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Pneumothorax Imaging

Article · August 2013

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Pneumothorax Imaging
• Author: Fahad M Al-Hameed, MD, AmBIM, FCCP, FRCPC; Chief Editor: Eugene C Lin, MD more...
 

Updated: Aug 1, 2013

 

Overview
Pneumothorax, the presence of air within the pleural space, is considered to be one of the most common forms of
thoracic disease. It is classified as spontaneous (not caused by trauma), traumatic, or iatrogenic (see the images
below).[1, 2, 3]

A large, right-sided pneumothorax has occurred from a rupture of a subpleural bleb.

A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the
pleural line.

Spontaneous pneumothorax may be either primary (occurring in persons without clinically or radiologically apparent
lung disease) or secondary (in which lung disease is present and apparent). Most individuals with primary
spontaneous pneumothorax (PSP) have unrecognized lung disease; many observations suggest that spontaneous
pneumothorax often results from rupture of a subpleural bleb.

Traumatic pneumothorax is caused by penetrating or blunt trauma to the chest, with air entering the pleural space
directly through the chest wall, through visceral pleural penetration, or through alveolar rupture resulting from sudden
compression of the chest.

Iatronic pneumothorax results from a complication of a diagnostic or therapeutic intervention. With the increasing use
of invasive diagnostic procedures, iatrogenic pneumothorax likely will become more common, although most cases
are of little clinical significance.

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Complications of pneumothorax

In most reported series, the rate of recurrence of spontaneous pneumothorax on the same side is as much as 30%;
on the contralateral side, the rate of recurrence is approximately 10%.

Other complications include the following:

• Reexpansion pulmonary edema

• Bronchopleural fistula - Occurs in 3-5% of patients
• Pneumomediastinum and pneumopericardium

Tension pneumothorax may occur after spontaneous pneumothorax, although it is more common after traumatic
pneumothorax or with mechanical ventilation.

Preferred examination

Chest radiography is the first investigation performed to assess pneumothorax, because it is simple, inexpensive,
rapid, and noninvasive; however, it is much less sensitive than chest computed tomography (CT) scanning in
detecting blebs or bullae or a small pneumothorax.[4, 5, 6, 7, 8, 9, 10]

Radiography
The diagnosis of pneumothorax is established by demonstrating the outer margin of the visceral pleura (and lung),
known as the pleural line, separated from the parietal pleura (and chest wall) by a lucent gas space devoid of
pulmonary vessels. The pleural line appears in the image below).

A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the
pleural line.

The pleural line may be difficult to detect with a small pneumothorax unless high-quality posteroanterior and lateral
chest films are obtained and viewed under a bright light. A skin fold may mimic the pleural line; usually, the patient is
asymptomatic (see the image below).

Note that although a skin fold can mimic a subtle pneumothorax, lung markings are visible beyond the skin fold.

In erect patients, pleural gas collects over the apex, and the space between the lung and the chest wall is most
notable at that point (see the image below).

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Pneumothorax Imaging Page 3 of 6

A large, right-sided pneumothorax has occurred from a rupture of a subpleural bleb.

In the supine position, the juxtacardiac area, the lateral chest wall, and the subpulmonic region are the best areas to
search for evidence of pneumothorax (see the image below). The presence of a deep costophrenic angle on a
supine film may be the only sign of pneumothorax; this has been termed the deep sulcus sign.

Deep sulcus sign in a supine patient in the ICU. The pneumothorax is subpulmonic.

When a suggested pneumothorax is not definitively observed on an inspiratory film, an expiratory film may be helpful.
At end expiration, the constant volume of the pneumothorax gas is accentuated by the reduction of the hemithorax,
and the pneumothorax is recognized more easily. Similar accentuation may be obtained with lateral decubitus
studies of the appropriate side (for a possible left pneumothorax, a right lateral decubitus film of the chest should be
obtained, with the beam centered over the left lung).

The most common radiographic manifestations of tension pneumothorax are mediastinal shift, diaphragmatic
depression, and rib cage expansion (see the image below).

An older man admitted to ICU postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small-
bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift
is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position.

Any significant degree of displacement of the mediastinum from the midline position on maximum inspiration, as well
as any depression of the diaphragm, should be taken as evidence of tension (see the image below), although a
definite diagnosis of tension pneumothorax is difficult to make on the basis of radiographic findings. The degree of
lung collapse is an unreliable sign of tension, since underlying lung disease may prevent collapse even in the
presence of tension.

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Pneumothorax Imaging Page 4 of 6

Right main stem intubation resulting in left-sided tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic
pneumothorax

Pleural effusions occur coincident with pneumothorax in 20–25% of patients, but they usually are quite small.
Hemopneumothorax occurs in 2–3% of patients with spontaneous pneumothorax. Bleeding is believed to represent
rupture or tearing of vascular adhesions between the visceral and parietal pleura as the lung collapses.

False positives/negatives

Differentiating the pleural line of a pneumothorax from that of a skin fold, clothing, tubing, or chest wall artifact is
important. Careful inspection of the film may reveal that the artifact extends beyond the thorax or that lung markings
are visible beyond the apparent pleural line. In the absence of underlying lung disease, the pleural line of a
pneumothorax usually parallels the shape of the chest wall (see the images below).

A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the
pleural line.

Note that although a skin fold can mimic a subtle pneumothorax, lung markings are visible beyond the skin fold.

Artifactual densities usually do not parallel the course of the chest wall over their entire length. Avascular bullae or
thin-walled cysts may be mistaken for a pneumothorax. The pleural line caused by a pneumothorax usually is bowed
at the center toward the lateral chest wall. Unlike in pneumothorax, the inner margins of bullae or cysts usually are
concave rather than convex and do not conform exactly to the contours of the costophrenic sulcus. A pneumothorax
with a pleural adhesion also may simulate bullae or lung cysts.

Computed Tomography
CT scanning of the chest is being used with increasing frequency in patients with pneumothorax. CT may be
necessary to diagnose pneumothorax in critically ill patients in whom upright or decubitus films are not possible.

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As indicated in a study by Warner et al, CT scanning may prove helpful in predicting the rate of recurrence in patients
with spontaneous pneumothorax. The authors found that patients with larger or more numerous blebs, as
demonstrated on thoracic CT, are more likely to experience recurrences.[7]

CT demonstrates focal areas of emphysema in more than 80% of patients with spontaneous pneumothorax, even in
lifelong nonsmokers. These areas are situated predominantly in the peripheral regions of the apex of the upper
lobes. (In patients in whom emphysema is not apparent on CT, it often is evident at surgery or on pathologic
examination.)

Degree of confidence

In a study by Mitlehner et al of 35 patients with PSP, localized emphysema with or without bulla formation was
identified on CT in 31 patients (89%) and on radiographs in 15 patients (43%).[4] Abnormal findings were observed in
the lung ipsilateral to the pneumothorax on 28 CT scans (80%) and on 11 chest radiographs (31%); abnormal
findings were observed in the contralateral lung on 23 CT scans (66%) and on 4 chest radiographs (11%). In most
patients, the abnormal findings consisted of a few localized areas of emphysema (n < 5) measuring less than 2 cm in
diameter.
 

Contributor Information and Disclosures

Author
Fahad M Al-Hameed, MD, AmBIM, FCCP, FRCPC  Deputy Chairman, Intensive Care Department, Director,
Ambulatory Care Center (Services), Professor Assistant of Medicine/Critical Care, College of Medicine, King Saud
Ben Abdulaziz for Health Sciences; Consultant in Critical Care and Pulmonary Medicine, King Khalid National
Guard Hospital, King Abdulaziz Medical City, Saudi Arabia

Fahad M Al-Hameed, MD, AmBIM, FCCP, FRCPC is a member of the following medical societies: American
College of Chest Physicians, American Thoracic Society, Canadian Medical Association, Royal College of
Physicians and Surgeons of Canada, and Saudi Association for Venous Thrombo-Embolism

Disclosure: Nothing to disclose.

Coauthor(s)
Sat Sharma, MD, FRCPC  Professor and Head, Division of Pulmonary Medicine, Department of Internal
Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine,
American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine,
American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada,
Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Bruce Maycher, MD  Director of Pulmonary Radiology, St Boniface General Hospital; Associate Professor,

Department of Radiology, University of Manitoba

Bruce Maycher, MD is a member of the following medical societies: American Roentgen Ray Society, Canadian
Medical Association, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Satinder P Singh, MD, FCCP  Professor of Radiology and Medicine, Chief of Cardiopulmonary Radiology,
Director of Cardiac CT, Director of Combined Cardiopulmonary and Abdominal Radiology, Department of
Radiology, University of Alabama at Birmingham School of Medicine

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD  Consulting Staff, Department of Specialist Rehabilitation Services, Hutt
Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

http://emedicine.medscape.com/article/360796-overview 8/14/2014
 Pneumothorax Imaging Page 6 of 6

W Richard Webb, MD  Professor, Department of Radiology, University of California, San Francisco, School of

Medicine

Disclosure: Nothing to disclose.

Robert M Krasny, MD  Resolution Imaging Medical Corporation 

Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and
Radiological Society of North America

Disclosure: Nothing to disclose.

Chief Editor
Eugene C Lin, MD  Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency
Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington
School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine,
American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine

Disclosure: Nothing to disclose.

References
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2. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. Mar 23 2000;342(12):868-74. [Medline].

3. Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous pneumothorax: state of the
art. Eur Respir J. Sep 2006;28(3):637-50. [Medline].

4. Mitlehner W, Friedrich M, Dissmann W. Value of computer tomography in the detection of bullae and blebs
in patients with primary spontaneous pneumothorax. Respiration. 1992;59(4):221-7. [Medline].

5. Lesur O, Delorme N, Fromaget JM, et al. Computed tomography in the etiologic assessment of idiopathic
spontaneous pneumothorax. Chest. Aug 1990;98(2):341-7. [Medline].

6. Slater A, Goodwin M, Anderson KE, Gleeson FV. COPD can mimic the appearance of pneumothorax on
thoracic ultrasound. Chest. Mar 2006;129(3):545-50. [Medline].

7. Warner BW, Bailey WW, Shipley RT. Value of computed tomography of the lung in the management of
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8. Barnes TW, Morgenthaler TI, Olson EJ, Hesley GK, Decker PA, Ryu JH. Sonographically guided
thoracentesis and rate of pneumothorax. J Clin Ultrasound. Dec 2005;33(9):442-6. [Medline].

9. Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ. Value of high-resolution ultrasound in detecting a
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