SIZE OF PNEUMOTHORAX

Quantification of the size

The simple method to estimate the size
• Small, a visible rim of < 2 cm between the lung
margin and the chest wall
• Large, a visible rim of ≥ 2 cm between the lung
margin and chest
Estimation of pneumothorax volume
• The size of pneumothorax does not correlate well with
the clinical manifestations.
• The clinical symptoms associated with secondary
pneumothorax are more severe in general than those
associated with primary pneumothorax, and may seem
out of proportion to the size of the pneumothorax.
• The clinical evaluation is therefore probably more
important than the size of the pneumothorax in
determining the management strategy.
• Standard erect chest x-rays in inspiration are
recommended for the initial diagnosis of pneumothorax
rather than expiratory films.
• The plain PA chest x-ray has been used to
quantify the size of the pneumothorax.
• It tends to underestimate the size because it is
a two-dimensional image while the pleural
cavity is a three-dimensional structure.
• 2 cm radiographic pneumothorax
approximates to a 50% pneumothorax by
volume.
• There are difficulties with this approach,
including the fact that some pneumothoraces are
localised (rather than uniform), so that
measurement ratios cannot be applied.
• The shape of the lung cannot be assumed to
remain constant during collapse.
• The measurement of the ratio of the lung to the
hemithorax diameter is accurate and relatively
easy with the new PACS systems by means of a
cursor, once familiar with the PACS auxiliary
functions.
• The choice of a 2 cm depth is a compromise
between the theoretical risk of needle trauma
with a more shallow pneumothorax and the
significant volume and length of time to
spontaneous resolution of a greater depth of
pneumothorax.
• Assuming a symmetrical pattern of lung collapse,
then this measure is normally taken from the
chest wall to the outer edge of the lung at the
level of the hilum.
• Guidelines from the USA estimated the volume of a
pneumothorax by measuring the distance from the
lung apex to the cupola, but this method would tend to
overestimate the volume in a localised apical
pneumothorax.
• Belgian guidelines have used yet another technique for
measuring pneumothorax size, and comparisons
between the different techniques have shown poor
agreement.
• CT scanning is regarded as the best means of
establishing the size of a pneumothorax and has been
calibrated in a lung model experiment.
 BTS GUIDELINES
Distances between pleura and chest wall

Less than 1cm  small

1-2cm  moderate

Greater than 2cm  large

DIFFERENCES BETWEEN ACCP VS BTS
GUIDELINES
• The American College of Chest Physicians
(ACCP) proposed using an apex to cupola
distance of 3 cm to distinguish small from
large pneumothorax.
• The British Thoracic Society (BTS) uses an
average pneumothorax width of 2 cm to
distinguish large from small pneumothorax,
although the exact method of measurement is
not specified.
• Although the amount of collapse cannot be
measured directly, a determination on a chest
roentgenogram of the areas of the collapsed lung
and the hemithorax on the involved side yields a
calculated per cent of pneumothorax similar to
the real volume percent of pneumothorax.
• The area of the collapsed lung is subtracted from
the area of the hemithorax.
• This difference divided by the area of the
hemithorax gives the percent of pneumothorax.
• The reference points for
determining the area of
collapsed lung in the figure are
the extreme superior (a),
lateral (b), and inferior (c)
borders of the lung and the
center of the mediastinum (d).
The reference points for
determining the area of
involved hemithorax are the
inferior border of the first rib
(A), the inner border of the
midlateral chest wall (B), the
tip of the costophrenic angle
(C), and the center of the
mediastinum (D).
Kircher and Swartzel
A: Total hemithorax area
(30x15=450)
B: Atelectatic lung area
(13x7=91)

(A-B)/Ax100=(450-
91)/450x100=79%=Size of
pneumothorax
 RHEA METHOD
Average intrapleural
distance to the
pneumothorax size
It uses a normogram 
average intrapleural
distance to the
pneumothorax size
10% pneumothorax for
every cm of intraplural
distance
• Because the lung is a three-
dimensional (3D) structure, the
size of a pneumothorax deduced
from the two-dimensional image
of a chest radiograph is often
inaccurate.
 SUBJECTS AND METHODS
• Twenty pneumothoraces from 19 patients (10 males, nine
females) were analyzed.
• Most pneumothoraces were on the right side (n = 16).
• The etiology was spontaneous in seven patients and iatrogenic in
thirteen.
• All patients underwent an erect inspiratory posteroanterior
radiograph and a helical CT scan of the thorax on the same visit to
the radiology department.
• The interpleural distance was measured at three locations and the
figures added together.
• Following helical CT of the thorax, the percentage pneumothorax
size was calculated by drawing regions of interest around the
relevant hemithorax and lung on 10-mm reconstructed slices.
• A scattergram of the sum of interpleural distances in centimeters
versus percentage pneumothorax size was plotted.
 RESULTS
• Twenty pneumothoraces from 19 patients were analyzed.
• True pneumothonax size varied from 2% to 92% as deter-
mined by helical CT (mean, 31 .5% ± 27.4%).
• A plot of the sum of interpleural distance values versus
helical CT revealed a well-ordered Set of data (r = .98, p <
.0001).
• Regnession of the helical CT values on interpleural distance
gave a predicted slope of 4.74 (standard error, ± 0.23). A
correction factor enabling accurate estimation of true
percentage pneumothorax size could be calculated from
the graph. This formula is expressed as V = 4.2 + [4.7 X (A +
B + C)].
• This study has identified a formula for accurately
calculating percentage pneumothorax size as
determined by helical CT from an
erectpostenoantenion radiograph.
• The interceptofthe regression line is 4.2, which might
be mistaken for indicating that a 4.2% pneumothorax is
present when the sum of the interpleural distances is
zero.
• However, the 95% confidence interval line lies at zero
for both x- and y-axes, implying that statistically a 4.2%
pneumothonax can be counted as zero.
COLLINS METHOD
 LIGHTS METHOD

Pneumothorax %

ratio of lung diameter cubed to hemithorax

diameter cubed
• Compare the estimated size of spontaneous pneumothoraces using the
established Rhea inter-pleural distances method with the CT-derived Collins
method.
• Adult patients with spontaneous pneumothorax treated conservatively were
identified from the ED databases. X-rays were reviewed independently by two
researchers and measured according to the methods described by Rhea and
Collins. Estimates of size derived by the two methods were compared using bias
plot analysis techniques.
• 156 X-rays in 57 patients were identified. 82% were male with a median age of
22 years. Pneumothoraces varied in size from 4% to 88%. The average difference
between methods was 4% (Collins method estimating larger size) with 95%
limits of agreement 􏰁 3.8% to 11.7%. Agreement was very close for small
pneumothoraces but deteriorated with increasing pneumothorax size (Collins
methods estimated larger pneumothorax size).
• The Rhea method for estimating pneumothorax size is acceptably accurate for
smaller pneumothoraces but may significantly under-estimate the size of larger
pneumothoraces.
THANK YOU