TRAUMA/CASE REPORT

A Method to Detect Occult Pneumothorax With

Chest Radiography
Shokei Matsumoto, MD, Masanobu Kishikawa, MD, Koichi Hayakawa, MD, Atsushi Narumi, MD,
Katsutoshi Matsunami, MD, Mitsuhide Kitano, MD
From the Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Kanagawa, Japan (Matsumoto,
Kitano); and the Division of Trauma, Critical Care, Burns, Saiseikai Fukuoka General Hospital, Fukuoka-city, Fukuoka, Japan (Kishikawa,
Hayakawa, Narumi, Matsunami).

Small pneumothoraces are often not visible on supine screening chest radiographs because they develop anteriorly
to the lung. These pneumothoraces are termed occult. Occult pneumothoraces account for an astonishingly high
52% to 63% of all traumatic pneumothoraces. A 19-year-old obese woman was involved in a head-on car accident.
The admission anteroposterior chest radiographs were unremarkable. Because of the presence of right chest
tenderness and an abrasion, we suspected the presence of a pneumothorax. Thus, we decided to take a supine
oblique chest radiograph of the right side of the thorax, which clearly revealed a visceral pleural line, consistent
with a diagnosis of traumatic pneumothorax. A pneumothorax may be present when a supine chest radiograph
reveals either an apparent deepening of the costophrenic angle (the deep sulcus sign) or the presence of 2
diaphragm-lung interfaces (the double diaphragm sign). However, in practice, supine chest radiographs have poor
sensitivity for occult pneumothoraces. Oblique chest radiograph is a useful and fast screening tool that should be
considered for cases of blunt chest trauma, especially when transport of critically ill patients to the computed
tomographic suite is dangerous or when imminent transfer to another hospital is being arranged and early
diagnosis of an occult pneumothorax is essential. [Ann Emerg Med. 2011;57:378-381.]

0196-0644/$-see front matter

Copyright 2010 by the American College of Emergency Physicians.
doi:10.1016/j.annemergmed.2010.08.012

INTRODUCTION with CT confirmation in a blunt trauma patient who had an

Traumatic pneumothoraces are a frequent cause of
preventable trauma death, despite that the majority of
pneumothoraces can be treated with a simple tube
thoracostomy. Even a small pneumothorax may progress and
can be life threatening in patients receiving general anesthesia or
mechanical ventilation. Thus, early and accurate diagnosis of
pneumothoraces is essential. At present, the advanced trauma
life support guidelines recommend that anteroposterior chest
radiographs be taken in cases of chest trauma.1 However, small
pneumothoraces are often not visible on supine screening chest
radiographs because they develop anteriorly to the lung. These
pneumothoraces are detected with thoracic or abdominal
computed tomography (CT) and termed occult.2 Occult
pneumothoraces account for an astonishingly high 52% to 63%
of all traumatic pneumothoraces.3-5 Occult pneumothoraces
may rapidly progress to tension pneumothoraces if they are
misdiagnosed or diagnosed too late, especially in patients
receiving mechanical ventilation.6,7 CT scans are highly
sensitive for detecting small pneumothoraces. However, it is
difficult to perform CT scans on patients in severe shock, and
CT scanning facilities are limited in developing countries. Thus,
we describe a method to detect occult pneumothoraces with
supine oblique chest radiograph (Figure, A). Here we report an
occult pneumothorax diagnosed by oblique chest radiograph
unremarkable traditional chest radiograph result.
CASE REPORT
A 19-year-old obese woman was involved in a head-on car
accident. She was brought to our hospital with stable vital signs
and normal blood oxygen saturation (97%) but complained
of chest and pelvic pains. Her medical history was
unremarkable. Her Glasgow Coma Scale score was 14 on
admission. Following the advanced trauma life support
guidelines, we performed a primary survey and found right-
sided chest and right-sided pelvic tenderness with abrasions. Her
breath sounds were judged to be equal bilaterally, except by one
member of the trauma team who thought that the breath
sounds were diminished on the right side. The admission
anteroposterior chest radiographs (Figure, B) were
unremarkable, but radiographs of the pelvis and the left femur
demonstrated obvious fractures.
Focused assessment with sonography for trauma showed no
obvious pleural or abdominal abnormalities. However, we
suspected the presence of a pneumothorax. Thus, an upright
and right-sided lateral decubitus chest radiograph was
attempted. However, maneuvering the patient was difficult
because of the backboard, her pelvic fracture, and severe pain
level. Thus, we decided to take an oblique chest radiograph of

378 Annals of Emergency Medicine Volume , . : April

Matsumoto et al Detecting Occult Pneumothorax With Chest Radiography

Figure. A, We created this method to detect occult pneumothoraces by supine oblique chest radiography without the need
for a CT scan. OPX, Occult pneumothorax. B, Anteroposterior supine radiograph shows no abnormality. Indeed, a left-sided
pneumothorax appears unlikely. C, Oblique supine chest radiograph on the right side clearly reveals a distinct visceral
pleural line (arrowheads). D, CT scan proves the existence of an occult pneumothorax on the right side. The pneumothorax
size is about 19% of the pleural cavity. E, Supine oblique chest radiographs are easily performed in our trauma
resuscitation area.

the right side of the thorax, clearly revealing a visceral pleural
line, which allowed us to make a diagnosis of traumatic
pneumothorax (Figure, C).
Because this was our first experience with this technique (Figure,
E), we confirmed the pneumothorax by CT scan of the chest,
which clearly revealed the anterior pneumothorax with lung
contusions and rib fractures. The pneumothorax was limited to the
anterior pleural cavity. The air pocket was almost 2.5 cm thick on
the greatest CT slice (Figure, D). The patient had stable vital signs
and needed no positive-pressure ventilation, so we chose not to
perform a thoracostomy. The patient was admitted to the ICU for
observation and monitoring. A follow-up anteroposterior chest
radiograph on the following day revealed an obvious
pneumothorax. We concluded that the pneumothorax had
progressed and thus inserted a chest tube.
DISCUSSION
The most common intrathoracic injury after a blunt trauma
is a pneumothorax, which is caused by air being trapped within
the pleural space. Occult pneumothoraces account for a high
percentage of traumatic pneumothoraces. Detecting a small
pneumothorax by clinical examination or with a supine
anteroposterior chest radiograph is difficult.3 The sensitivity and
specificity of supine chest radiographs are 12% to 24% and
89% to 100%, respectively.8 Free air in the pleural space usually
migrates to the most nondependent portion. In an upright
patient, a pneumothorax is usually most visible at the apex of
the chest. Erect chest radiographs are superior to supine chest
radiographs for detecting pneumothoraces, with sensitivities of
92% and 50%, respectively.9 In addition, MacEwan et al10

Volume , . : April Annals of Emergency Medicine 379

Detecting Occult Pneumothorax With Chest Radiography
reported the use of a lateral decubitus radiograph for a supine
pneumothorax.10 However, most trauma victims must remain
in a supine position because of fear of spinal cord injury or
pelvic fracture. The utility of a supine oblique radiograph was
discussed by Galanski et al,11 who argued that this technique
offers the advantage of not needing to turn critically ill patients.
In our literature search, we were unable to find a
thorough comparison of the merits of upright, decubitus, or
oblique chest radiograph for detecting traumatic
pneumothoraces. In a supine patient, the anterior, inferior,
and medial portions of the pleural space are the most
nondependent; free pleural air is directly positioned over the
aerated lung. The incident radiographic beam of an
anteroposterior radiograph is vertical, not parallel to the
visceral pleura, which is the boundary between the
pneumothorax and the underlying lung. Thus, the boundary
line of an occult pneumothorax cannot be seen on an
anteroposterior radiograph. A supine oblique chest
radiograph may therefore be a useful method for detecting
occult pneumothoraces.
It is thought that a pneumothorax may be suspected when a
supine chest radiograph reveals an apparent deepening of the
costophrenic angle (the deep sulcus sign) or the presence of 2
diaphragm-lung interfaces (the double diaphragm sign).
However, chest radiographs have a poor sensitivity (12% to
24%) for the detection of occult pneumothoraces, and they
have poor interobserver agreement.8
Because supine chest radiographs have poor sensitivity for
detecting occult pneumothoraces, it is important to find a
more sensitive technique. Ball et al12 reported that
subcutaneous emphysema, pulmonary contusions, and rib
fractures are clinical risk factors for the presence of an occult
pneumothorax.12 Misthos et al13 also observed that
associated chest wall muscle contusions are present in 79% of
patients with occult pneumothoraces.13 Thus, in cases in
which there are certain clinical markets but no evidence of a
pneumothorax on a supine chest radiograph, an oblique
chest radiograph may be a useful technique for detecting an
occult pneumothorax.
In the present case, there were no suspicious signs on the
initial radiograph (Figure, B) and there was no consensus
among our team after the physical examination. In this case,
the oblique chest radiograph revealed an occult
pneumothorax that was limited to the anterior pleural cavity.
The air pocket was almost 2.5 cm on CT. It may be difficult
to detect extremely small pneumothoraces with this
technique; however, the true utility of this technique will
have to be confirmed in future studies.
Several authors have reported that ultrasonography is a
useful way to detect pneumothoraces.5,14,15 The diagnostic
sensitivity and specificity of this technique for detecting
pneumothoraces range from 58.9% to 100% and 94% to
100%, respectively.5,14,15 The ultrasonographic diagnosis of
pneumothoraces is mainly based on the inability to detect
380 Annals of Emergency Medicine
Matsumoto et al
pleural motion (lung sliding). Kirkpatrick et al5 reported that
the extended focused assessment with sonography for trauma
is useful for the detection of occult pneumothoraces. We
agree that ultrasonography is useful for detecting
pneumothoraces, used in conjunction with focused
assessment with sonography for trauma directed solely at
identifying the presence of free intraperitoneal or pericardial
fluid. But potential impediments to ultrasonography are
pleural adhesions, thoracic skin defects, and emphysematous
bullae.15 Furthermore, ultrasonography is operator
dependent. Moreover, ultrasonography is difficult for obese
patients such as the present patient. In cases such as these,
diagnosis by oblique chest radiograph is simpler and easier.
That said, we are not proposing oblique chest radiograph as a
replacement for ultrasonography. Rather, oblique chest
radiograph may be used alongside other techniques or alone
when there are no other methods available.
In recent years, CT has gained importance in the early
diagnostic phase of trauma care. For many institutions, it has
become an essential part of the imaging of severe trauma
patients who are at risk for occult pneumothoraces.
However, critical patients in severe shock are difficult to
transport to the CT suite, and many hospitals in developing
countries do not have access to CT. Thus, we think this is a
valuable and novel technique.
We conclude that oblique chest radiograph is an additional
useful and fast screening tool to be considered in blunt chest
trauma, especially when transport of critically ill patients to the
CT suite is dangerous or when imminent transfer to another
hospital is being arranged and early diagnosis of an occult
pneumothorax is essential.
Supervising editor: Amy H. Kaji, MD, PhD
Funding and support: By Annals policy, all authors are required
to disclose any and all commercial, financial, and other
relationships in any way related to the subject of this article
that might create any potential conflict of interest. The authors
have stated that no such relationships exist. See the
Manuscript Submission Agreement in this issue for examples
of specific conflicts covered by this statement.
Publication dates: Received for publication March 27, 2010.
Revisions received July 29, 2010, and August 2, 2010.
Accepted for publication August 6, 2010. Available online
September 22, 2010.
Presented at 13th International Conference on Emergency
Medicine, June 2010.
Reprints not available from the authors.
Address for correspondence: Shokei Matsumoto, MD,
Department of Trauma and Emergency Surgery, Saiseikai
Yokohama-shi Tobu Hospital, 3-6-1 Shimosueyoshi Tsurumi-ku
Yokohama-shi, Kanagawa 230-0012, Japan; 81-45-576-3000,
fax 81-45-576-3586; E-mail m-shokei@feel.ocn.ne.jp.
Volume , . : April
Matsumoto et al Detecting Occult Pneumothorax With Chest Radiography

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