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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 

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

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:

 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.

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.

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.

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.

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.

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.

Right main stem intubation resulting in left-sided

tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax
Pleural effusions occur coincident with pneumothorax in 20–25% of patients, but they usually are quite
small. Hemopneumothorax occurs in 2–3% 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).

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.

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.
 

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]
 

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

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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