8/7/2017 Pneumothorax Imaging: Practice Essentials, Radiography, Computed Tomography

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Pneumothorax Imaging
Updated: Mar 29, 2017
Author: Fahad M Al-Hameed, MD, AmBIM, FCCP, FRCPC; Chief Editor: Eugene C Lin, MD more...

Practice Essentials
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, 4]

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. [3, 5, 6, 7, 8, 9, 10, 11, 12,
13] High-resolution thin-slice CT has been found to have a greater senstivity for blebs and bullae than

routine CT. [14] The use of ultrasound for detection of pneumothorax has been studied for both adults
and children and has been shown to be particularly sensitive in newborns. [3, 9, 10, 11, 12, 13, 15, 16, 17]

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

View Media Gallery

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8/7/2017 Pneumothorax Imaging: Practice Essentials, Radiography, Computed Tomography

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

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. [1, 2, 3, 5, 6] In a study of spontaneous pneumothorax in 55 children, 9 had visible bullae on initial
radiograph, and apical emphysematous-like changes (ELC) were identified in 37 children by CT.
The most successful surgical approach was thoracoscopic staple bullectomy and pleurectomy. [3]

In neonates with pneumothorax, [15, 16, 17] ultrasound has been found in some studies to be
comparable to chest radiography. A study by Cattarossi et al found that ultrasound was able to detect
pneumothorax in all 23 affected patients. [15] Another study, by Raimondi et al, found that in 26
critically ill newborns, sensitivity, specificity, positive predictive value, and negative predictive value
were all 100%. [16]

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.

Persistent pneumothorax is defined as a continued air leak from an in situ chest drain for more than
48 hours after insertion. This may result from a kink in, or malposition of, the tube; lung parenchymal
disease; bronchopleural fistula; or esophageal-pleural fistula. [4]

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:

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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.

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.
View Media Gallery

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.
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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).

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

View Media Gallery

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. The supine radiograph is of particular importance in trauma or critically ill patients.
[18]

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

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

Pleural effusions occur coincident with pneumothorax in 2025% of patients, but they usually are quite
small. Hemopneumothorax occurs in 23% 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).

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8/7/2017 Pneumothorax Imaging: Practice Essentials, Radiography, Computed Tomography

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

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

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.

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. [8]

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.)

Multidetector CT (MDCT) has been found to be highly effective in measuring the volume of
pneumothoraces. [19, 20, 21]

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%). [5]
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.

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Ultrasonography
The use of ultrasound for detection of pneumothorax has been studied for both adults and children. [3,
12, 13, 15, 16, 17] On ultrasonography, the sliding movement or lung pulse at the pleural interface

indicates the absence of a pneumothorax. [13]

A study by Kumar et al found that in 8 patients who developed pneumothorax after flexible
bronchoscopy and transbronchial lung biopsy, ultrasonography was able to detect pneumothorax in all
the cases. [13]

In a study of spontaneous pneumothorax in 55 children, 9 had visible bullae on initial radiograph, and
apical emphysematous-like changes (ELC) were identified in 37 children by CT. The most
successful surgical approach was thoracoscopic staple bullectomy and pleurectomy. [3] In neonates
with pneumothorax, [15, 16, 17] ultrasound has been found in some studies to be comparable to chest
radiography. A study by Cattarossi et al found that ultrasound was able to detect pneumothorax in all
23 affected newborns. [15] Another study, by Raimondi et al, found that in 26 critically ill newborns,
sensitivity, specificity, positive predictive value, and negative predictive value were all 100%. [16]

References

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2. Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous pneumothorax:

state of the art. Eur Respir J. 2006 Sep. 28(3):637-50. [Medline].

3. Soccorso G, Anbarasan R, Singh M, Lindley RM, Marven SS, Parikh DH. Management of large
primary spontaneous pneumothorax in children: radiological guidance, surgical intervention and
proposed guideline. Pediatr Surg Int. 2015 Aug 26. [Medline].

4. Chaturvedi A, Lee S, Klionsky N, Chaturvedi A. Demystifying the persistent pneumothorax: role

of imaging. Insights Imaging. 2016 Jun. 7 (3):411-29. [Medline].

5. 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].

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

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

8. Warner BW, Bailey WW, Shipley RT. Value of computed tomography of the lung in the
management of primary spontaneous pneumothorax. Am J Surg. 1991 Jul. 162(1):39-42.
[Medline].

9. Barnes TW, Morgenthaler TI, Olson EJ, Hesley GK, Decker PA, Ryu JH. Sonographically guided
thoracentesis and rate of pneumothorax. J Clin Ultrasound. 2005 Dec. 33(9):442-6. [Medline].

10. Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ. Value of high-resolution ultrasound in
detecting a pneumothorax. Eur Radiol. 2005 May. 15(5):930-5. [Medline].

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11. Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post-interventional

pneumothorax and hydropneumothorax. Comparison to chest radiography. Eur J Radiol. 2005
Mar. 53(3):463-70. [Medline].

12. Quick JA, Uhlich RM, Ahmad S, Barnes SL, Coughenour JP. In-flight ultrasound identification of
pneumothorax. Emerg Radiol. 2015 Sep 25. [Medline].

13. Kumar S, Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Role of ultrasonography in the
diagnosis and management of pneumothorax following transbronchial lung biopsy. J
Bronchology Interv Pulmonol. 2015 Jan. 22 (1):14-9. [Medline].

14. Lee KH, Kim KW, Kim EY, Lee JI, Kim YS, Hyun SY, et al. Detection of blebs and bullae in
patients with primary spontaneous pneumothorax by multi-detector CT reconstruction using
different slice thicknesses. J Med Imaging Radiat Oncol. 2014 Dec. 58 (6):663-7. [Medline].

15. Cattarossi L, Copetti R, Brusa G, Pintaldi S. Lung Ultrasound Diagnostic Accuracy in Neonatal
Pneumothorax. Can Respir J. 2016. 2016:6515069. [Medline].

16. Raimondi F, Rodriguez Fanjul J, Aversa S, Chirico G, Yousef N, De Luca D, et al. Lung
Ultrasound for Diagnosing Pneumothorax in the Critically Ill Neonate. J Pediatr. 2016 Aug.
175:74-78.e1. [Medline].

17. Bhatia R, Davis PG, Doyle LW, Wong C, Morley CJ. Identification of pneumothorax in very
preterm infants. J Pediatr. 2011 Jul. 159 (1):115-120.e1. [Medline].

18. Rierson D, Bueno J. Pneumothorax in the Supine Patient: Subtle Radiographic Signs. J Thorac
Imaging. 2016 Jul. 31 (4):W16-22. [Medline].

19. Cai W, de Moya M. Use of multidetector computed tomography to guide management of

pneumothorax. Curr Opin Pulm Med. 2013 Jul. 19 (4):387-93. [Medline].

20. Do S, Salvaggio K, Gupta S, Kalra M, Ali NU, Pien H. Automated quantification of pneumothorax
in CT. Comput Math Methods Med. 2012. 2012:736320. [Medline].

21. Cai W, Lee JG, Fikry K, Yoshida H, Novelline R, de Moya M. MDCT quantification is the
dominant parameter in decision-making regarding chest tube drainage for stable patients with
traumatic pneumothorax. Comput Med Imaging Graph. 2012 Jul. 36 (5):375-86. [Medline].

22. Light RW. Pleural Diseases. 3rd ed. Baltimore: Williams & Wilkins. 1995.

23. Shostak E, Brylka D, Krepp J, Pua B, Sanders A. Bedside sonography for detection of
postprocedure pneumothorax. J Ultrasound Med. 2013 Jun. 32 (6):1003-9. [Medline].

Media Gallery

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.
Note that although a skin fold can mimic a subtle pneumothorax, lung markings are visible
beyond the skin fold.
Deep sulcus sign in a supine patient in the ICU. The pneumothorax is subpulmonic.
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.

http://emedicine.medscape.com/article/360796-overview 9/11
8/7/2017 Pneumothorax Imaging: Practice Essentials, Radiography, Computed Tomography

Right main stem intubation resulting in left-sided tension pneumothorax, right mediastinal shift,
deep sulcus sign, and subpulmonic pneumothorax
Pneumomediastinum from barotrauma may result in tension pneumothorax and obstructive
shock.
A patient in ICU developed pneumopericardium as a manifestation of barotrauma.

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Contributor Information and Disclosures

Author

Fahad M Al-Hameed, MD, AmBIM, FCCP, FRCPC Chairman, Intensive Care Department, Director,
Ambulatory Care Center (Services), Professor Associate of Medicine/Critical Care, College of
Medicine, King Saud Ben Abdulaziz University 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, 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 Faculty of Medicine; Site Director, Respiratory Medicine, St
Boniface General Hospital, Canada

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,
World Medical Association

Disclosure: Nothing to disclose.

Bruce Maycher, MD

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

Disclosure: Nothing to disclose.

Specialty Editor Board

http://emedicine.medscape.com/article/360796-overview 10/11
8/7/2017 Pneumothorax Imaging: Practice Essentials, Radiography, Computed Tomography

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

Disclosure: Nothing to disclose.

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

School of Medicine

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, Society of Nuclear
Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Additional Contributors

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.

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