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Rolf P. Gobien, M.D.

Localized Tension Pneumothorax:

H. David Reines, M.D.
Stephen I. Schabel, M.D. Unrecognized Form of Barotrauma
in Adult Respiratory Distress

Loculated tension pneumothorax, usually T HE adult respiratory distress syndrome (ARDS) is a well-recog-
localized in an inferior subpulmonic or nized clinical entity characterized by noncardiogenic pulmonary
paracardiac location, is a frequent com- edema, small airway collapse, and decreasing lung compliance (1-3).
plication of respiratory therapy in adult There are several reviews of the clinical, pathologic, and radiologic
respiratory distress syndrome (ARDS), manifestations of this syndrome in the recent literature (4-12). An
and may occur in spite of a functioning aggressive approach to therapy employing vigorous ventilatory and
ipsilateral chest tube. The only radio- cardiovascular support has resulted in a mortality often below 50%,
graphic evidence of tension may be slight with full recovery possible in survivors (13-16). Treatment of ARDS
flattening of the cardiac border and ipsi- with positive end expiratory pressure (PEEP) and high peak inspi-
lateral contour change or depression of ratory pressure (PIP) has led to an increased incidence of pulmonary
the diaphragm. Severe cardiovascular and barotrauma, especially pneumothorax (5, 6, 17, 18). Although any
pulmonary compromise may result from pneumothorax in the clinical setting of ARDS should be treated with
a small volume of pleural air under ten- tube thoracostomy, tension pneumothorax in particular requires
sion, and rapid recognition and drainage immediate treatment due to its catastrophic cardiorespiratory con-
are required. sequences (4, 19).
We recently encountered a group of patients with ARDS in whom
Index terms: Pneumothorax, 6[6].731 . Respiratory a loculated tension pneumothorax developed, in spite of a functioning
distress syndrome. adult, 6[0].413 ipsilateral chest tube. The purpose of this report is to describe the
radiographic features of tension pneumothorax seen in this group.
Radiology 142: 15-19, January 1982


The charts and radiographs of all patients with pneumothorax were

reviewed. The study group selected consisted of patients who had:
(a) classical clinical and radiographic findings of ARDS, and (b)
clinical evidence of tension pneumothorax in spite of having an
ipsilateral chest tube in place.
The clinical findings of the study group are outlined in TABLE I.
Sixteen patients were found ranging in age from 8 months to 81 years.
There were 6 females and 10 males. Although a variety of underlying
causes (such as near drowning, ruptured uterus, and burns) led to the
development of ARDS, the most common events were multiple
trauma, with supervening gram-negative infection in adults, and viral
infection in children.


The duration of ARDS before the onset of the tension pneumo-

1 From the Department of Radiology (R.P.G., S.I.S.) thorax ranged from 1 to 28 days with an average of 12.6 days. All pa-
and the Department of Surgery/Anesthesiology
tients were intubated and undergoing vigorous respiratory therapy
(H.D.R.), Medical University of South Carolina,
Charleston, SC. Received Nov. 13, 1980; revision re-
with PIP (range 51-115cm H2O; mean 83cm H2O) and PEEP (range
quested Feb. 11, 1981; revision received and accepted 8-40 cm H20; mean 24 cm H2O). There was no relationship between
March 17. the duration of ARDS, or the time elapsed before the onset of the

TABLE I: Clinical Findings in 16 Patients with Localized Tension Pneumothorax in the Presence of an Ipsilateral Chest

Patient Superimposed of ARDS
No. Age (yrs.)/Sex Primary Event* Infection (Days)t Outcome

1 81/M Trauma: flail chest No 10 Survived

2 39/F Multiple trauma No 21 Survived
3 28/M Chest trauma Gram-negative pneumonia 28 Death
4 44/M Chest trauma Pseudomonas pneumonia 8 Death
5 26/M Gunshot wound Mediastinitis I Death
6 69/M Trauma: flail chest Gram-negative pneumonia 14 Death
7 25/F Multiple trauma Gram-negative pneumonia 9 Death
8 35/M Burn (30%) Gram-negative pneumonia 6 Death
9 28/F Ruptured uterus No 20 Survived
10 9/F Viral pneumonia Yes (type not determined) 7 Survived
11 15/F Cystic fibrosis No 13 Death
12 8/12/M Viral pneumonia Yes (type not determined) 28 Deatht
13 14/12/F Aspiration pneumonia No 4 Survived
14 3/M Viral pneumonia Yes (type not determined) 11 Death
15 3/M Burn (30%) Staphylococcal pneumonia 11 Deatht
16 3/M Near drowning Gram-negative pneumonia 10 Death

* Cause of hospitalization
Before occurrence of pneumothorax
4 Autopsy performed

TABLE II: Radiographic Features of Loculated Tension Pneumothorax in 16 Patients

Location of Pneumothorax Mediastinal Changes

Patient Paracardiac/ Cardiac Contour Diaphragmatic Changes
No. Subpulmonic Other Shift Change Alone None Flattening Depression
1 + + + +
2 + + +
3 + + +
4 + + +
5 + + +
6 + + + +
7 + + +
8 + + + +
9 + + + +
10 + + +
11 + + +
12 + + + +
13 + + + +
14 + + + +
15 + + + +
16 + + +

tension pneumothorax, and the even- pression of the hemidiaphragm when lungs. This in turn leads to a prolifer-
tual survival or demise of the patient. compared with prior radiographs. ation of the cells lining the alveoli, fi-
Of the group, 1 1 died (69%) and five Eleven of the patients (69%) exhibited brosis, and regions of alveolar consol-
survived (31%). None of the survivors cardiac contour change alone, without idation. The resulting lung is increased
had manifested clinical or radiographic measurable mediastinal shift (Fig. 2). in weight, noncompliant, and ineffec-
evidence of superimposed infection. Ten of these had associated flattening tive in gas exchange, requiring tracheal
Autopsy was performed on four of the of the diaphragm, but only 3 had ap- intubation and mechanical ventilation.
patients, all of whom demonstrated preciable depression. The one patient PEEP and PIP, often at high pressures,
pathologic findings of ARDS, as well as whose pneumothorax was laterally are employed.
numerous and dense pleural adhe- loculated failed to reveal any evidence The combination of this form of
sions. of diaphragmatic change. mechanical ventilation and the
A summary of the radiographic underlying pulmonary pathology fre-
findings is seen in TABLE II. A loculated quently results in pulmonary baro-
tension pneumothorax was detected in trauma, particularly pneumothorax.
all patients. It was located in the sub- The altered respiratory and cardio- This has prompted some authors to
pulmonic or paracardiac region in 15 vascular physiology of barotrauma recommend prophylactic chest tubes in
patients (94%) and along the lateral complicating ARDS, as well as the as- these patients (19). All would agree
chest wall in one (6%). Five of the pa- sociated radiographic manifestations, that pneumothorax should be treated
tients (31%) had subtle mediastinal have received wide attention (4-7, rapidly by chest tube drainage and that
shift as evidence of tension (Fig. 1). In 20-23). The initial insult in ARDS tension pneumothorax is especially
all of these there was a small but dis- causes proteinaceous fluid to leak into important to recognize since, if left
cernible amount of flattening and de- the alveoli and interstitium of the untreated, it can rapidly lead to car-

16 January 1982 Volume 142, Number 1 Gobien and Others

a. This patient with pneumomediastinum was previously treated
for pneumothorax and has bilateral chest tubes in place. Note
position of the right heart border (black arrows) and relative
position of hemidiaphragms.
b. One day later the development of tension pneumothorax locu-
lated in the subpulmonic space has caused a shift of the mcdi-
astinum (black arrows) as well as a change in the contour and
minimal depression of the right hemidiaphragm.
c. Close-up of lower lung field more clearly reveals the lung ele-
vated above the hemidiaphragm and “pushed” out of the cos-
tophrenic angle.

diovascular collapse and death (19, very little volume loss of the ipsilateral account for subpulmonic and paracar-
25). lung (23, 24) due to the inability of the diac loculation of the pneumothorax.
As demonstrated in the present se- lung to collapse. Instead, tension These factors include the presence of
ries of patients, however, the radio- pneumothorax presents radiographi- adhesions, the relative compressibility
graphic findings usually associated cally as a loculated paracardiac or sub- and mobility of surrounding struc-
with tension pneumothorax (5, 17, 24), pulmonic air collection. This is associ- tures, and patient position. Autopsies
such as striking collapse of the lung ated with a subtle shift of the medias- on all four patients showed numerous
with pleural air surrounding its edges, tinum or flattening of the cardiac con- and dense pleural adhesions. The fact
contralateral shift of the heart and tour, and flattening or minimal de- that two of the patients were very
mediastinum, and inversion of the pression of the hemidiaphragm. young and none of the patients had a
hemidiaphragm, may well be absent in On the basis of all available data, a history of known pulmonary disease is
patients with ARDS. There is often combination of factors is thought to strong evidence pointing to adhesions

Localized Tension Pneumothorax DIAGNOSTIC RADIOLOGY 17

Figure 2

a. Development of a pneumothorax loculated in the paracardiac

and subpulmonic regions on the left in spite of the presence of
a chest tube. Note shape of the left heart border, position of the
right heart border, as well as the position and configuration of
the left hemidiaphragm.
b. Following the insertion of a second chest tube into the lower
anterior pleural space, there is considerable change in the shape
of the left heart border without significant change in position
of the right heart border. The left hem idiaphragm has changed
in configuration and returned to its baseline position.
c. Detail view of Figure a shows the loculated pneumothorax more
clearly. An adhesive band is seen tethering the lung (arrow).



due to ARDS. The pathologic appear- which in this case results in a change in thorax is highest. This may play some
ance of the lung in patients with ARDS shape of the cardiac silhouette and role in the tendency of the pneumo-
is well known (11, 21). Increased in- hemidiaphragm. Patients who are se- thorax to loculate in this location.
trathoracic pressure exerted by a ten- verely ill with ARDS are almost always Radiographic manifestations of
sion pneumothorax causes a shift of in the supine position, where the ven- tension in the present series can be ac-
those structures that are most pliant, tral and inferior portion of the hemi- counted for in a similar fashion. In

18 January 1982 Volume 142, Number 1 Gobien and Others

tension pneumothorax, the degree of References 14. Klein JJ, van Haeringen JR. Sluiter HJ,
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Localized Tension Pneumothorax DIAGNOSTIC RADIOLOGY 19