JAMA Revisited September 30, 1939

Landmarks in Simple Pleural Effusions Julius Kaunitz, M.D. Modern methods of examination have greatly facilitated the diagnosis of pleural effusion, particularly radiography. In spite of this it is nothing unusual for experienced clinicians to be embarrassed by a “dry tap” when there is clearcut evidence of pleural effusion. Nor is the embarrassment lessened when a successful thoracentesis is performed on the patient on the same day by another clinician who elected to introduce his needle one or two interspaces higher. In most instances “dry taps” in simple effusions are due to the eagerness of the operator to remove every ounce. The patient is placed in the sitting position regardless of his physical condition, and the needle is introduced at a low level, frequently so low that it encounters diaphragm instead of liquid. One of the chief reasons for failure in thoracentesis is that the landmarks of the effusion are not clearly established. This is particularly true of the more common type, the simple pleural effusion, which is to be distinguished from hydropneumothorax and from cases in which tumor and adhesions complicate and distort the picture. Before the advent of the x-rays many clinicians described the upper level of effusions as curved or straight, depending entirely on the upper margin of the flat percussion note. Probably one of the earliest descriptions is the curved line of Damoiseau1 mentioned in most of the foreign textbooks. In this country we are taught the curved line of Ellis.2 As shall be shown, neither of these lines truly represents the upper level of the effusion.… For the sake of convenience I have divided simple pleural effusions into three radiographic zones, 3 as follows, described from below upward: 1. A radiopaque zone, the area below the lung, visualized as a dense shadow. 2. A radiotranslucent zone, the area between the lung and chest wall, seen as a hazy shadow but dense in the lateral aspect. 3. A radiotransparent zone, the area of liquid between the lung and chest wall too thin to cast a shadow except in its lateral aspect. The volume of liquid at the various levels of the second and third zones is easily gaged by observing the curved dense

Editor’s Note: JAMA Revisited is transcribed verbatim from articles published previously, unless otherwise noted. 2444

shadow as it tapers off from below upward. This curved shadow is in fact a side view of that portion of the effusion interposed between the lung and chest wall, the tip of the curved shadow representing the upper margin of the effusion. With the three zones as a landmark it is possible with a greater degree of accuracy to choose the site for thoracentesis. In effusions of moderate size it has been my custom to insert the aspirating needle at a point corresponding to the junction of zones 1 and 2 in the posterior axillary line. This corresponds to the beginning of absolute flatness in percussion. Aspirating below this point may be successful with large effusions; in small effusions the diaphragm may be encountered and may not be recognized, particularly on the right side where the flat percussion note over the liver merges with that over the effusion and the dense homogeneous x-ray shadow includes diaphragm, liver and effusion. When feebleness of the patient precludes aspiration in the erect position, the reclining position may advantageously be employed. The usual procedure in right-sided effusions is to place the patient on his right side at the edge of the right side of the bed, and vice versa in left-sided effusions. The needle is inserted in an interspace near the posterior axillary line. In this position the liquid will gravitate downward from between the lung, mediastinum and diaphragm and permit almost complete aspiration.…

Conclusions It is important to know the landmarks of a pleural effusion before attempting thoracentesis. By special roentgenographic technic it was established that the simple pleural effusion extends well above the area of percussion flatness and above the dense radiographic shadow. On the basis of distinct radiographic zones in simple pleural effusions, several principles have been formulated for locating with greater accuracy the site for thoracentesis. 1. Damoiseau, H.: Recherches cliniques sur plusieurs points du diagnostic des epanchements, Extrait des Archives générales de médecine, 1844; from Garland, G. M.: Pneumo Dynamics, p. 2. 2. Ellis, Calvin: Boston M. & S. J. 90:13, 1874. 3. Kaunitz, Julius: The Three Zones of Simple Pleural Effusions, Am. J. Roentgenol. 35:57 (Jan.) 1936; The Three Radiographic Zones of Simple Pleural Effusions, Brit. J. Radiol. 9:644 (Oct.) 1936.

JAMA. 1939;113(14):1312-1314.

Section Editor: Jennifer Reiling, Assistant Editor.

JAMA June 18, 2014 Volume 311, Number 23

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Landmarks in simple pleural effusions.

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