Pneumothorax

Correlation
Anteroposterior
Posteroanterior
Radiographs

Byung Gil Choi, MD

Seog Hee Park, MD
Eun Hee Yun, MD
Kyung

Ok Chae,

Kyung

Sub Shinn,

Index terms:
Lung, collapse,
Pneumothorax,
Radiology

MD
MD

60.73
60.73

i998;

From

University
Hospital,

209:567-569

the Department

of Medicine,
of Korea,

of Radiology,

the

Kangnam

relationship
of average
interpleural
tances
on supine
AP and erect
radiographs
and to estimate
the
age pneumothorax
on supine
radiographs
as it has been
on
radiographs
(2).

Findings
in 30 consecutive
patients
with
pneumothorax
were prospectively analyzed.
All patients underwent supine
anteroposterior(AP)
and
erect posteroanterior
(PA) chest radiography.
The interpleural
distances
were
measured
at three
locations.
Average interpleural
distances on supine AP and erect PA radiographs
were analyzed
by means of correlation and linear regression
analysis.
The
authors
developed
a formula
that can be used to estimate the size
of a pneumothorax
on a supine AP
chest radiograph.

Catholic
St Marys

505 Banpo-Dong,
SeochoKu, Seoul 1 37-701,
Korea. Received
December
22, 1 997;
revision
requested
March
10, 1998;
revision
received
May 5; accepted
July 7.
Supported
in part by the Clinical
Research Fund of the College of Medicine, the Catholic
University of Korea.
Address
reprint
requests
to B.G.C.
#{176}RSNA,
1998

A pneumothorax
larger than 35% usually
requires
management
with
a chest
tube
(1), whereas
a smaller
pneumothorax
can
be observed
or aspirated
as long as symptoms
are mild.
The decision
to place
a
chest
tube
is often
based
not
only
on
pneumothorax
size on a single
radiograph
but also on rate of change
in size
on serial

radiographs.

difficult

if some

Comparison

is very

radiographs

are supine

anteropostenior
(AP) and others
are erect
posteroantenior
(PA). Patients
with pneumothorax
are often
too
ill to undergo
erect PA chest
radiography.
In that situation,
supine
AP radiography
is the only
study
Author

Guarantor

Erect

Abbreviations:
AP = anteroposterior
PA = posteroanterior

College

Size:
of Supine
with
Chest

contributions:

of integrity

of entire study,
B.G.C.; study concepts,
S.H.P.; study
design, B.G.C., S.H.P.; definition
of
intellectual
content,
S.H.P.; literature
research,
B.G.C.,
E.H.Y.; clinical studies, B.G.C.,
S.H.P.; data acquisition,
E.H.Y.; data analysis, K.O.C.; manuscript preparation
and editing, B.G.C.;
manuscript
review, B.G.C., K.S.S.

for

our hospital,
radiography
ing modality
4%-5%.

evaluation

of pneumothorax.

the frequency
as the only
in a trauma

In

of supine
AP
available
imagsetting
is about

To our knowledge,
measurement
of the
percentage
pneumothorax
on supine
AP
chest
radiographs
has not been
reported

in the literature.
ent

study

We undertook

to determine

the

the presmathematic

Materials

and

disPA chest
percentAP chest
erect
PA

Methods

FromJune
1994 throughJanuary
1997,
we evaluated
prospectively
53 patients
with sudden
onset
of dyspnea
and chest
pain by means
of supine
AP and erect PA
chest
radiography.
Informed
consent
was
obtained.
Thirty
patients
had a unilateral
pneumothorax,
three
had bilateral
pneumothoraces,
and 20 had no pneumothorax. The 30 patients
with unilateral
pneumothorax
depicted
on
both
sets
of
radiographs
were included
in this study.
The patients
included
22 men
and eight
women
(mean
age, 46 years;
age range,
23-74
years).
Among
the 30 patients,
the unilateral
pneumothorax
was located
on the
left

side

in

21

and

on

the

right

side

in

nine.

The causes
of pneumothorax
were spontaneous
in 20 patients,
iatrogenic
in six,
and
traumatic
in four.
Among
the
20
patients
with
spontaneous
pneumothorax, three
had lung cancer
and eight
had
pulmonary
tuberculosis.
In all 30 cases,
the time between
supine
AP and erect PA
radiography
was less than
10 minutes.
On each
set of supine
AP and erect
PA
chest
radiographs,
the interpleural
tances
were
measured
linearly
at
locations
(Fig 1): apex
and
upper
lower
one-quarter
of the ipsilateral

disthree
and
lung.

At the

apex,
the maximum
vertical
interpleural
distance
was measured
between
the parietal
pleura
on the inferior
border
of the apical
rib and the visceral
pleura
on
the superior
border
of the collapsed
upper
lobe. At the level of the upper
and lower
quarters,
the horizontal
distance
between

567

the panietal
pleura
on the inner
border
of
the rib and
the visceral
pleura
on the
lateral
border
of the passively
collapsed
lung was measured
as described
by Rhea

Parietal

et al in 1982
(2). The radiographs
were
analyzed
by three
radiologists
(B.G.C.,
S.H.P.,
E.H.Y.),
and
the three
distances
were
measured
by consensus.
The three
measurements
were
by 3 to provide

added
the

vided

Upper

half

Lower

half

and then
diaverage
inter-

pleural
distance
(in centimeters).
The average interpleural
distances
on supine
AP
and erect
PA radiographs
were
analyzed
by means
of correlation
and linear
regression

analysis,

package

with

(sAs

a statistical

SAS

sYsr1M;

software

Institute,

Cary,

NC).

Results

Detection
erect

PA

of the

pneumothorax

radiograph

on the

facilitated

its

detec-

tion

on the supine
AP radiograph.
There
were no instances
in which
pneumothorax was detected
on only one of the views
(erect
PA or supine AP).
The
correlation
coefficient
(r) of the
average
interpleural
distance
(AID) measured on supine
AP and on erect PA chest
radiographs

was

0.91,

which

was

radiographs
tion (2-4),

12

ci
0
C
B

U)

--S

studies,
has been

the
percentage
assessed
on chest

has

percentage

radiography

is

been

made

to

pneumothorax

usually

the

if pneumothorax

Radiology

is seen

November1998

to

increase

a)
>

Average Interpleural
Distance
on AP Radiographs

the
basis

---

nadiogracan be
no at-

estimate
on

0)

findings
on a supine
AP chest
radiograph.
Insertion
of a chest
tube can be consid-

#{149}

i.cr

Because
of their critical
condias multiple
trauma
or assisted
some
patients
are not able to

sustain
an erect position
at chest
phy and only supine
radiography
performed.
To our
knowledge,
tempt

Q)D

.2

obtained
in the erect PA posiwhich
is the position
in which

diagnostic

performed.
tion,
such
ventilation,

568

E
0

Discussion

In previous
pneumothorax

ered

14

Cl,

(Fig 3).

initial

hemithorax

Figure 1. Schematic
demonstrates
calculation
of the average
interpleural
distance
(AID) on the basis of measurements
at three locations: AID = (a + b + c)/3, where a is the maximum
apical interpleural
distance,
b is the interpleural
distance
at the midpoint
of the upper
half, and C IS the interpleural
distance
at the midpoint
of the lower
half.

statisti-

cally significant.
We obtained
the following correlation
formula:
AID1,
=
0.43
+
1.14 x AIDAJ. Intercept
and line slope
P
values
were
.16 and
.0001,
respectively
(Fig 2). By using
the traditional
formula
(percentage
pneumothorax
=
4.95 + 8.8 x
AID1)
deduced
from the data of Rhea et al
(2) and by placing
our correlation
formula
into that formula,
we created
a formula
for
estimation
of pneumothorax
size on the
basis of average
interpleural
distances
on
supine
AP radiographs:
percentage
pneumothorax
=
8.73 + 10.03
x AID.
This
formula
was simplified
to 9 + i0(AID1).
We also obtained
a simplified
diagram

Right

of
Figure

axis)
0.43

2.

Scattengram

radiographs.
+ 1.14x.

plots

average

interpleural

distance

on

supine

10

(cm)

AP (x axis)

The A (regression)
line shows predicted
values (r = 0.91), and
The B lines show the 95% Cl. The C lines show the 95% prediction

versus

erect

its formula
interval.

PA (y

is y

Choi et al

(Fig
cm

4.5

45

55

4.0

40

3.5

35

5.0

50

40

careful

30
2.5

35
25

2.0

30

20

25

15

20

10

15

I .5

1.0

.5

Figure

3.

AID
Simplified

A
diagram

tion
basis

B
allows

of the percentage
pneumothorax
of average
interpleural
distance
measured
on erect PA (A) and supine

predicon

the
(AID)

AP (B)
radiographs.
For example,
as derived
with A, if the average
interpleural
distance
on
an erect PA radiograph
is about 2.5 cm, the
percentage
pneumothorax
is about
27%. As
derived
with B, if the average interpleural
distance on a supine
AP radiograph
is about 2.0
cm, the percentage
pneumothorax
is about
chest

29%.

on follow-up
radiographs.
When
the location of the pneumothorax
differs
on the
initial
and follow-up
studies,
it is difficult
to compare
pneumothorax
size on chest
radiographs.
With
our simplified
correlation formula,
9 + 10(AIDAp),
and diagram

Volume

209

Number

#{149}

size

can

be easily

one of the two views,

probably
because
we examined
two views.
Once
the pneumothorax
was detected
on an erect
PA
radiograph,
the detection
of pneumothorax on a supine
AP radiograph,
with

45

3.0

3), pneumothorax

and accurately
estimated
on a supine
AP
chest radiograph,
as it has been traditionally on an erect PA radiograph.
Although
pneumothorax
can be difficult to see on a supine
AP radiograph,
we
did not see any pneumothorax
on only

observation,

was

easier

than

ex-

pected.
In all cases with
pneumothorax,
visceral
pleura
along
the lateral
chest wall
was seen on both
supine
AP and erect PA
radiographs.
Our study
has several
limitations.
First,
because
the intercept
of our unsimplified
formula
is 8.73, it might
mistakenly
mdicate the presence
of an 8.73%
pneumothorax
when
the average
mnterpleural
distance
is zero. Second,
pneumothorax
size
in two cases was beyond
the 95% prediction interval
when
the average
interpleural distance
on a supine
AP radiograph
was larger
than
4 cm (Fig 2). Third,
we
have
no standard
of reference
such
as
spiral
CT. However,
a patient
with
mild
pneumothorax
smaller
than
8.73%
usually
undergoes
conservative
treatment,
and
average
interpleural
distance
larger
than
4 cm indicates
severe
pneumothorax, which
requires
management
with
a
chest
tube.
With
borderline
pneumothorax, we encountered
no major
problems
in applying
our simplified
formula
and
diagram.
We used the usual
method,
described
by Rhea et al (2), as the standard
of reference.
Collins
et al (3) reported
a correlation
formula
for pneumothorax
size as depicted
on an erect
PA chest
radiograph
and
on a helical
CT scan.
The formula

raised
the question
of variable
lung
and
chest
cavity
volume
based
on posture.
Alterations
in lung
and
chest
cavity
volume
after
changes
in posture
have
been
described.
In a healthy
person,
the
lung and chest cavity
volume
decreases
in
the supine
position
due to upward
displacement
of the
diaphragm.
This
is
thought
to be the
result
of increased
congestion
of pulmonary
vessels
in this
posture
(3,5).
For accurate
evaluation
of
pneumothorax

size

radiograph,

on

correlation

supine

chest

of pneumothorax

size as depicted
on a supine
chest
radiograph
and on a breath-hold
spiral CT scan
is required.
In conclusion,
with our simplified
correlation
formula
and diagram,
pneumothorax
size can be estimated
easily
and
accurately
on supine
AP chest
radiographs
as it has been
on erect
PA radiographs.
This
method
will be especially
useful
when
a patient
undergoes
erect PA
and supine
AP chest radiography
at different times.
References
1. Casola G, vanSonnenberg
E, Keightley
A,
Ho M, Withers
C, Lee AS. Pneumothorax:
radiologic
treatment
with small catheters.
Radiology
1988; 166:89-91.
2. Rhea iT, DeLuca SA, Greene RE. Determining the size of pneumothorax
In the upright

3.

from

4.

5.

patient.

Radiology

736.
Collins
CD, Lopez
Jackson
JE, Roddie
pneumothorax
size
using
interpleural
analysis
based on
helical

1982;

144:733-

A, Mathie
A, Wood V.
ME. Quantification
of
on chest radlographs
distances:
regression
volume
measurements

CT. AJR 1995;

165:1127-1130.

Axel L. A simple way to estimate

the size of
a pneumothorax.
Invest Radiol 1981; 16:
165-166.
Blair E, Hickam JB. The effect of change
in
body posture on lung volume and intrapulmonary
gas mixing
in normal
subjects.
J
Clin Invest 1955; 34:383-389.

Pneumothorax

Size on Chest

Radiographs

569

#{149}