The pleura and pleural spaces are only clearly visible when abnormal. Some diseases, such as mesothelioma, cause pleural thickening. Other pleural diseases lead to fluid accumulation (pleural effusion) or air gathering in the pleural spaces (pneumothorax).
Chest X-ray Anatomy
Pleura and pleural spaces
Key points
- The pleura are only clearly visible when abnormal
- Lung markings should reach the thoracic wall
Normal pleura and pleural spaces
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Normal pleura and pleural spaces
- Trace round the entire edge of the lung where pleural abnormalities are more readily seen
- Start and end at the hila
- Is there pleural thickening?
- Is there a pneumothorax? The lung markings should be visible to the chest wall
- Is there an effusion? The costophrenic angles and hemidiaphragms should be well defined
Assessing the pleura
Pleural abnormalities can be subtle, so it is important to check carefully around the edge of each lung where abnormalities are seen more easily.
Make sure you can see lung markings all the way to the edge of the chest wall. If the lung edge (visceral pleura) is visible and there is black surrounding this edge, then a pneumothorax should be suspected. This should lead to immediate assessment of the patient's trachea and mediastinum, both on the X-ray and, more importantly, clinically. Deviation of midline structures away from the side of a pneumothorax is evidence of a tension pneumothorax which is a medical emergency.
Failure to diagnose a tension pneumothorax on a chest X-ray is the quickest way to fail your Radiology exam!
Every chest X-ray should also be checked for pleural thickening, and pleural effusions.