Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment

Abstract

Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.

Keywords: Catheters; Critical care; Lung; Pleural effusion; Ultrasonography.

Fig. 1

a Supine chest X-ray showing a modest right pleural obstruction. b The corresponding ultrasound image, showing a pleural effusion of about 2 cm

Fig. 2

Ultrasound technique to measure the pleural effusion (in centimeters), from chest wall to pulmonary parenchyma (dashed line)

Fig. 3

Position of the probe and the marker on the chest wall according to different methods. a Supine patient, transverse approach, probe on the posterior axillary line at the lung base/PLEFF lower limit [–31, 33]. b Supine patient, transverse approach, probe on the posterior axillary line at the lung apex/PLEFF upper limit [29, 33]. c Supine patient, transverse approach, probe on the posterior axillary line at the middle point of PLEFF height [33]. d Supine patient, longitudinal approach, probe on the posterior axillary line to identify the liver on the right side, the spleen on the left side, and the diaphragm [30]. e Sitting patient, longitudinal approach, probe on the mid-scapular line on the right lung base [32]. f Sitting patient, longitudinal approach, probe on the mid-scapular line on the left lung base [32]

Fig. 4

a Left pleural effusion. b Right pleural effusion. c Infra-hepatic view of a right pleural effusion. The main recognizable anatomical structures are marked

Fig. 5

Different types of pleural effusion on ultrasound scan: a exudate, b empyema, c haemothorax, d complex septation pleural effusion

Fig. 6

Right pleural effusion seen through a linear (a) and convex (b) ultrasound probe. The hyperechoic line visible within the pleural hypoechoic effusion is the metallic wire inserted to guide the introduction of the pleural drainage