
cessity of the lateral decubitus radiograph, it could
Figure 1. Linear regression showing the amount of pleural fluid (in centimeters) as assessed by chest
radiographs with lateral erect and lateral decubitus views in 20 patients (p ⬍ 0.001).
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© 2003 American College of Chest Physicians
be argued that it is inexpensive and without risk, and
therefore should be performed. However, when a
pleural effusion is found, performing the lateral
decubitus radiograph generally necessitates sending
the patient back to the radiology suite. Although
therapy with antibiotics should never be delayed in
order to perform a thoracentesis, a second trip to
radiology could result in such a delay. This could
detrimentally affect patient outcomes, since a delay
in the start of antibiotic therapy of even a few hours
may increase the risk of mortality from pneumonia.17
The performance of a radiograph with the lateral
decubitus view also might delay thoracentesis, which
has been associated with worsened outcomes in
some patients.4,18 While ideally the performance of
the lateral decubitus radiograph would delay the
thoracentesis only minimally, by the time the results
are obtained, the attending physician may have left
the hospital or the house officer may have moved
onto the next person who has been admitted to the
hospital.
Despite having worked at several institutions, I do
not recall any pulmonary specialists who routinely
have obtained lateral decubitus radiographs. In ad-
dition, at least one respected chest radiologist be-
lieves that the lateral decubitus chest radiograph is
overused.19 Recommending, without adequate evi-
dence, a practice that is apparently widely disagreed
with, can breed skepticism about the entire guideline
in question.
In summary, a parapneumonic effusion that is
large enough to be potentially clinically significant
can almost always be defined by chest radiographs
with posteroanterior and lateral erect views. Patients
with effusions clearly occupying ⬎ 20% of the hemi-
thorax should have a thoracentesis performed, and
thoracentesis should be considered strongly for
CHEST / 124 / 3 / SEPTEMBER, 2003 1131
smaller effusions that have a column of fluid of ⬎ 5
cm that is visible on the lateral erect radiograph.
Since an effusion of this size correlates with an
effusion with 1-cm thickness on the lateral decubitus
view, an effusion smaller than this should resolve
without drainage. If loculations are suspected, based
either on the appearance of the standard radiographs
or on the inability to completely drain the fluid, then
a CT scan will define the pleural anatomy more
accurately than will the lateral decubitus radiograph.
Occasionally, the lateral decubitus radiograph can
confirm the presence of fluid if there is a subpul-
monic effusion or if the costophrenic angles are
obscured by infiltrate. In most cases, however, it
yields no clinically useful information but may un-
necessarily delay proper therapy.
Appendix: Methods
The radiographs of all patients with pleural effusions who had
radiographs performed with a lateral decubitus view between
January 1, 1999, and December 31, 2001, at the University of
Connecticut Health Center were reviewed. Patients in whom
radiographs with lateral decubitus views did not allow the
measurement of the amount of fluid due to poor technical quality
were excluded, as were patients with bilateral effusions that
obscured all landmarks, those who had radiographs with no
lateral erect view performed, those who had near complete filling
of the hemithorax, or those in whom the fluid was loculated. In all
patients, the two radiographs were performed within ⱕ 27 h of
each other. The height in centimeters of the pleural fluid above
the inferior aspect of the contralateral posterior sulcus was
measured on the lateral erect radiograph. These results were
compared to the thickness of the pleural fluid layering measured
on the lateral decubitus view. Linear regression analysis20 was
performed (Excel 97; Microsoft Inc; Redmond, WA). Radio-
graphs were assessed while the reader was blinded to the results
of the alternate view of the same patient. This study was approved
by the Institutional Review Board of the University of Connect-
icut Health Center.
ACKNOWLEDGMENT: The author would like to thank
Jonathan Fine, MD, for his critical review of the manuscript, and
Jan Tate, MPH, for assistance with the statistical analysis.
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Opinions/Hypotheses
Is the Lateral Decubitus Radiograph Necessary for the Management of a
Parapneumonic Pleural Effusion? *
Mark L. Metersky
Chest 2003;124; 1129-1132
DOI 10.1378/chest.124.3.1129
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