Imaging of Pneumothorax - UpToDate

Imaging of pneumothorax - UpToDate
04/10/2016, 6:02 AM
Official reprint from UpToDate

www.uptodate.com 2016 UpToDate
Imaging of pneumothorax
Author: Paul Stark, MD
Section Editors: Nestor L Muller, MD, PhD, Polly E Parsons, MD
Deputy Editor: Geraldine Finlay, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Feb 03, 2015.
INTRODUCTION Pneumothorax refers to gas within the pleural space [1-3]. Its clinical manifestations are
widely variable. Small pneumothoraces can be asymptomatic and self-limited, but need to be monitored for
progression. Large pneumothoraces can cause hypoventilation, hypoxemia, and/or hemodynamic instability. If
such pneumothoraces are not promptly treated, progression to cardiac arrest and death is possible.
Radiographic imaging of a pneumothorax is reviewed here. The causes and management of a pneumothorax are
discussed separately. (See "Primary spontaneous pneumothorax in adults" and "Secondary spontaneous
pneumothorax in adults".)
IDENTIFYING A PNEUMOTHORAX The first-line imaging modalities used to identify a pneumothorax are
chest radiography and computed tomography (CT). While some investigators have reported using ultrasound to
diagnose pneumothorax, particularly in bedridden patients, ultrasound is not a preferred modality for imaging the
chest.
Chest radiographs The main feature of a pneumothorax on a chest radiograph is a white visceral pleural
line, which is separated from the parietal pleura by a collection of gas (image 1). In most cases, no pulmonary
vessels are visible beyond the visceral pleural line (the collection of pleural gas is avascular). A pneumothorax
may be identified on an upright, supine, or lateral decubitus chest radiograph. The lateral decubitus view tends to
be the most sensitive, while the supine view is the least sensitive.
Upright In an upright patient with a pneumothorax, most pleural gas accumulates in an apicolateral
location (image 2). The visceral pleural line appears either straight or convex towards the chest wall. As little
as 50 mL of pleural gas may be visible on a chest radiograph [4]. Although a pneumothorax is generally
accompanied by a considerable loss of lung volume, the collapsed lung preserves its transradiancy because
hypoxic vasoconstriction diminishes the blood flow to the collapsed lung.
The value of upright expiratory chest radiographs in detecting pneumothoraces has been grossly overstated.
In one study, inspiratory and expiratory upright chest radiographs detected pneumothorax with equal
sensitivity [5]. These findings, combined with the limitations of expiratory radiographs, have led us to
recommend only inspiratory imaging for the initial examination of a potential pneumothorax in our clinical
practice.
Supine In a supine patient with a pneumothorax, most pleural gas accumulates in a subpulmonic location.
Gas in this location outlines the anterior pleural reflection, the costophrenic sulcus (creating the deep
sulcus sign), and the anterolateral border of the mediastinum (image 3). In rare instances, pleural gas can
also accumulate in the phrenicovertebral sulcus. The visceral pleural line may be seen at the lung base and
has a concave contour (image 4 and image 5). Approximately 500 mL of pleural gas are needed for
definitive diagnosis of a pneumothorax on a supine chest radiograph [4]. The transradiancy and size of the
entire hemithorax may be increased on the side of a pneumothorax.
A hydropneumothorax (including sero-, hemo-, pyo-, and chylothoraces) in a supine patient can produce a
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veillike opacity, more opaque than a pure pneumothorax and less opaque than a pure hydrothorax (image
6 and image 7). This is explained by en face imaging of the pleural effusion posteriorly and intrapleural gas
anteriorly, with its attending summation effect (image 8). Occasionally, the visceral pleural line of a partially
collapsed lung floating on the dependent pleural effusion can be seen, facilitating the diagnosis. In upright
patients with a hydropneumothorax, a horizontal gas-liquid level is diagnostic for this entity (image 9).
Lateral decubitus A pneumothorax can be most easily detected with a lateral decubitus view. In this
position, most pleural gas accumulates in the non-dependent lateral location. The visceral pleural line
appears either straight or convex towards the chest wall. As little as 5 mL of pleural gas may be visible on a
lateral decubitus chest radiograph [4].
Computed tomography Computed tomography (CT) scanning is the most accurate imaging modality for the
detection of pneumothorax (image 10A-B) [6]. Even small amounts of intrapleural gas, atypical collections of
pleural gas, and loculated pneumothoraces can be identified by CT. In addition, complex pleural pathology (eg,
pleural effusion, pneumothorax, and pleural adhesions) can be optimally displayed by CT scanning (image 11
and image 12). Pleural interventional procedures are vastly facilitated by CT guidance.
Ultrasound Ultrasound of the chest is sometimes used to evaluate a patient for pneumothorax. This is most
common in situations in which the diagnosis must be made emergently at the bedside, such as an ICU patient or
a trauma patient in the emergency department, so-called point-of-care ultrasound [7-9]. (See "Emergency
ultrasound in adults with abdominal and thoracic trauma", section on 'Pneumothorax and hemothorax' and "Initial
evaluation and management of penetrating thoracic trauma in adults", section on 'Thoracic ultrasound'.)
The ultrasonographic signs of a pneumothorax reflect the absence of a normal interface between the lung and
pleura. Signs of a normal lung and pleural interface include lung sliding, due to sliding of the visceral and
parietal pleura relative to each other. Absence of lung sliding should raise the suspicion of a pneumothorax. In
the presence of a pneumothorax, smooth, horizontal echogenic lines demarcate pleural line. The absence of
lung sliding allows for the diagnosis of pneumothorax in real time with focused ultrasound at the point of care
[10,11], although the role of operator experience has not been fully examined. (See "Thoracic ultrasound:
Indications, advantages, and technique", section on 'Identification of pneumothorax'.)
The accuracy of thoracic ultrasound for the detection of pneumothorax has been examined in a number of
studies [6,8,12-14], including a meta-analysis of eight studies that compared thoracic ultrasound with chest
radiography [12]. The sensitivities of ultrasound and chest radiography (supine and semi-erect) were 91 and 50
percent, respectively. The low sensitivity of chest radiography was likely due to the supine position of patients in
seven of the eight studies. Both ultrasound and chest radiography demonstrated a high specificity, from 98 to 99
percent. Thus, ultrasound appears more sensitive than supine chest radiography for detecting a pneumothorax.
(See 'Chest radiographs' above.)
In a series that compared thoracic ultrasound with chest CT, ultrasonography, performed by a radiologist
detected 80 percent of the pneumothoraces identified by CT [6].
SIZE OF PNEUMOTHORAX Accurate estimation of the size of a pneumothorax is difficult. The average
interpleural distance (AID) approximates the size of a pneumothorax from a frontal chest radiograph by taking
the sum of the distances (measured in millimeters) between the ribs and the visceral pleura at the apical,
midthoracic, and basal levels, then dividing the sum by three (figure 1 and image 13). An alternative method,
called the Light Index, uses the following equation to estimate the size of a pneumothorax [15,16]:
Percent pneumothorax = 100 [(average lung diameter to the power of 3/average hemithorax diameter to the
power of 3) x 100]
Both the AID and the Light Index express the size of the pneumothorax as the percent pneumothorax. The Light
Index correlates better with the amount of pneumothorax gas removed by suction [15,16].
Such methods are difficult to apply and tend to underestimate the size of a pneumothorax. As a result, some
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clinicians tend to describe a pneumothorax as large or small, rather than utilize percentages. British Thoracic
Society guidelines define a pneumothorax as small if the distance from chest wall to the visceral pleural line is
less than 2 cm or large if the distance from the chest wall to the visceral pleural line is 2 cm or greater [17]. Some
clinicians prefer 3 cm laterally and 4 cm apically as the threshold to distinguish small pneumothoraces that can
be treated expectantly versus large pneumothoraces that may necessitate thoracentesis.
TYPES OF PNEUMOTHORAX Imaging may provide important clues about the type of pneumothorax that
exists. However, imaging alone is seldom sufficient to determine the type of pneumothorax. The clinical context
always needs to be considered along with the imaging findings.
Simple pneumothorax With a simple pneumothorax, the pleural pressure in the affected hemithorax
remains subatmospheric and is only slightly more positive than the pleural pressure in the contralateral
hemithorax. A simple pneumothorax usually has only modest repercussions unless the patient has limited
respiratory reserve or is being mechanically ventilated. Radiographically, simple pneumothoraces tend to be
small and without mediastinal shift to the contralateral side (image 14).
Tension pneumothorax With a tension pneumothorax, the pleural pressure in the affected hemithorax
exceeds atmospheric pressure, particularly during expiration. This is frequently the result of a "check valve"
mechanism that facilitates the ingress of gas into the pleural space during inspiration, but blocks the egress
of gas from the pleural space during expiration. The results are the accumulation of gas, the build-up of
pressure within the pleural space, and eventually respiratory failure from compression of the contralateral
normal lung. Radiographically, tension pneumothorax shows a distinct shift of the mediastinum to the
contralateral side and flattening or inversion of the ipsilateral hemidiaphragm (image 15A-B and image 16).
Open pneumothorax Open pneumothorax occurs when a traumatic chest wall defect persists, through
which ambient air enters the pleural space during inspiration (ie, a "sucking wound"). As a result, the
mediastinum shifts toward the normal hemithorax and the lung within the injured hemithorax remains
collapsed. During expiration, air exits the pleural space through the chest wall defect and the mediastinum
swings back toward the injured hemithorax. Expiratory air from the normal lung (ie, pendulum air) fills the
collapsed lung. The mediastinal flutter" may cause respiratory failure. Radiographically, an open
pneumothorax is characterized by a visible chest wall defect and by massive expiratory mediastinal shift
towards the injured side: this mediastinal behavior is different from tension pneumothorax where the
expiratory shift of the mediastinum occurs towards the normal lung, resulting from air-trapping in the affected
pleural space.
Pneumothorax ex vacuo This rare type of pneumothorax forms adjacent to an atelectatic lobe (image
17). It is seen preferentially with atelectasis of the right upper lobe and is the result of rapid atelectasis
producing an abrupt decrease in the intrapleural pressure with subsequent release of nitrogen from pleural
capillaries. Treatment consists of bronchoscopy with re-expansion of the atelectatic lung rather than chest
tube drainage. Radiographically, pneumothorax ex vacuo is suggested when an atelectatic lobe or lung,
particularly right upper lobe atelectasis, is surrounded by a focal pneumothorax. A similar presentation can
occur in patients with visceral pleural thickening and a "trapped lung" following drainage of an effusion
(image 18 and image 19 and image 20) [18]. (See "Diagnosis and management of pleural causes of
unexpandable lung".)
Bilateral postoperative simultaneous pneumothoraces Bilateral simultaneous pneumothoraces have
been described after cardiac surgery, particularly in recipients of heartlung transplants. They are a
consequence of extensive mediastinal dissection disrupting the anterior junction line complex, formed by the
parietal pleural reflections of both hemithoraces, allowing a unilateral pneumothorax to propagate to the
contralateral hemithorax [19]. A single thoracostomy tube is able to evacuate both pleural cavities. This type
of pneumothorax has been dubbed buffalo chest, since these animals have pleural spaces that
communicate anteriorly and, as a result, they are susceptible to bilateral simultaneous pneumothorax
(image 21 and image 22) [20].
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CONDITIONS MIMICKING PNEUMOTHORAX Numerous conditions can mimic a pneumothorax

radiographically.
Bullae Large subpleural bullae can mimic a loculated pneumothorax. Both bullae and pneumothoraces
usually have a visceral pleural contour that is either straight or convex laterally, but only bullae typically have
a medial border that is concave to the chest wall (image 23 and image 24A-B) [21]. Exceptions to this
distinction occur with subpulmonic collections of gas, loculated collections of gas, or pleural adhesions
(image 25). Bullae and pneumothoraces can occasionally coexist (image 26) [1].
Trauma The stomach can herniate into the chest following traumatic rupture of the left hemidiaphragm
and a gas-filled, intrathoracic stomach may be mistaken for a loculated pneumothorax (image 27). This can
be disastrous if drainage with a thoracostomy tube is attempted.
Skin folds A skin fold can generally be distinguished from a pneumothorax by careful evaluation of the
radiograph. Skin folds frequently extend beyond the rib cage, stop short of the ribs, and/or gradually
increase in opacity with an abrupt dropoff at the edge of the skin fold. Blood vessels often extend beyond
the skin fold [22]. Skin folds can also be differentiated from a pneumothorax by their attenuation profile,
forming a negative black Mach band instead of the white visceral pleural line. Mach bands are a retinal
phenomenon or illusion resulting from lateral inhibition of receptors induced by an abrupt transition between
a white and a black interface, with subsequent visual generation of edge enhancement [23,24]. This can
lead to the formation of a positive (white) or a negative (black) Mach band (image 28 and image 29). Skin
folds are primarily seen on bedside radiographs, caused by the radiographic cassette that is slid from the
side under the patients back.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and
Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)
Basics topic (see "Patient education: Pneumothorax (collapsed lung) (The Basics)")
SUMMARY AND RECOMMENDATIONS
Pneumothorax refers to gas within the pleural space. Its clinical manifestations are widely variable. (See
'Introduction' above.)
The first-line imaging modalities used to identify a pneumothorax are chest radiography and computed
tomography. Computed tomography is definitive, but generally necessary only in complex cases. (See
'Identifying a pneumothorax' above.)
The main feature of a pneumothorax on a chest radiograph is a white visceral pleural line, which is
separated from the parietal pleura by a collection of gas. In most cases, no pulmonary vessels are visible
beyond the visceral pleural line. A pneumothorax may be identified on an upright, supine, or lateral
decubitus chest radiograph. (See 'Chest radiographs' above.)
Ultrasound that demonstrates the absence of sliding of the visceral and parietal pleura can be utilized at
the point of care for a timely diagnosis of a pneumothorax. (See 'Ultrasound' above and "Thoracic
ultrasound: Indications, advantages, and technique", section on 'Identification of pneumothorax'.)
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Clinicians tend to describe a pneumothorax as large or small, rather than utilize a percentage scale. (See
'Size of pneumothorax' above.)
Imaging may provide important clues about the etiology and pathophysiology of pneumothorax. (See 'Types
of pneumothorax' above.)
Numerous conditions can mimic a pneumothorax radiographically, including bullae, skin folds, and stomach
herniation into the chest following traumatic rupture of the left hemidiaphragm. (See 'Conditions mimicking
pneumothorax' above.)
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REFERENCES
1. O'Connor AR, Morgan WE. Radiological review of pneumothorax. BMJ 2005; 330:1493.
2. Stark, P. The Pleura. In: Radiology, Diagnosis, Imaging, Intervention, Taveras and Ferrucci (Ed), Lippincott,
Philadelphia 2000.
3. Greene, R, McLoud, TC, Stark, P. Pneumothorax. Semin Roentgenol 1977; 4:13.
4. Carr JJ, Reed JC, Choplin RH, et al. Plain and computed radiography for detecting experimentally induced
pneumothorax in cadavers: implications for detection in patients. Radiology 1992; 183:193.
5. Seow A, Kazerooni EA, Pernicano PG, Neary M. Comparison of upright inspiratory and expiratory chest
radiographs for detecting pneumothoraces. AJR Am J Roentgenol 1996; 166:313.
6. Jalli R, Sefidbakht S, Jafari SH. Value of ultrasound in diagnosis of pneumothorax: a prospective study.
Emerg Radiol 2013; 20:131.
7. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic
pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma
2004; 57:288.
8. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs
for the identification of pneumothorax after blunt trauma. Acad Emerg Med 2010; 17:11.
9. Mandavia DP, Joseph A. Bedside echocardiography in chest trauma. Emerg Med Clin North Am 2004;
22:601.
10. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011; 364:749.
11. Lichtenstein D. General ultrasound in the critically ill. Springer 2005; 105.
12. Raja AS, Jacobus CH. How accurate is ultrasonography for excluding pneumothorax? Ann Emerg Med
2013; 61:207.
13. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of
pneumothorax: a systematic review and meta-analysis. Chest 2012; 141:703.
14. Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest radiography for the
diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care 2013; 17:R208.
15. Light, RW. Pneumothorax. In: Pleural Diseases, 3rd, Light, RW (Eds), Williams and Wilkins, Baltimore
1990. p.242.
16. Noppen M, Alexander P, Driesen P, et al. Quantification of the size of primary spontaneous pneumothorax:
accuracy of the Light index. Respiration 2001; 68:396.
17. MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group. Management of spontaneous
pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii18.
18. Woodring JH, Baker MD, Stark P. Pneumothorax ex vacuo. Chest 1996; 110:1102.
19. Engeler CE, Olson PN, Engeler CM, et al. Shifting pneumothorax after heart-lung transplantation.
Radiology 1992; 185:715.
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20. Chan F, Stark P. Bilateral pneumothoraces after coronary bypass suregery a case of buffalo chest. Clin
Intensive Care 1997; 8:154.
21. Jacobson, F, Stark, P. Pneumothorax or giant bullae? Clin Intensive Care 1992; 3:188.
22. Stark, P, Eber, C. Pneumothorax or skin fold?. Clin Intensive Care 1993; 4:45.
23. Chasen MH. Practical applications of Mach band theory in thoracic analysis. Radiology 2001; 219:596.
24. Buckle CE, Udawatta V, Straus CM. Now you see it, now you don't: visual illusions in radiology.
Radiographics 2013; 33:2087.
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GRAPHICS
Right simple pneumothorax with complete lung collapse
Chest radiograph shows spontaneous, simple right-sided pneumothorax with

complete collapse of the right lung and asymptomatic, non strangulating,
uncomplicated, torsion of the right upper lobe (arrow) and with only minimal
contralateral shift of the mediastinal structures.
Graphic 90385 Version 2.0
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Simple pneumothorax in patient with lung fibrosis
Chest radiograph in a patient with advanced idiopathic pulmonary fibrosis

and spontaneous right apical pneumothorax (arrow).
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Deep sulcus sign displaying a pneumothorax in a supine

patient
Bedside supine chest radiograph in a trauma patient with left pneumothorax

and deep sulcus sign. Contusion of the left lung precludes its complete
collapse. Pulmonary edema is visible in the contralateral right lung.
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Basal pneumothorax in a supine patient
Bedside, supine chest radiograph demonstrates an atypical right basal

pneumothorax in a patient on mechanical ventilation. Note right basal pleural
adhesion that extends towards the right hemidiaphragm and is outlined by
pneumothorax gas.
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Chest radiograph of bilateral pneumothoraces
Patient with ARDS, increased permeability pulmonary edema, and

barotrauma. Supine chest radiograph shows right subpulmonic and left
apicolateral pneumothorax. Streaky lucencies are permeating the otherwise
consolidated lungs as a reflection of interstitial pulmonary emphysema.
Subcutaneous air is also seen in the right hemithorax. The patient has a
tracheostomy tube in place with a markedly hyperexpanded cuff, due to
tracheomalacia.
ARDS: acute respiratory distress syndrome.
Courtesy of Paul Stark, MD.
Normal chest radiograph
Posteroanterior view of a normal chest radiograph.

Courtesy of Carol M Black, MD.
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Chest radiograph of hydropneumothorax
Chest radiograph shows left-sided hydropneumothorax due to a bronchopleural fistula

in a patient with a chronic empyema and prior known semi-invasive aspergillosis.
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Chest radiograph of hemopneumothorax due to blunt trauma
Left panel: Supine chest radiograph shows hyperexpansion of the left hemithorax
with filter effect and veil-like opacification due to dorsal blood and ventral gas.
Right panel: After insertion of chest tubes, the dorsal component of blood has been
drained and only the pneumothorax remains. The contused lung is too rigid and
noncompliant to collapse completely.
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CT scan of an atypical hydropneumothorax
Atypical right hydropneumothorax in patient with previous sclerotherapy. CT

scan shows dorsal gas-liquid level with the right lung adherent to the
anterior chest wall.
CT: computed tomography.
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Left hydropneumothorax in a patient with metastatic

osteogenic sarcoma
Chest radiograph in a young patient with metastatic osteogenic sarcoma,

status post right forequarter amputation and left spontaneous
hydropneumothorax. Multiple bilateral pulmonary nodules are visible and a
left basal gas-liquid level is present (arrow).
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CT scan of traumatic bilateral pneumothoraces
CT thorax with bilateral anterior pneumothoraces and pneumomediastinum in

a patient with tracheobronchial injury after car accident.
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CT scan of posttraumatic bilateral pneumothoraces
CT scan shows large right and small left anterior pneumothoraces, bibasal
pulmonary contusions, and bilateral subcutaneous emphysema.
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Hydropneumothorax with irregular pleural thickening in a patient

with rheumatoid arthritis
Chest radiograph (A) shows an atypical loculated right pneumothorax with two separate
collections of pleural gas in a patient with known rheumatoid arthritis. CT thorax image
(B) shows chronic right hydropneumothorax with gas-liquid level due to bronchopleural
fistula and irregular visceral and parietal pleural thickening.
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Bullous lung disease and spontaneous pneumothorax
CT thorax in a patient with severe bullous lung disease and a spontaneous right-sided
pneumothorax.
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Pneumothorax size estimated by the average intrapleural

distance
The schematic diagram details the use of the average intrapleural distance
(in millimeters) to estimate the size of a pneumothorax from a frontal chest
radiograph.
Ptx: pneumothorax.
Courtesy of Helga E Stark, MD, PhD.
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Left simple pneumothorax
Chest radiograph shows left simple pneumothorax with arrows pointing to

the site of measurements in order to estimate the percentage pneumothorax
as the average of the three measurements in millimeters.

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Large left simple pneumothorax
Chest radiograph shows simple, spontaneous left pneumothorax with non

strangulating, uncomplicated, asymptomatic, torsion of the left upper lobe
(arrow).
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Chest radiograph of a tension pneumothorax
Tension pneumothorax caused by extensive tuberculosis in the subjacent left

lung. Chest radiograph shows a large collection of gas in the left hemithorax
with inversion of the left hemidiaphragm and cardiomediastinal shift to the
right. The left intercostal spaces are wider than the right ones.

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Chest radiograph of a tension pneumothorax
Tension pneumothorax due to insertion of right-sided Swan-Ganz catheter in

patient with left ventricular failure and pulmonary edema. Chest radiograph
shows collapse of the right lung and cardiomediastinal silhouette to the left
with marked compression of the left lung, leading to respiratory failure. The
right hemidiaphragm is depressed caudad, and the right-sided rib spaces are
markedly widened.

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Right tension pneumothorax due to bronchial rupture
Chest radiograph with right-sided tension pneumothorax in a patient with

bronchial rupture after car accident. Marked shift of the cardiomediastinal
structures into the left hemithorax is evident.
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Chest radiograph of a pneumothorax ex vacuo
Chest radiograph shows right upper lobe atelectasis and a pneumothorax

surrounding strictly the atelectatic lobe. After bronchoscopy and removal of
the obstructing mucous plug, the pneumothorax disappeared.

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Right anterior pneumothorax with trapped lung
CT thorax shows a right anterior pneumothorax in a patient with a so called

trapped lung due to malignant pleural disease with thickening of the visceral
pleura encasing the lung and hampering the re-expansion.
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Persistent basal pneumothorax due to obstructive

atelectasis
Chest radiograph in a patient with atelectasis of the right middle and right
lower lobes due to bronchogenic carcinoma with an accompanying malignant
pleural effusion. After thoracentesis, a residual right basal pneumothorax ex
vacuo persists related to the retractile effect of the overlying atelectatic lung.
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CT scan of a trapped lung
Chronic left pneumothorax in patient post CABG due to trapped lung. CT

scan shows left pneumothorax with chest tube in place, filiform posterior
adhesions, and a thick visceral pleura encasing the collapsed left lung.
CABG: coronary artery bypass graft.
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Bilateral pneumothorax post cardiac surgery: The "buffalo

chest"
Postoperative upright chest radiograph post cardiac transplant with bilateral

apical pneumothoraces (arrows) due to disruption of the anterior junction
line complex and subsequent free communication of both pleural spaces, so
called buffalo chest physiology.
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Bilateral pneumothorax post cardiac surgery: The "buffalo

chest"
Postoperative, semiupright chest radiograph in a patient after cardiac

transplantation. Bilateral pneumothoraces with lateral collections of pleural
gas outlining the visceral pleura. This is an example of a "buffalo chest" with
disruption of the anterior pleural junction line and free communication of the
right and left pleural space.
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Bullae mimicking pneumothorax
Chest radiograph in a patient with bilateral large upper lobe bullae. The
inferomedial contour of the bullae is concave superolaterally and allows for
differentiation from the straight or convex visceral pleural lines formed by a
pneumothorax.
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Giant bullae mimicking pneumothorax with compressive

atelectasis
Chest radiograph in a patient with bilateral giant upper lobe bullae. The
straight or convex visceral pleural line characteristic of a pneumothorax is
absent. The lower lobes on both sides are retracted caudad.
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Iatrogenic pneumothorax due to chest tube in bulla
Chest radiograph in the same patient with bilateral giant upper lobe bullae. A
right-sided chest tube was inserted by mistake. Now a small inferolateral
pneumothorax can be seen with a vertical visceral pleural line visible (arrow).
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Basal pneumothorax in an upright patient
Chest radiograph with atypical right basal pneumothorax in a patient with

pleural adhesions. Due to the adhesions, gas is trapped in a basal position.
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Left simple pneumothorax with apical bulla
Chest radiograph shows simple, spontaneous pneumothorax on the left side.

The left lung is completely collapsed (arrow) with an apical bulla (arrowhead)
which may have been the source of the air leak.
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Gastric hernia simulating pneumothorax
Chest radiograph demonstrates a herniated, gas-filled stomach through a

rent in the left hemidiaphragm, mimicking a left-sided tension
pneumothorax.
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04/10/2016, 6:02 AM
Skin fold mimicking a left simple pneumothorax
Chest radiograph in a patient with left ventricular failure and pulmonary

edema. The left-sided skin fold that was initially mistaken for a
pneumothorax displays a gradual lateral increase in opacity with an abrupt
drop-off and a dark Mach band as its lateral contour (arrows) instead of a
white visceral pleural line. Note the pulmonary vascular structures and the
lung texture extending beyond the skin fold. These skin folds can develop
when technologists insert the cassette under a supine patient from the
opposite side of the skin fold and bunch up the skin of the back.
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04/10/2016, 6:02 AM
Skin fold mimicking a right simple pneumothorax
Chest radiograph demonstrates a right skin fold superimposed on the right

lung (arrows). This skin fold shows gradual increase in opacity towards the
periphery with an abrupt drop-off and a black Mach band. Pulmonary vessels
extend beyond the edge of the skin fold towards the periphery. The skin fold
was formed during the insertion of the cassette from left to right.
Page 39 of 40
04/10/2016, 6:02 AM
Contributor Disclosures
Paul Stark, MD Nothing to disclose Nestor L Muller, MD, PhD Nothing to disclose Polly E Parsons,
MD Nothing to disclose Geraldine Finlay, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
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