Chest X-ray Anatomy
Pleura and pleural spaces

Key points

  • The pleura and pleural spaces are only visible when abnormal
  • Lung markings should reach the thoracic wall

The pleura are only visible when there is an abnormality present. Some diseases cause pleural thickening, and others lead to fluid or air gathering in the pleural spaces.

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 and it is important to check carefully around the edge of each lung where abnormalities are usually 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. If there is a deviation of these midline structures away from the side of a pneumothorax, this is a medical emergency. A tension pneumothorax must be acted on immediately. If in doubt get senior help without delay.

Missing a tension pneumothorax is the quickest way of failing your Radiology exam!

Every chest X-ray should also be checked for pleural thickening, or collections of fluid or air in the pleural spaces.