CASE

REPORT

The Journal of TRAUMA Injury, Infection, and Critical Care

Enhanced Recognition of Lung Sliding with Power Color

Doppler Imaging in the Diagnosis of Pneumothorax
Johann Cunningham, MD, FRCSC, Andrew W. Kirkpatrick, MD, FRCSC, Savvas Nicolaou, MD, FRCPC,
David Liu, MD, Douglas R. Hamilton, MD, Bernard Lawless, MD, FRCSC, Mark Lee, BSc,
CDR D. Ross Brown, MD, FRCSC, and Richard K. Simons, MD, FRCSC
J Trauma. 2002;52:769 771.

ltrasonographic assessment of the thorax for the detection of pneumothoraces is now well documented in the
literature.1 6 Several groups have also specifically described the diagnosis of posttraumatic pneumothorax using
sonography,7,8 further noting that it may be more sensitive in
the detection of pneumothoraces as compared with plain
supine anteroposterior (AP) chest radiography.9 Determination of the presence of a pneumothorax relies on excluding
the presence of normal physiologic to-and-fro pleural motion synchronized with respiration, a sonographic sign that
has been labeled as the lung gliding or sliding sign. With
the advent of portable handheld ultrasound devices, trauma
sonography may be performed in a number of nontraditional
settings including remote locations, military operations, or in
a first responder/paramedical environment. Unfortunately, at
present, as the diagnostic criteria to exclude pneumothorax
requires real-time imaging (and subsequently a large media
footprint to archive the entire examination), the portability of
the technique is greatly limited, defeating the original aim of
such portable devices. We describe a modified examination
focusing on the use of power color Doppler to facilitate the
diagnosis of pneumothorax in a patient after blunt trauma.
Power color Doppler allows the synthesis of the dynamic
lung sliding process into a single still image with implications for image storage, documentation, transmission, and
interpretation.

CASE REPORT
A 16-year-old man sustained blunt trauma to the thorax after
a fall. He was transferred directly from the scene to a tertiary
care hospital. An emergent supine AP chest radiograph was
obtained, which revealed a small right-sided hemopneumothorax, for which a tube thoracostomy was placed (Fig. 1).
Submitted for publication September 4, 2001.
Accepted for publication November 12, 2001.
Copyright 2002 by Lippincott Williams & Wilkins, Inc.
From the Sections of Trauma (J.C., A.W.K., B.L., D.R.B., R.K.S.) and
Radiology (S.N., M.L.), Vancouver General Hospital, Vancouver, British
Columbia, and Wyle Life Sciences (D.R.H.), Houston, Texas.
Address for reprints: Andrew W. Kirkpatrick, MD, FRCSC, Trauma
Services, Vancouver Hospital and Health Sciences Centre, 3rd Floor, 855
West 10th Avenue, Vancouver, British Columbia V5Z 1L7, Canada; email:
akirkpat@vanhosp.bc.ca.

Volume 52 Number 4

Before placement, a portable sonogram of the chest was

obtained using the Sonosite 180 portable handheld ultrasound
unit (Sonosite, Bothell, WA), using a L38 broadband linear
array 10- to 5.0-MHz transducer. There was clear evidence of
lung sliding and comet-tail artifacts over the normal left
chest. There was also a distinct color power Doppler signal at
the thoracopleural interface (Fig. 2). However, no lung sliding, comet tail artifacts, or color power Doppler signal was
detected at the right pleural interface (Fig. 3). (Real-time
sonographic videos of the complete scanning sequence can
also be downloaded at http://www.vghtraumaresearch.com.
The pneumothorax resolved with treatment and the patient
made an uneventful recovery, being discharged 96 hours
later.

DISCUSSION
Pneumothorax frequently accompanies penetrating chest
trauma, significant blunt chest injuries may follow barotrauma, and is a leading cause of preventable morbidity and
mortality. Most pneumothoraces are detected through a combination of clinical symptoms and plain chest radiography. In
settings where the clinical findings and plain film chest radiograph are not confirmatory in diagnosing the pneumothorax, computed tomography may be used. Many remote and
isolated locations may not have radiography equipment, radiology technicians, or radiologists readily available. Sonography has generally not been routinely used in the emergent
diagnosis of pneumothoraces. However, recent advances in
both technology and technique have demonstrated the ability
to use sonography in the emergency diagnosis of thoracic
trauma, and several groups have reported early success in
diagnosing posttraumatic pneumothoraces.79 Coupled with
the recent availability of portable handheld ultrasound units,
sonography might provide an imaging modality with portability and accessibility unheralded in prehospital, military,
and disaster medicine.
Although still a novel technique in acute trauma resuscitations, the use of sonography to infer the presence of
pneumothorax has an established scientific basis. The first
case report documenting the use of sonography to diagnose a
pneumothorax was in a horse,10 and the first reported human
use was described in 1987.3 These first reports inferred the
presence of a pneumothorax when lung sliding and comet tail
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The Journal of TRAUMA Injury, Infection, and Critical Care

Fig. 1. Anteroposterior supine chest radiograph confirming the

presence of a right hemopneumothorax before treatment with a tube
thoracostomy.

artifacts were not identified. Most groups have gone on to

confirm these findings in a number of settings with the same
conclusions. It has been consistently found that the identification of lung sliding confidently excludes a pneumothorax,
and the confidence in this determination is strengthened
through the detection of comet tail artifacts.1,4 6 These artifacts are believed to be small, subpleural, water-rich struc-

Fig. 2. Black and white representation of static longitudinal

sonographic color power Doppler image obtained with a 10to 5-MHz linear probe of the left anterior hemithorax with power
color Doppler signal present (power slide) confirming movement at the visceroparietal pleural interface. This finding confirms pleural apposition, excluding pneumothorax. (See http://
www.vghtraumaresearch.com for real-time video.)

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Fig. 3. Black and white representation of static longitudinal sonographic color power Doppler image obtained with a 10- to
5-MHz linear probe of the anterior right hemothorax. Images show
absent power color Doppler signal (no power slide) from the
thoracopleural interface, because of the absence of synchronized
to-and-fro motion of the visceral pleura in apposition with the
parietal pleura, because of pneumothorax-induced pleural separation. (See http://www.vghtraumaresearch.com for real-time video.)

tures surrounded by air in the visceral pleura that are the

sonographic equivalent of the familiar Kerley B lines in the
interlobular septae.11
Not all reports have been without caution. Sistrom reported a high interobserver variability and a positive predictive value of only 40% in diagnosing pneumothorax on the
basis of a retrospective videotape review. These findings
seem to emphasize that both ultrasonographic examination
and normal lung excursion are dynamic processes that require
real-time imaging (because of the high degree of operator
dependence) and real-time interpretation (to observe lung
sliding and comet tail artifact).
We propose, though, that presence or absence of the
dynamic pleural lung sliding, captured on a single static
image using power color Doppler may provide enough information to diagnose pneumothorax. The absence of a power
color Doppler signal (which we have coined the power
slide) at the thoracopleural interface may serve as a criterion
in identification of pneumothorax that has not been described
in the literature to date. The technique requires a high-frequency linear array transducer (within the 7- to 10-Mhz
range) and an ultrasound device capable of power color
Doppler imaging. For the purposes of this case report, a
Sonosite 180 ultrasound device was paired with a 10- to
5-MHz multifrequency linear transducer (5/10L38, Sonosite).
With the linear probe in position, the thoracopleural interface
is identified as an echogenic interface between the shadowing
ribs. The color power Doppler signal is then activated. The
area of imaging is centered over the interface and the gain is
gradually increased. In normal lung without a pneumothorax,
as the gain is increased, there will be a flow signal initially at
April 2002

Recognition of Lung Sliding in Diagnosis of Pneumothorax

the interface corresponding to the gliding or sliding movement of the two pleural surfaces, confirming apposition, and
thus excluding pneumothorax. If there is a pneumothorax
present, there will be no color power Doppler signal obtained
at the interface and, as the signal gain is increased, there will
be spurious noise throughout all layers of the image, including proximal to the thoracopleural interface. Because of the
nature of the Doppler wave shift, care must be taken to hold
the transducer in a fixed location for this aspect of the
examination.
Color Doppler (or duplex Doppler) imaging applies the
well-known principle of the Doppler effect to translate reactive shifts in the frequency of transmitted waves to identify
and quantify movement. With conventional duplex Doppler,
color depicts both direction and velocity of flow. Power color
Doppler (also known as amplitude-encoded color Doppler)
analyzes and displays the integrated power regardless of flow
velocity or direction. The color map or spectrum is a reflection of the intensity of the signal and approximates the number of moving reflectors within a given volume.1214 Power
color Doppler is superior to regular color Doppler in determining the presence or absence of flow, at the expense of
direction and speed information.12,13,15 Subsequently, power
color Doppler has the ability to identify low-velocity and
low-volume flow (or motion). One of the most important
differences between the two Doppler modes relates to characteristics at low intensities and velocities. High gain settings
that would produce noise that obscures conventional color
Doppler generate only a nondescript homogeneous appearance with power color Doppler, with the image remaining
interpretable.1315 Furthermore, although respiratory artifacts
and the ability to identify flow on the near fields were initially
felt to be limitations of power color Doppler, they prove to be
ideal for the power slide examination.
Our report demonstrates a successful diagnosis of a small
pneumothorax with power color Doppler ultrasound in a
patient with blunt trauma, which was confirmed by standard
supine AP chest radiography. Like all areas of sonography,
the real-time presence of an experienced sonographer and the
real-time study of a dynamic physiologic process are invaluable. The use of the power color Doppler mode to detect the
pleural sliding movement is an enhancement of the diagnostic
technique. Particular benefits of this evaluation include the
simplification of the documentation and interpretation process. If either an operator or a remote reviewer notes a
positive power color Doppler signal specifically from the
pleural interface, it is inferred that there must be two pleural
surfaces moving in apposition to each other to generate the
signal and hence no pneumothorax. This single sonographic
image thus represents the dynamic sliding process without the
need to record a lengthy period of the respiratory cycle. With

Volume 52 Number 4

appropriate software, the whole process might be automated,

giving a diagnosis of absence of pneumothorax, without operator interpretation being required.
We suggest that trauma sonographers consider using the
power color Doppler mode in the examination for ruling out
pneumothorax, in the examination that we recognize as the
extended focused assessment with sonography for trauma
(EFAST). We have incorporated this technique into our clinical practice and continue to audit our results.

ACKNOWLEDGMENT
We thank the Sonosite Corporation for the loan of a Sonosite 180
ultrasound unit for clinical testing.

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