Download PDF
Ultraschall Med 2024; 45(02): 118-146
DOI: 10.1055/a-2189-5050
Continuing Medical Education

Sonography of the pleura

Article in several languages: English | deutsch
Rudolf Horn
1   Emergency Department, Center da Sandà Val Müstair, Switzerland
,
Christian Görg
2   Interdisciplinary Center of Ultrasound Diagnostics, Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital Giessen and Marburg, Philipp University of Marburg, Baldingerstraße, Marburg
,
Helmut Prosch 
3   Abteilung für Allgemeine Radiologie und Kinderradiologie, Medizinische Universität Wien, Austria
,
Ehsan Safai Zadeh 
3   Abteilung für Allgemeine Radiologie und Kinderradiologie, Medizinische Universität Wien, Austria
,
Christian Jenssen 
4   Klinik für Innere Medizin, Krankenhaus Märkisch-Oderland Strausberg/Wriezen and Brandenburg Institute for Clinical Ultrasound at Medical University Brandenburg, Neuruppin, Germany
,
Christoph F. Dietrich 
5   Department of General Internal Medicine, Kliniken Hirslanden Beau-Site, Salem und Permanence, Bern, Switzerland
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

The CME review presented here is intended to explain the significance of pleural sonography to the interested reader and to provide information on its application. At the beginning of sonography in the 80 s of the 20th centuries, with the possible resolution of the devices at that time, the pleura could only be perceived as a white line. Due to the high impedance differences, the pleura can be delineated particularly well. With the increasing high-resolution devices of more than 10 MHz, even a normal pleura with a thickness of 0.2 mm can be assessed. This article explains the special features of the examination technique with knowledge of the pre-test probability and describes the indications for pleural sonography. Pleural sonography has a high value in emergency and intensive care medicine, preclinical, outpatient and inpatient, in the general practitioner as well as in the specialist practice of pneumologists. The special features in childhood (pediatrics) as well as in geriatrics are presented. The recognition of a pneumothorax even in difficult situations as well as the assessment of pleural effusion are explained. With the high-resolution technology, both the pleura itself and small subpleural consolidations can be assessed and used diagnostically. Both the direct and indirect sonographic signs and accompanying symptoms are described, and the concrete clinical significance of sonography is presented. The significance and criteria of conventional brightness-encoded B-scan, colour Doppler sonography (CDS) with or without spectral analysis of the Doppler signal (SDS) and contrast medium ultrasound (CEUS) are outlined. Elastography and ultrasound-guided interventions are also mentioned. A related further paper deals with the diseases of the lung parenchyma and another paper with the diseases of the thoracic wall, diaphragm and mediastinum.



Publication History

Article published online:
18 January 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Jaworska J, Buda N, Ciuca IM. et al. Ultrasound of the pleura in children, WFUMB review paper. Med Ultrason 2021;
    CrossrefPubMedSearch in Google Scholar
  • 2 Dietrich CF, Buda N, Ciuca IM. et al. Lung ultrasound in children, WFUMB review paper (part 2). Med Ultrason 2021;
    CrossrefPubMedSearch in Google Scholar
  • 3 Fang C, Jaworska J, Buda N. et al. Ultrasound of the chest and mediastinum in children, interventions and artefacts. WFUMB review paper (part 3). Med Ultrason 2022; 24: 65-67
    CrossrefPubMedSearch in Google Scholar
  • 4 Findeisen H, Trenker C, Zadeh ES. et al. Further aspects concering peripheral lung carcinoma in CEUS. Ultraschall in der Medizin – European Journal of Ultrasound 2020;
    Thieme ConnectPubMedSearch in Google Scholar
  • 5 Safai Zadeh E, Beutel B, Dietrich CF. et al. Perfusion Patterns of Peripheral Pulmonary Lesions in COVID-19 Patients Using Contrast-Enhanced Ultrasound (CEUS): A Case Series. J Ultrasound Med 2021; 40: 2403-2411
    CrossrefPubMedSearch in Google Scholar
  • 6 Safai Zadeh E, Dietrich CF, Kmoth L. et al. Peripheral Pulmonary Lesions in Confirmed Pulmonary Arterial Embolism: Follow-up Study of B-Mode Ultrasound and of Perfusion Patterns Using Contrast-Enhanced Ultrasound (CEUS). J Ultrasound Med 2021;
    CrossrefPubMedSearch in Google Scholar
  • 7 Safai Zadeh E, Gorg C, Prosch H. et al. WFUMB Technological Review: How to Perform Contrast-Enhanced Ultrasound of the Lung. Ultrasound Med Biol 2022;
    CrossrefPubMedSearch in Google Scholar
  • 8 Safai Zadeh E, Huber KP, Dietrich CF. et al. The Value of Lung Ultrasound to Detect the Early Pleural and Pulmonary Pathologies in Nonhospitalized COVID-19-Suspected Cases in a Population with a Low Prevalence of COVID-19 Infection: A Prospective Study in 297 Subjects. J Ultrasound Med 2021;
    CrossrefPubMedSearch in Google Scholar
  • 9 Safai Zadeh E, Keber CU, Dietrich CF. et al. Perfusion Patterns of Peripheral Pulmonary Granulomatous Lesions Using Contrast-Enhanced Ultrasound (CEUS) and Their Correlation with Immunohistochemically Detected Vascularization Patterns. J Ultrasound Med 2022; 41: 565-574
    CrossrefPubMedSearch in Google Scholar
  • 10 Safai Zadeh E, Weide J, Dietrich CF. et al. Diagnostic Accuracy of B-Mode- and Contrast-Enhanced Ultrasound in Differentiating Malignant from Benign Pleural Effusions. Diagnostics (Basel) 2021; 11
    CrossrefPubMedSearch in Google Scholar
  • 11 Demi L, Wolfram F, Klersy C. et al. New International Guidelines and Consensus on the Use of Lung Ultrasound. J Ultrasound Med 2023; 42: 309-344
    CrossrefPubMedSearch in Google Scholar
  • 12 Alhyari A, Gorg C, Dietrich CF. et al. Diagnostic Performance of Point Shear Wave Elastography Using Acoustic Radiation Force Impulse Technology in Peripheral Pulmonary Consolidations: A Feasibility Study. Ultrasound Med Biol 2022;
    CrossrefPubMedSearch in Google Scholar
  • 13 Dietrich CF, Gorg C, Horn R. et al. Ultrasound of the lung. Ultraschall Med 2023; 44: 2-19
    PubMedSearch in Google Scholar
  • 14 Safai Zadeh E, Gorg C, Prosch H. et al. The Role of Thoracic Ultrasound for Diagnosis of Diseases of the Chest Wall, the Mediastinum, and the Diaphragm-Narrative Review and Pictorial Essay. Diagnostics (Basel) 2023; 13
    CrossrefPubMedSearch in Google Scholar
  • 15 Dietrich CF, Goudie A, Chiorean L. et al. Point of Care Ultrasound: A WFUMB Position Paper. Ultrasound Med Biol 2017; 43: 49-58
    CrossrefPubMedSearch in Google Scholar
  • 16 Maio G. Medicine and the Holistic Understanding of the Human Being: Ultrasound Examination as Dialog. Ultraschall in der Medizin – European Journal of Ultrasound 2014; 35: 98-107
    Thieme ConnectPubMedSearch in Google Scholar
  • 17 Volpicelli G, Elbarbary M, Blaivas M. et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38: 577-591
    CrossrefPubMedSearch in Google Scholar
  • 18 Volpicelli G, Caramello V, Cardinale L. et al. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med 2008; 26: 585-591
    CrossrefPubMedSearch in Google Scholar
  • 19 Jambrik Z, Monti S, Coppola V. et al. Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. Am J Cardiol 2004; 93: 1265-1270
    CrossrefPubMedSearch in Google Scholar
  • 20 Picano E, Frassi F, Agricola E. et al. Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr 2006; 19: 356-363
    CrossrefPubMedSearch in Google Scholar
  • 21 Soldati G, Smargiassi A, Inchingolo R. et al. Proposal for International Standardization of the Use of Lung Ultrasound for Patients With COVID-19: A Simple, Quantitative, Reproducible Method. J Ultrasound Med 2020; 39: 1413-1419
    CrossrefPubMedSearch in Google Scholar
  • 22 Allinovi M, Parise A, Giacalone M. et al. Lung Ultrasound May Support Diagnosis and Monitoring of COVID-19 Pneumonia. Ultrasound Med Biol 2020; 46: 2908-2917
    CrossrefPubMedSearch in Google Scholar
  • 23 Matthias I, Panebianco NL, Maltenfort MG. et al. Effect of Machine Settings on Ultrasound Assessment of B-lines. J Ultrasound Med 2020; 40: 2039-2046
    CrossrefPubMedSearch in Google Scholar
  • 24 Mento F, Demi L. Dependence of lung ultrasound vertical artifacts on frequency, bandwidth, focus and angle of incidence: An in vitro study. J Acoust Soc Am 2021; 150: 4075
    CrossrefPubMedSearch in Google Scholar
  • 25 Leote J, Muxagata T, Guerreiro D. et al. Influence of Ultrasound Settings on Laboratory Vertical Artifacts. Ultrasound Med Biol 2023; 49: 1901-1908
    CrossrefPubMedSearch in Google Scholar
  • 26 Mento F, Demi L. On the influence of imaging parameters on lung ultrasound B-line artifacts, in vitro study. J Acoust Soc Am 2020; 148: 975
    CrossrefPubMedSearch in Google Scholar
  • 27 Miller DL, Dou C, Raghavendran K. Dependence of thresholds for pulmonary capillary hemorrhage on diagnostic ultrasound frequency. Ultrasound Med Biol 2015; 41: 1640-1650
    CrossrefPubMedSearch in Google Scholar
  • 28 Wolfram F, Miller D, Demi L. et al. Best Practice Recommendations for the Safe use of Lung Ultrasound. Ultraschall Med 2023;
    Thieme ConnectPubMedSearch in Google Scholar
  • 29 Miserocchi G. Physiology and pathophysiology of pleural fluid turnover. Eur Respir J 1997; 10: 219-225
    CrossrefPubMedSearch in Google Scholar
  • 30 Dickman E, Terentiev V, Likourezos A. et al. Extension of the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion. J Ultrasound Med 2015; 34: 1555-1561
    CrossrefPubMedSearch in Google Scholar
  • 31 Vargas CA, Quintero J, Figueroa R. et al. Extension of the thoracic spine sign as a diagnostic marker for thoracic trauma. Eur J Trauma Emerg Surg 2020;
    CrossrefPubMedSearch in Google Scholar
  • 32 Hassan M, Rizk R, Essam H. et al. Validation of equations for pleural effusion volume estimation by ultrasonography. J Ultrasound 2017; 20: 267-271
    CrossrefPubMedSearch in Google Scholar
  • 33 Balik M, Plasil P, Waldauf P. et al. Ultrasound estimation of volume of pleural fluid in mechanically ventilated patients. Intensive Care Med 2006; 32: 318
    CrossrefPubMedSearch in Google Scholar
  • 34 Mayo PH, Doelken P. Pleural ultrasonography. Clin Chest Med 2006; 27: 215-227
    CrossrefPubMedSearch in Google Scholar
  • 35 Dietrich CF, Mathis G, Cui XW. et al. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015; 41: 351-365
    CrossrefPubMedSearch in Google Scholar
  • 36 Bedawi EO, Hassan M, Rahman NM. Recent developments in the management of pleural infection: A comprehensive review. Clin Respir J 2018; 12: 2309-2320
    CrossrefPubMedSearch in Google Scholar
  • 37 Mercer RM, Corcoran JP, Porcel JM. et al. Interpreting pleural fluid results. Clin Med (Lond) 2019; 19: 213-217
    CrossrefPubMedSearch in Google Scholar
  • 38 Joseph J, Badrinath P, Basran GS. et al. Do we need all three criteria for the diagnostic separation of pleural fluid into transudates and exudates? An appraisal of the traditional criteria. Med Sci Monit 2003; 9: CR474-CR476
    PubMedSearch in Google Scholar
  • 39 Light RW, Macgregor MI, Luchsinger PC. et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972; 77: 507-513
    CrossrefPubMedSearch in Google Scholar
  • 40 Porcel JM. Identifying transudates misclassified by Light's criteria. Curr Opin Pulm Med 2013; 19: 362-367
    CrossrefPubMedSearch in Google Scholar
  • 41 Rufino R, Marques BL, Azambuja Rde L. et al. Pleural cholesterol to the diagnosis of exudative effusion. Open Respir Med J 2014; 8: 14-17
    CrossrefPubMedSearch in Google Scholar
  • 42 Shi HZ, Liang QL, Jiang J. et al. Diagnostic value of carcinoembryonic antigen in malignant pleural effusion: a meta-analysis. Respirology 2008; 13: 518-527
    CrossrefPubMedSearch in Google Scholar
  • 43 Shen Y, Zhu H, Wan C. et al. Can cholesterol be used to distinguish pleural exudates from transudates? evidence from a bivariate meta-analysis. BMC Pulm Med 2014; 14: 61
    CrossrefPubMedSearch in Google Scholar
  • 44 Wilcox ME, Chong CA, Stanbrook MB et al. Does this patient have an exudative pleural effusion? The Rational Clinical Examination systematic review. JAMA 2014; 311: 2422-2431
    CrossrefPubMedSearch in Google Scholar
  • 45 Ferreiro L, Toubes ME, San Jose ME. et al. Advances in pleural effusion diagnostics. Expert Rev Respir Med 2020; 14: 51-66
    CrossrefPubMedSearch in Google Scholar
  • 46 Bhoil R, Kumar R, Kaur J. et al. Diagnosis of Traumatic Pneumothorax: A Comparison between Lung Ultrasound and Supine Chest Radiographs. Indian J Crit Care Med 2021; 25: 176-180
    CrossrefPubMedSearch in Google Scholar
  • 47 Karpathiou G, Stefanou D, Froudarakis ME. Pleural neoplastic pathology. Respir Med 2015; 109: 931-943
    CrossrefPubMedSearch in Google Scholar
  • 48 Katzman D, Sterman DH. Updates in the diagnosis and treatment of malignant pleural mesothelioma. Curr Opin Pulm Med 2018; 24: 319-326
    CrossrefPubMedSearch in Google Scholar
  • 49 Lin Z, Wu D, Wang J. et al. Diagnostic value of ultrasound-guided needle biopsy in undiagnosed pleural effusions: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99: e21076
    CrossrefPubMedSearch in Google Scholar
  • 50 Murata Y, Aoe K, Mimura Y. Pleural effusion related to IgG4. Curr Opin Pulm Med 2019; 25: 384-390
    CrossrefPubMedSearch in Google Scholar
  • 51 Tello-Sanchez M, Rodriguez-Duque MS, Loidi-Lopez C. et al. Pleural and Pericardial Effusion as the Only Manifestation of IgG4-Related Disease. Arch Bronconeumol 2020; 56: 597-599
    CrossrefPubMedSearch in Google Scholar
  • 52 Felekis VA. Causes and management of pleural fibrosis. Respirology 2005; 10: 402
    CrossrefPubMedSearch in Google Scholar
  • 53 Huggins JT, Sahn SA. Causes and management of pleural fibrosis. Respirology 2004; 9: 441-447
    CrossrefPubMedSearch in Google Scholar
  • 54 Wang XB, Yin Y, Miao Y. et al. Flex-rigid pleuroscopic biopsy with the SB knife Jr is a novel technique for diagnosis of malignant or benign fibrothorax. J Thorac Dis 2016; 8: E1555-E1559
    CrossrefPubMedSearch in Google Scholar
  • 55 Mathis G, Horn R, Morf S. et al. WFUMB position paper on reverberation artefacts in lung ultrasound: B-lines or comet-tails?. Med Ultrason 2021; 23: 70-73
    CrossrefPubMedSearch in Google Scholar