The pleura and pleural spaces are only visible when abnormal
There should be no visible space between the visceral and parietal pleura
Check for pleural thickening and pleural effusions
If you miss a tension pneumothorax you risk your patient's life – as well as your result at finals!
The pleura only become visible when there is an abnormality present. Pleural abnormalities can be subtle and it is important to check carefully around the edge of each lung where pleural abnormalities are usually more easily seen. Some diseases of the pleura cause pleural thickening, and others lead to fluid or air gathering in the pleural spaces.
Pneumothorax
A pneumothorax forms when there is air trapped in the pleural space. This may occur spontaneously, or as a result of underlying lung disease. The most common cause is trauma, with laceration of the visceral pleura by a fractured rib.
If the lung edge measures more than 2 cm from the inner chest wall at the level of the hilum, it is said to be 'large.' If there is tracheal or mediastinal shift away from the pneumothorax, the pneumothorax is said to be under 'tension.' This is a medical emergency! Missing a tension pneumothorax may not only harm your patient, it is also the quickest way to fail the radiology OSCE at finals!
Shadowing over the whole right lung due to circumferential pleural thickening
Clinical information
Shortness of breath and right-sided chest pain
History of asbestos exposure
Diagnosis
Biopsy results showed this to be a mesothelioma - a malignancy of the pleura caused by exposure to asbestos
Asbestos plaques
Calcified asbestos related pleural plaques have a characteristic appearance, and are generally considered to be benign. They are irregular, well-defined, and classically said to look like holly leaves.
Bilateral well defined irregular shadows that are as dense as the bones
Peripheral pleural thickening
Clinical information
Chronic mild shortness of breath
Retired dock worker with history of multiple exposures to asbestos
Diagnosis
Bilateral calcified asbestos related pleural plaques
Pleural effusions
A pleural effusion is a collection of fluid in the pleural space. Fluid gathers in the lowest part of the chest, according to the patient's position.
If the patient is upright when the X-ray is taken, then fluid will surround the lung base forming a 'meniscus' – a concave line obscuring the costophrenic angle and part or all of the hemidiaphragm.
If a patient is supine, then a pleural effusion layers along the posterior aspect of the chest cavity and becomes difficult to see on a chest X-ray.
