Pleural effusion physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]


Physical findings for effusions are determined by the volume of pleural fluid and the extent of lung compression. Pleural fluid also interferes with transmission of low-frequency vibrations and results in diminished tactile fremitus, asymmetric chest expansion, decreased or absent fremitus posteriorly and laterally, dullness on percussion, decreased or absent breath sounds, and reduced vocal resonance.[1]

Physical Examination

Physical signs for pleural effusions were first recognized by Josef Leopold Auenbrugger, who described dullness to percussion and diminished expansion of the chest wall,[2] and René-Théophile-Hyacinthe Laennec, who described the abnormal vocal resonance and bronchial breath sounds in patients with effusions.[3] Excessive accumulation of fluid in the pleural cavity expands the hemithorax and collapses the involved lungs, which produces asymmetric chest expansion with reduced breath sounds. Pleural fluid also interferes with transmission of low-frequency vibrations and results in diminished tactile fremitus. Asymmetric chest expansion, diminished fremitus, dullness on percussion, decreased or absent breath sounds, and reduced vocal resonance were reported to have a sensitivity and specificity of 74% and 91%, 82% and 86%, 89% and 81%, 88% and 83%, and 76% and 88%, respectively.[1]

Physical Findings Based on Pleural Fluid Volume[4][5]

Pleural fluid volume Physical findings
250 to 300 ml May be unremarkable
500 ml Decreased intensity of breath sounds
Dullness to percussion
Decreased fremitus
1000 ml Absence of inspiratory retraction
Mild bulging of the intercostal spaces
Decreased chest expansion
Bronchovesicular breath sounds of decreased intensity
Dullness to percussion up to the level of the scapula and axilla
Decreased or absent fremitus posteriorly and laterally
When fluid fills the entire hemithorax No expansion of the chest wall
Bulging of the intercostal spaces
Minimal bronchovesicular breath sounds
Dullness to percussion over the entire hemithorax
A palpable liver or spleen due to diaphragmatic depression


  1. 1.0 1.1 Kalantri S, Joshi R, Lokhande T; et al. (2007). "Accuracy and reliability of physical signs in the diagnosis of pleural effusion". Respir Med. 101 (3): 431–8. doi:10.1016/j.rmed.2006.07.014. PMID 16965906. Unknown parameter |month= ignored (help)
  2. Auenbrugger, Leopold (1763). Inventum novum ex percussione thoracis humani ut signo abstrusos interni pectoris morbos detegendi. Vindobonae : Typis Joannis Thomae Trattner, MDCCLXIII.
  3. Laennec, René-Théophile-Hyacinthe (1823). A treatise on the diseases of the chest :in which they are described according to their anatomical characters, and their diagnosis, established on a new principle by means of acoustic instruments.
  4. Leopold SS; Hopkins HU (1965). Principles and methods of physical diagnosis (3rd ed.). W.B. Saunders. ISBN 0721647707.
  5. Sahn SA (1982). "The differential diagnosis of pleural effusions". West J Med. 137 (2): 99–108. PMC 1274018. PMID 6182697.

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