J Ultrasound (2017) 20:267–271

https://doi.org/10.1007/s40477-017-0266-1

ORIGINAL ARTICLE

Validation of equations for pleural effusion volume estimation

by ultrasonography
Maged Hassan1,2 • Rana Rizk2 • Hatem Essam2 • Ahmed Abouelnour2

Received: 26 July 2017 / Accepted: 4 September 2017 / Published online: 27 October 2017
Ó Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2017

Abstract Sommario
Purpose To validate the accuracy of previously published Scopo Per convalidare l’accuratezza di equazioni che sti-
equations that estimate pleural effusion volume using mano il volume versamento pleurico.
ultrasonography. Metodi Abbiamo testato le equazioni che hanno usato le
Methods Only equations using simple measurements were misurazioni semplici. Sono state prese tre misure: altezza
tested. Three measurements were taken at the posterior di effusione (H), la distanza tra il polmone collassato e la
axillary line for each case with effusion: lateral height of parete toracica (C) e la distanza tra polmone e diaframma
effusion (H), distance between collapsed lung and chest (D). Il versamento è stato aspirato e il volume è stato
wall (C) and distance between lung and diaphragm (D). registrato. Coefficiente di correlazione intra-classe (ICC) è
Cases whose effusion was aspirated to dryness were stato utilizzato per determinare l’accuratezza predittiva
included and drained volume was recorded. Intra-class delle misurazioni.
correlation coefficient (ICC) was used to determine the Risultati 46 pazienti sono stati inclusi. L’equazione più
predictive accuracy of five equations against the actual accurata nel predire il volume di effusione era
volume of aspirated effusion. (H ? D) 9 70 (ICC 0,83). La più semplice equazione
Results 46 cases with effusion were included. The most accurata era H 9 100 (ICC 0,79).
accurate equation in predicting effusion volume was Conclusione L’altezza del versamento pleurico misurato
(H ? D) 9 70 (ICC 0.83). The simplest and yet accurate con ecografia fornisce una stima ragionevole del volume di
equation was H 9 100 (ICC 0.79). versamento. La distanza tra la base del polmone e il dia-
Conclusion Pleural effusion height measured by ultra- framma migliora la precisione.
sonography gives a reasonable estimate of effusion vol-
ume. Incorporating distance between lung base and Parole chiave Ultrasuoni  Versamento pleurico 
diaphragm into estimation improves accuracy from 79% Equazione previsione  Sonde
with the first method to 83% with the latter.

Keywords Ultrasound  Pleural effusion  Prediction Introduction

equation  Real-time  Probes
The use of ultrasonography (US) in examining the pleural
space has become a standard practice worldwide [1].
Physicians in many different disciplines are acquiring the
& Maged Hassan skills to adequately examine the pleural space, using US.
maged.fayed@ouh.nhs.uk
This has positive impact on patient’s overall care as there
1
Oxford Centre for Respiratory Medicine, Oxford University are many advantages of US over other radiological inves-
Hospitals, Oxford, UK tigations. US is a relatively cheap test which does not
2
Chest Diseases Department, Alexandria University Faculty of expose the patient to the risk of radiation and the easy
Medicine, Alexandria, Egypt mobility of US machines makes the procedure useful as a

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bedside test. This has revolutionised the practice in dif- the validity of equations that rely on simple measurements
ferent medical disciplines such as the emergency rooms, (Fig. 1) to accurately predict the volume of pleural effusion
intensive care units and pulmonology departments [2]. The in seated patients.
scope of thoracic US has expanded from evaluating the
pleural space to encompass newer domains like evaluating
lung parenchymal changes in the acutely breathless patient Methods
[3] and assessing diaphragmatic kinetics in patients on
mechanical ventilation [4]. This study was approved by the Medical Ethics Depart-
The use of US in the identification and management of ment of Alexandria Faculty of Medicine. Informed consent
pleural disease is one of the oldest indications in the field of was obtained from all involved patients.
pulmonology. In addition to its value in diagnosing the Patients with pleural effusion, in whom therapeutic
presence of pleural effusion, it is possible to evaluate the aspiration or medical thoracoscopy was clinically indi-
echogenicity of the fluid and the presence and degree of cated, presenting to the Chest Diseases Department at
septations, which are key parameters in stratifying pleural Alexandria University Hospital between January and June
infections and choosing the optimum treatment pathway 2016 were included in the study. Cases with evidence of
[5]. Given its real-time potential, US has the advantage of encystment/loculation or diaphragmatic pathology were
safely guiding pleural procedures, leading to lower com- excluded.
plication rates and reduced healthcare costs [6] which has Ultrasound examination was performed at the posterior
been translated in recent guidelines for pleural procedures axillary line using either a 3–5 MHz convex-array probe or
[7]. a 3.5 MHz phased-array probe. An image that captures the
Among the interesting uses of US, is estimating the effusion, collapsed lung and the hemi-diaphragm at end
volume of pleural effusion. Ultrasound is much more expiration in B mode was frozen for measurements
sensitive than standard X ray in detecting small volumes of (Fig. 2). Two measurements were taken:
effusion. At least 150 ml of fluid is required to be picked
Distance from visceral pleura to chest wall (C)
up by a chest X ray even if the procedure is done under
Distance from lung base to apex of diaphragm cupola
favourable conditions [8]. The threshold of US for detect-
(D)
ing pleural effusion is lower than 5 ml [9].
Various attempts have been made to derive equations to The probe was then moved to more superior and inferior
predict the volume of pleural effusion. There have been rib spaces marking points where effusion was last
many endeavours to develop formulas to estimate effusion detectable on the skin. The lateral height (H) was measured
volume using computed tomography (CT) [10]. Such for- as the distance between the two marks (Fig. 1).
mulas have not been validated against the actual volume of Aspiration was performed at the site determined by US
fluid after aspiration. In addition, CT is an expensive examination. Only cases that were aspirated to dryness or
technique with large radiation dose that makes repeating near-dryness (post procedure D B 2 mm) were included.
the procedure for comparison impractical unlike US Volume of effusion was then recorded.
examination, which can be repeated without any radiation The value of C, H and D were used to calculate the
hazard. predicted volume based on the following equations
Some practitioners prefer to use qualitative estimations [14–16]:
of volume size based on crude measurements such as Volume ¼ C ðin mmÞ  20; ð1Þ
number of probe ranges [11] or rib spaces [1] where
effusion is visible. Others have tested using the depth of Volume ¼ D ðin mmÞ  16; ð2Þ
effusion from chest wall laterally [12] or posteriorly [13] to Volume ¼ H ðin cmÞ  90; ð3Þ
evaluate the need of aspiration in ICU patients with pleural
Volume ¼ H þ D ðboth in cmÞ  70: ð4Þ
effusion. There are several methods in the literature to
accurately estimate the volume of effusion. Most methods In addition, to further simplify Eq. 3 we tested the fol-
have evaluated patients in the sitting position, which makes lowing equation:
examining effusion easier at the posterior axillary line [11]. Volume ¼ H ðin cmÞ  100: ð5Þ
Examination at the supine position is more difficult
because most of effusion gravitates posteriorly. Table 1 The authors found the method suggested by Remérand
summarises some of the methods reported, their strengths et al. [17] (Table 1) impractical due to two reasons. First,
and the setting of the patients. These equations have not the measurements were taken at the paravertebral line
been independently validated on different samples which which is very challenging in critically unwell and immobile
questions their accuracy [1]. This study aimed to examine patients. Second, measuring the area of the effusion is not

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Table 1 Equations for

Authors Setting Probe used Equation R2
estimation of pleural effusion
sonographically Goecke and Schwerk [14] Wards, outpatients Curvilinear H 9 90 0.68
Goecke and Schwerk [14] Wards, outpatients Curvilinear (H ? D) 9 70 0.87
Balik et al. [12] ICU Sector C 9 20 0.52
Usta at al [13] Post-cardiac surgery Sector D 9 16 0.79
Remérand et al. [15] ICU Curvilinear Paravertebral effusion area 9 H 0.70
C chest wall, D diaphragm, H lateral height, R2 squared regression coefficient

straightforward we felt that it can lead to variability

between different operators. It was decided not to include
this method in the study.

Statistical analysis

This study used the intraclass correlation coefficient (ICC)

to measure the degree of agreement between the volume
estimation made by each equation with the actual aspirated
volume. ICC is used to assess the reliability of a given
instrument to measure the parameter which it is supposed
to measure [18] and it is more appropriate than Pearson’s
correlation coefficient to achieve this purpose [19].
Estimated effusion volume was calculated for all cases
using the aforementioned equations. The results were
compared to the actual volume aspirated by means of ICC.
Level of agreement was defined as being:
Poor for ICC \ 0.5
Moderate for ICC 0.5–0.75
Good for ICC 0.75–0.9
Excellent for ICC [ 0.9 [18].
Fig. 1 Schematic representation for the three parameters measured in
study subjects. C chest wall, D diaphragm, H height All statistics were performed using PASW software
(version 19; SPSS inc, Chicago, IL, USA).

Results

Forty-six cases were available for analysis. 29 (63%) cases

had right effusion. 20 cases (43%) were admitted to the
ICU. Regarding aetiology, the two commonest causes were
heart failure (48%), followed by malignant pleural disease
(23%). Other aetiologies included uraemia, liver failure
and trauma.
The mean volume aspirated was 1350 ? 540 ml (min
330 ml, max 3100 ml). None of the cases developed seri-
ous complications (e.g., pneumothorax, re-expansion pul-
monary oedema, bleeding). Therapeutic aspiration was
performed in 42 cases (91%) and effusion was drained
during medical thoracoscopy in the remaining 4 patients.
Fig. 2 Ultrasound image at the basal part of the effusion showing
how C and D are measured. (C chest wall, D diaphragm) Table 2 shows the ICC for each of the five equations
with 95% confidence intervals. There was poor agreement
between actual and estimated volumes using Eqs. 1 and 2.

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Table 2 ICC with 95% confidence intervals for the five tested The oldest equation studied, proposed by Goerke and
equations against measured volume Schwerk, was published in 1990 (Table 1) [16]. It is
Equation ICC 95% confidence interval interesting that one of these equations (H ? D 9 70)
showed the highest level of accuracy. The other equation
Upper limit Lower limit
they proposed (H 9 90) also showed good accuracy but to
C 9 20 0.342 - 0.103 0.679 a lesser degree (in concordance to their own findings). We
D 9 16 0.382 - 0.103 0.719 thought of trying a modification on the latter equation
H 9 90 0.773 0.452 0.894 which makes the process of calculation much easier which
(H ? D) 9 70 0.835 0.687 0.913 is to multiply effusion height by 100. This simplification
H 9 100 0.798 0.651 0.888 did not weaken the equation, but rather led to slightly
increased accuracy to predict effusion volume (Table 2).
C chest wall, D diaphragm, H lateral height, ICC intra-class corre-
lation coefficient It was noticed that the equations performed differently
according to the side of the effusion (data not shown in
results). The most accurate equations tended to overestimate
Good agreement was noted with Eqs. 3 and 5 which were the size of the effusion on the left size. This is not surprising,
very close in accuracy. Equation 4 had excellent agreement given that left hemithorax is smaller in size in comparison
with the highest ICC noted among the studied equations. with the right side. In our view, this discrepancy did not lead
to large calculation errors. A larger study with more patients
would be needed to address whether different equations
Discussion should be used according to the side of the effusion.

Estimating the size of pleural effusion can be useful in

mechanically ventilated patients to determine if aspiration Conclusion
is needed and in patients with transudative effusions to
monitor their response to therapy. Pleural effusion height measured by US gives a reasonable
This study provides independent validation that ultra- estimate of effusion volume with 79% accuracy when
sound can be used in volume estimation of free-flowing correlated with the actual aspirated volume. The formula
pleural effusion. In previous reports, the study population with the highest level of accuracy used both the distance
was either ICU patients on positive pressure ventilation from chest wall to visceral pleura added to the distance
[14, 15] or ward/outpatients [16]. We included patients from the lung base to the apex of the diaphragm and it
from the both settings for two reasons; first, we wanted to could predict the actual volume with 83% accuracy.
examine the feasibility of performing these measurements
Acknowledgements The authors thank Marwa Hassan for providing
in ICU patients who can, at times, be difficult to mobilise in
the schematic drawings and are very grateful to Dr. Rachel Mercer,
bed. Second, we wanted to establish the reliability of a who critically revised the final manuscript for language and scientific
given equation to accurately predict volume in the presence content.
of positive pressure ventilation or lack thereof. More than
Compliance with ethical standards
one-third of our patients were receiving positive pressure
ventilation, and measurements were feasible in all of them. Conflict of interest None to be declared.
In addition, the inclusion for their measurements provides
evidence that the accurate equations have good predictive Ethical approval This study was approved by the Medical Ethics
capability in this setting. Department of Alexandria Faculty of Medicine.
Different practitioners use different probes. The most Informed consent Informed consent was obtained from all involved
commonly used probes to examine the chest are the curvi- patients.
linear and sector probes [1, 2]. We used both types of probes
and we did not find any difficulty to obtain the desired image Funding MH is a recipient of European Respiratory Society long-
term research fellowship—ERS 2016-7333. This is not related to and
that captures the collapsed lung just above the diaphragm. has not affected the substance of this paper.
The factor that is most important is how comfortable a
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