Sometimes, the rub is confused with low-pitched rhonchi, produced by secretions partially blocking the airway A vigorous cough will eliminate these secretions and sounds but will not affect the pleural friction rub Grunting may occur, although this is typically related to pain rather than respiratory distress in most patients with dry pleurisy For patients with pleural effusions, characteristic physical findings include restriction of movement of the chest wall on the affected side, dullness to percussion, decreased or absent breath sounds, and diminished to absent tactile and vocal fremitus These signs are similar to patients with large areas of atelectasis or collapse, although pleural effusions decrease the available space within the hemithorax, which may cause the trachea to deviate away from the diseased side Conversely, atelectasis can cause the trachea to deviate toward the diseased side Radiographs may be used to evaluate for pleural thickening or effusion, as well as to help determine underlying etiology Pleural inflammation alone can be difficult to appreciate on CXRs Instead, effusion is the most common radiographic manifestation of pleural disease The first radiographic sign of a pleural effusion is usually blunting of the costophrenic angles on upright posteroanterior (PA) or AP CXR views, producing wedge-like menisci that extend upward along the lateral chest wall Similar collections can be seen in the posterior costophrenic angles on lateral views Larger effusions may be seen to extend up the entire lateral chest wall or retrosternally Pleural effusions may alternatively present with apparent prominence or thickening of the interlobar fissures or by wedge-shaped accumulations of fluid at either end of these fissures The latter may be mistaken for focal infiltrates or segmental atelectasis on some views Although small effusions may be overlooked on radiograph, with proper technique, collections as small as 25 mL have been identified In adults, pleural effusions are visible on lateral CXRs at a volume of approximately 50 mL At a volume of 200 mL, the meniscus can be identified on the PA radiograph, whereas at a volume of 500 mL, the meniscus obscures the hemidiaphragm Ultrasound has been shown to have increased sensitivity compared to radiography in determining the presence of effusion, and has added benefit in providing more detailed information including determining the presence of complex effusion with possible loculations (see Chapter 131 Ultrasound ) Management Management of pleural disease should focus on determining the cause, treating the primary disorder, and relieving associated functional cardiopulmonary