William Herring, M.D.

2002

Recognizing
A Pneumothorax
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Remember

There are two layers of pleura- parietal and visceral-the

pleural space between them
Normally there is no air in the pleural space
The visceral pleura is inseparable from the lung parenchyma
and moves with the lung

Visceral
pleura

Pleural space

Parietal
pleura

Frank Netter, MD Novartis

The Visceral Pleural White Line

When air enters the pleural space, the parietal and visceral
pleura separate making the visceral pleura visible

The thin white line of the visceral pleura is called the

visceral pleural white line

You must see the visceral pleural white line to make

diagnosis of pneumothorax!

A pneumothorax will be
visible as a thin white
line - the visceral pleural
white line

Lung Markings
Lung markings may be absent distal to the visceral pleural
white line

But they can be seen distal to the visceral pleural white line
even with a pneumothorax if lung is folded on itself

Absence of lung markings is not sufficient to make diagnosis

of pneumothorax!

Why The Pleural White Line

Is Important

ARRS R3

Large bulla in the LLL. Note there is no

visceral pleural white line paralleling the chest wall

Why The Pleural White Line

Is Important

ARRS R3

Chest tube erroneously inserted into bulla

in LUL produces an intractable pneumothorax.

Why The Pleural White Line

Is Important
There are diseases other than a pneumothorax that
can cause an absence of lung markings

For example

Bullous disease

Large cysts in the lung

Pulmonary embolism

Why The Pleural White Line

Is Important

None of those diseases is treated with a chest

tube

In fact, insertion of a chest tube into a bulla can

produce an intractable pneumothorax

Skin fold or Pneumothorax

A fold of the patients skin may become trapped between
the patient and cassette

Skin folds are common

Especially in patients who have lost a great deal of

weight

This skin fold can mimic a pneumothorax

Skin Fold

Pneumothorax

How can we tell them apart?

This is an edge
Dense
Lucent

Skin Fold
The key difference is that a skin fold is an edge
consisting of a density (light) and then a lucency (dark)

This is a line
Lucent
Dense
Lucent

Pneumothorax

Whereas the visceral pleural line is a

thin white line with a lucency (darker) on both sides of it

Skin Fold

Pneumothorax

Here they are again side-by-side: the skin fold is an edge,

the pneumothorax is a line

Which is this?

Skin fold or Pneumothorax

This is an
edge =
skin fold

Which is this?

Skin fold or Pneumothorax

This is a line =
pneumothorax

Types of Pneumothoraces

Two major types of pneumothorax

Simple

Tension

Simple Pneumothorax
In a simple pneumothorax, there is no shift of
the heart or mediastinal structures (trachea)

Air in left hemithorax balances the air in the

right hemithorax

No shift of
midline
structures

Visceral
pleural white
line

Simple pneumothorax on the left side

No shift of the heart or trachea

Tension Pneumothorax
Progressive loss of air into pleural space causing a
shift of the heart and mediastinal structures away from
side of pneumothorax

Opposite lung is compressed

Respiratory function severely compromised

Tension Pneumothorax

Frank Netter, MD Novartis

Air enters Right hemithorax either from tear in lung or hole in chest
wall on inspiration; does not exit on expiration

Complete right-sided
pneumothorax
Lung is compressed
against mediastinum

Shift of heart and

trachea to left

Which is this?

Simple or Tension Pneumothorax

Tension pneumothorax-heart is shifted slightly

to right by large left-sided pneumothorax

Shifts with a Pneumothorax

If simple, there is no shift of heart and/or trachea

If tension, there is a shift of heart and/or trachea

away from side of pneumothorax

There is never a shift toward the side of a

pneumothorax

Causes of a Pneumothorax
Spontaneous

Rupture of an apical sub-pleural bleb usually in a tall,

thin male

Trauma

Through chest wall, e.g. stab wound

Internal, e.g. rupture of a bronchus from a motor vehicle

collision

Causes of a Pneumothorax
Diseases that decrease lung compliance

Chronic fibrotic diseases, e.g. eosinophilic granuloma

Diseases that stiffen the lung, e.g. hyaline membrane

disease

Rupture of an alveolus or bronchiole

E.g., asthma

Important Points

You must see the visceral pleural white line to

diagnose a pneumothorax

A skin fold is an edge; the visceral pleural line

is a line

There is a never a shift toward the side of a

pneumothorax

Pneumothorax

The visceral pleural white

line is seen and there are no
lung marking distal to it. This
is a simple pneumothorax
since there is no shift.

No Pneumothorax

This is a skin fold. It is an edge,

not a line.

No Pneumothorax

This is a skin
fold. It is an
edge, not a
line.

ARRS R3

Pneumothorax

There is a left-sided
tension
pneumothorax with
shift of the heart
and mediastinal
structures to the
right.