European Journal of Radiology 53 (2005) 463–470

Accuracy of transthoracic sonography in excluding post-interventional

pneumothorax and hydropneumothorax
Comparison to chest radiography
Angelika Reißig∗ , Claus Kroegel
Pneumology & Allergology, Department I, Medical University Clinics, Friedrich-Schiller-University, Erlanger Allee 101, D-07740 Jena, Germany

Received 13 February 2004; received in revised form 15 April 2004; accepted 19 April 2004

Abstract

Objective: Transthoracic sonography (TS) has evolved as an important imaging technique for diagnosing pleural and pulmonary conditions.
However, the value of TS in either excluding or diagnosing pneumothorax is still under debate. This study was conducted to examine whether
TS could replace chest radiography for the diagnosis of post-interventional pneumothorax and hydropneumothorax.
Methods: 53 patients (21 females, 32 males; median age 64 years, range 37–94 years), 35 of whom underwent transbronchial biopsy (TBB)
and 18 patients who had an ultrasound-guided chest tube placement (U-GCTP) were enrolled in the study. TS was performed three hours
after either TBB or removal of a chest tube, followed by postero-anterior chest radiograph (CRX). If any discrepancy between TS, the clinical
presentation and the CRX became apparent, either a lateral CRX or a computed tomography (CT) of the thorax was performed. TS was
assessed according to the presence of the following criteria: (1) “gliding sign” of the pleural line, (2) comet tail artifacts, (3) reverberation
artifacts, (4) air/fluid mirror, (5) hyperechoic reflectors within the pleural effusion and (6) “lung point”.
Results: In four out of the 53 patients (7.5%) a post-interventional pneumothorax or hydropneumothorax occurred. One out of the 35 patients
(2.9%) developed a pneumothorax after TBB, requiring chest tube placement. Three patients (16.7%) developed a hydropneumothorax due to
U-GCTP which was detected by sonography but was missed by postero-anterior CRX in one patient. The sensitivity, specificity and accuracy
of TS were 100% in excluding post-interventional pneumothorax/hydropneumothorax.
Conclusion: TS is a cost-effective and safe bed-side-method, allowing for an immediate exclusion or diagnosis of post-interventional pneu-
mothorax/hydropneumothorax in patients who have undergone TBB or U-GCTP. Thus, these preliminary results suggest that CXR may only
be required in patients with pneumothorax diagnosed by TS in order to assess its extension or to exclude any discrepancy between the TS-result
and the clinical presentation.
© 2004 Elsevier Ireland Ltd. All rights reserved.

Keywords: Pneumothorax; Hydropneumothorax; Transthoracic sonography; Transbronchial biopsy; Ultrasound-guided chest tube placement; Comet tail
artifacts

1. Introduction appropriate treatment or observation is required. Since most

Transbronchial biopsy (TBB) during bronchoscopy as
well as ultrasound-guided chest tube placement (U-GCTP)
may be complicated by a post-interventional pneumothorax,
irrespective of a correctly performed manipulation. This
complication occurs in about 5.5% of the patients after TBB
under X-ray-control [1] and in about 2.5 to 13.9% of the
patients after ultrasound-guided thoracentesis [2]. Depend-
ing on the volume of the intrapleural air, an immediate and
∗ Corresponding author. Tel.: +49 3641 939 625;
fax: +49 3641 939 326.
E-mail address: angelika.reissig@med.uni-jena.de (A. Reißig).
post-interventional pneumothoraces develop within three
hours, a routine X-ray of the chest in expiration is usually
performed after this interval. However, a postero-anterior
chest radiograph (CXR) will only show a large pneumotho-
rax, whereas a small quantity of intrapleural air, especially
in supine patients, can escape detection. Thus, an additional
lateral view or even a computed tomography (CT) may be
occasionally required.
To date, CT is considered the most sensitive method for
diagnosing both a pneumothorax or a hydropneumothorax.
However, due to the potential risks associated with the ex-
posure to ionising radiation, together with the considerable
costs of the procedure, as well as the difficulties arising in

0720-048X/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2004.04.014
464 A. Reißig, C. Kroegel / European Journal of Radiology 53 (2005) 463–470
transporting the patient, CT is not the method of choice for
diagnosing pneumothorax. Thus, alternative methods that
could substitute for radiological techniques in routine post-
interventional exclusion of pneumothorax are called for.
Transthoracic sonography (TS) has proved to be an ex-
tremely useful method for the evaluation of pleural effu-
sion and as a guidance for thoracentesis. In recent years,
this technique has emerged as a diagnostic tool in vari-
ous pulmonary, pleural, and mediastinal conditions such as
pulmonary embolism, carcinoma of the lung and diffuse
parenchymal lung disease [3–7]. Its main drawback is that
the healthy lung parenchyma cannot be penetrated and im-
aged by sonography. However, since the ultrasound pattern
of the air-containing lung differs from the artifacts induced
by air within the pleural space [8], the diagnosis of pneu-
mothorax may be revealed by sonography. On the basis of
these observations, the present prospective study was car-
ried out to investigate the potential diagnostic value of TS
in post-interventional pneumothorax or hydropneumothorax
on a pneumological ward.
2. Materials and methods
2.1. Patients
A total of 53 consecutive patients (21 females, 32 males;
median age 64 years, range 37–94 years) were enrolled
in this prospective study. Thirty-five patients underwent
transbronchial biopsy during bronchoscopy (16 females, 19
males; median age 63 years, range 48–79 years). Eighteen
patients (5 females, 13 males; median age 66.5 years, range
37–94 years) were subjected to an ultrasound-guided chest
tube placement for pleural effusion. Pleural fluid drainage
using a small diameter tube was performed in all of these
patients. In two of the 18 patients, pleural drainage was
inserted following pleural biopsy.
The final diagnosis of all patients (n = 53) enrolled in
the study included squamous cell carcinoma of the lung (n
= 5), non small cell lung cancer (n = 10), adenocarcinoma
of the lung (n = 5), small cell lung cancer (n = 3), cervical
carcinoma of the uterus (n = 1), squamous cell carcinoma of
the upper jaw (n = 1), breast cancer (n = 1), ovarian cancer
(n = 1), chronic pneumonia (n = 9), bronchiolitis obliterans
organising pneumonia (n = 2), congestive heart failure (n
= 5), aspergilloma (n = 2), empyema (n = 1), idiopathic
pulmonary fibrosis (n = 6), and leukemia (n = 1).
2.2. Study design
Three hours after transbronchial biopsy or removal of the
chest tube, respectively, the patients first underwent sono-
graphic examination followed by a clinical examination and
lastly a postero-anterior CRX. If any discrepancy between
TS, clinical presentation and result of the CRX became ap-
parent, a CRX in a lateral view or a thoracic CT was per-
formed for further clarification. The study protocol followed
the guidelines of the local ethics committee. Informed con-
sent was obtained from all patients enrolled in the study.
2.3. Transthoracic sonography
All patients underwent transthoracic examination using a
5 MHz convex scanner (AU5 Harmonic, Esaote Biomedica;
Munich, Germany), regularly supplemented by examina-
tion with power colour Doppler mode, occasionally supple-
mented by a 7.5 MHz linear scanner. Transthoracic sonogra-
phy was performed by an experienced pneumologist trained
in chest sonography. The patients were examined in a seated
position from the anterior and the posterior aspect of the
chest. Selected sonographic images of major abnormalities
were recorded on photographic film. Sonography was con-
ducted via a systematic examination of the intercostal spaces
at the biopsy or tube thoracostomy side. The sonographic
findings of the left and right lung were compared. Further,
the breath-dependent motion of the pleural line was care-
fully evaluated for about five respiratory cycles.
The following criteria were assessed for TS excluding
pneumothorax: (1) presence of “gliding sign” or “lung
sliding” of the pleural line and (2) presence of comet tail
artifacts (CTA). When required, “lung sliding” was further
reviewed using power colour Doppler imaging, the so-called
“power slide”.
In addition, the following criteria were assessed for TS,
suggesting the presence of pneumothorax/hydropneumo-
thorax: (3) occurrence of reverberation artifacts, (4) presence
of an air-fluid mirror, (5) presence of hyperechoic reflectors
within the pleural effusion [8–13] and (6) the “lung point”
was assessed in case of pneumothorax [14,15]. Furthermore,
TS was assessed for (7) pleural effusion in all patients.
The diagnostic criteria of TS are defined as follows:
(1) “Gliding sign” or “lung sliding” of the pleural line:
Under physiological conditions, the visceral pleura and
lung surface form an echoic line, the so-called “pleu-
ral line”. The respiration-dependent up- and down-
movement of the “pleural line” is called “gliding sign”
or “lung sliding”. This sign needs to be demonstrated
under real-time-conditions (Fig. 1A).
“Power slide”: “Lung sliding” is made visible via
power colour Doppler imaging [14] (Fig. 1B).
(2) Presence of comet tail artifacts (CTA): CTA become
visible when a marked difference in acoustic impedance
between an object and its surroundings exists, demar-
cating the edge of the aerated normal lung [16]. These
artifacts are best visible under real-time conditions,
since often their appearance is less striking on frozen
sonograms. CTA are only generated by an intact lung
surface. Thus, the presence of CTA excludes a pneu-
mothorax (Figs. 2 and 3).
(3) Occurrence of reverberation artifacts: Pneumothorax
is defined as the presence of air within the pleural
 A. Reißig, C. Kroegel / European Journal of Radiology 53 (2005) 463–470
Fig. 1. (A) “Gliding sign”, sonogram (linear scanner) in a patient with
unaffected pleura. The sonogram reveals a normal lung surface with a
smooth and regular hyperechoic “pleural line”. One single comet tail arti-
fact is detectable reflecting a normally aerated lung. Under real-time con-
ditions, the breath-dependent motion of the pleural line can be seen (“glid-
ing sign”). (B) “Power slide”, sonogram (convex scanner supplemented
by power Doppler mode) in a patient with unaffected pleura. The sono-
gram shows a normal lung surface. Under real-time conditions, the power
colour Doppler signal along the pleural line reveals a breath-dependent
movement of the lung (“Power slide”).
space preventing full expansion of the lung. The pleural
air generates reverberation artifacts that form parallel
horizontal echoic lines (Fig. 3).
(4) Air-fluid mirror: In case of a hydropneumothorax an
air/fluid level may develop, with air accumulating in
the upper zones of the thoracic cavity. The horizontal
line of the air/fluid-level has been designated as the
air-fluid mirror [10,13] (Fig. 4).
(5) Hyperechoic reflectors: Air inclusions within the pleu-
465
Fig. 2. Comet tail artifacts, sonogram (linear scanner) in idiopathic pul-
monary fibrosis in a 62-year-old woman with established idiopathic pul-
monary fibrosis. Examination with a linear scanner revealed an irregular,
fragmented and thickened pleural line with numerous comet tail artifacts.
Fig. 3. Reverberation-artifacts, sonogram (linear scanner) in a patient
with pneumothorax. Comparison to the unaffected contralateral lung.
Pneumothorax in a 65-year-old woman following transbronchial biopsy
for idiopathic pulmonary fibrosis. On the left side, a thickened, irregular
pleural surface with comet tail artifacts reflecting the interstitial lung
disease is seen. In contrast, on the contralateral side no comet tail artifact
can be detected, since reverberation-artifacts are present. Under real-time
conditions, the loss of the breath-dependent motion of the pleural line
could be demonstrated.
ral effusion may also become visible as hyperechogenic
reflectors within the effusion [10,13] (Fig. 5).
(6) The “lung point”: In pneumothorax, the border be-
tween aerated lung and pneumothorax is depicted as
“lung point” [15] (Fig. 6).
(7) Pleural effusion: The presence of pleural effusion (E)
is demonstrated as an echo-poor or echo-free space
between the pleura visceralis and parietalis, and is best
visible above the diaphragm (Fig. 7).
2.4. Chest radiograph
Directly following a sonographic examination, all patients
underwent a postero-anterior chest radiograph (Vertix Poly-
466 A. Reißig, C. Kroegel / European Journal of Radiology 53 (2005) 463–470

Fig. 4. Air-fluid mirror, sonogram (convex scanner) in a patient with
a hydropneumothorax. The 58-year-old woman suffered from pleural
effusion due to non small cell lung cancer. During the removal of the
effusion, the sonogram revealed an air-fluid mirror that is suggestive of
hydropneumothorax.
Fig. 5. Hyperechoic reflectors within the effusion, sonogram (convex
scanner) in a patient with hydropneumothorax. The 77-year-old woman
suffered from pleural effusion due to non small cell lung cancer. The
sonogram shows hyperechoic reflectors within the effusion representing
hydropneumothorax.

2.5. Spiral computed tomography

dros SX 80, Siemens, Erlangen, Germany and Optimus Didi,
Philips, Hamburg, Germany). When necessary, an additional
CRX in a lateral view was obtained. CRX was interpreted
by an expert in chest radiology who was unaware of the re-
sults obtained by TS.
If any discrepancy between the results obtained from chest
sonography, clinical presentation and the CRX was present,
a CT (Somatom Plus 4, Siemens, Erlangen, Germany) of the
thorax was carried out for clarification purposes.

Fig. 6. “Lung point”, sonogram (linear scanner) in a patient with pneumothorax. The sonogram reveals the “lung point”, the border between aerated lung
and pneumothorax (arrow).
 A. Reißig, C. Kroegel / European Journal of Radiology 53 (2005) 463–470 467

Table 1
Exclusion and depiction of pneumothorax and hydropneumothorax by
transthoracic sonography and postero-anterior chest radiography in 53
patients who underwent transbronchial biopsy (n = 35) and ultrasound-
guided tube thoracostomy (n = 18)
Patients (n = 53) Transthoracic Postero-anterior
sonography chest radiography
Without pneumothorax (n = 49) 49/49 49/49
With pneumothorax (n = 1) 1/1 1/1
With hydropneumothorax (n = 3) 3/3 2/3a
a In one case after positive findings by sonography, an additional CRX

in a lateral decubitus view was necessary to detect hydropneumothorax.

mirror (Fig. 4), which was detected by sonography during

Fig. 7. Pleural effusion, sonogram (convex scanner): pleural effusion is
demonstrated as an echo-tree space between the pleura visceralis and
parietalis, best visible above the diaphragm. A colour signal appears within
the fluid depending on respiratory and cardiac cycles. The sonogram also
shows an atelectasis (arrow).
2.6. Statistics
Data are given as percentage. The sensitivity, specificity
as well as accuracy of TS for diagnosing pneumotho-
rax/hydropneumothorax were calculated.
3. Results
In four out of the 53 patients (7.5%), a post-interventional
pneumothorax or hydropneumothorax was observed. One of
the 35 patients (2.9%) who had undergone TBB developed
a pneumothorax measuring approximately 20% of the tho-
racic volume. A chest tube was inserted over a period of 4
days to remove the air from the pleural space and ensure
full extension of the lung. In these patients, pneumothorax
was correctly diagnosed by TS (Fig. 3) as well as by CRX
(Table 1). In the remaining 34 out of 35 patients (97.1%),
pneumothorax was correctly excluded by means of TS.
In the 18 patients in whom ultrasound-guided chest tube
placement was performed, there were no cases of pneu-
mothorax, but three patients developed a hydropneumotho-
rax (16.7%) (Fig. 5), which could be detected by TS. Only
one of these three patients was symptomatic, complaining of
nocturnal pleuritic pain. Another patient revealed an air/fluid
fluid removal by means of a chest tube. In contrast, the
postero-anterior chest radiograph did not depict a hydrop-
neumothorax in this patient. Therefore, an additional lateral
decubitus CRX was performed which confirmed the hydrop-
neumothorax diagnosed by sonography (Table 1). In all pa-
tients, there was no further necessity for performing CT for
any discrepancy between clinical presentation, chest sonog-
raphy and result of the CRX.
For thoracic ultrasound, a sensitivity of 100% (49/49), a
specificity of 100% (4/4) as well as an accuracy of 100%
(53/53) were calculated in excluding post-interventional
pneumothorax/hydropneumothorax. In contrast, postero-
anterior CRX showed a sensitivity of 98% (48/49), a speci-
ficity of 100% (3/3) and an accuracy of 96.3% (51/53).
3.1. Sonographic findings in TBB patients
Among the 35 patients who underwent TBB only one
(2.9%) developed pneumothorax. In this patient, the loss
of “gliding sign”, “lung sliding” and comet tail artifacts
were evident on sonography. However, neither pleural
effusion nor an air/fluid mirror was detected. Multiple re-
verberation artifacts within the region of pneumothorax
were observed and the “lung point”, i.e. the checkpoint to
the aerated lung, was assessed. In a second patient suf-
fering from pneumonia, pleural effusion was detected on
sonography.
In all other patients without a pneumothorax, the breath-
dependent motion of the pleural line (“gliding sign” or
“lung sliding”) could be clearly demonstrated. Moreover,
a small number of comet tail artifacts were also observed
(Table 2).

Table 2
Sonographic criteria in patients without pneumothorax, with pneumothorax and with hydropneumothorax, who underwent transbronchial biopsy (n = 35)
and ultrasound-guided tube thoracostomy (n = 18)
“Gliding sign”/ Comet tail Reverberation Air-fluid Hyperechoic reflectors “Lung Pleural
“power slide” artifacts artifacts mirror within the effusion point” effusion
Without pneumothorax (n = 49) 49/49 47/49 0/49 0/49 0/49 0/49 15/49
Pneumothorax (n = 1) 0/1 0/1 1/1 0/1 0/1 1/1 0/1
Hydropneumothorax (n = 3) 0/3 0/3 3/3 3/3 1/3 3/3 3/3
468 A. Reißig, C. Kroegel / European Journal of Radiology 53 (2005) 463–470
3.2. Sonographic findings in ultrasound-guided chest tube
placement patients
Among the 18 patients who underwent tube thoracostomy,
none developed a pneumothorax. However, in three patients
(16.7%) a hydropneumothorax was depicted in association
with persistent pleural effusion. In these patients, at least one
air/fluid mirror as well as the loss of the “gliding sign” and
comet tail artifacts within the area of hydropneumothorax
were observed. Moreover, hyperechoic reflections within the
pleural effusion could be detected in one patient (Table 2).
The 15 patients without pneumothorax revealed an unim-
paired breath-dependent motion of the pleural line (“gliding
sign” or “lung sliding”), and in 14 cases a small pleural ef-
fusion persisted after removal of the chest tube (Table 2).
4. Discussion
To date, the method of choice for the exclusion of a post-
interventional pneumothorax is an erect expiratory CRX per-
formed approximately 3 h following the diagnostic proce-
dure. However, this investigation requires a transport of the
patients to the investigation site, and administration of ion-
ising radiation. In addition, small pneumothoraces may be
missed, and severely ill or traumatised patients can only
be radiographed in recumbent position, which makes di-
agnosis of a pneumothorax by CRX even more difficult.
Because of this, the purpose of this prospective investiga-
tion was to determine the accuracy of transthoracic sonogra-
phy in excluding/diagnosing post-interventional pneumoth-
orax or hydropneumothorax in patients who underwent di-
agnostic transbronchial biopsy or ultrasound-guided chest
tube placement. The results demonstrate, that TS is a non-
invasive and safe bed-side-method which allows an imme-
diate exclusion/diagnosis of post-interventional pneumoth-
orax/hydropneumothorax.
Pneumothorax or hydropneumothorax are potentially life-
threatening post-interventional complications that need to be
addressed in daily routine. Prospective studies without direct
imaging guidance following thoracentesis revealed an inci-
dence of pneumothorax of between 4.0 and 30.3%, with up to
50% of these patients requiring chest tube drainage [17–20].
The frequency of pneumothorax for ultrasound-guided tho-
racentesis ranged from 2.5 to 13.9%, with less than 1%
of the patients requiring chest tube drainage [2,21–23]. In
contrast, approximately 5–6% of the patients developed
a pneumothorax as a complication of transbronchial lung
biopsy [1]. In the present study, a comparable rate of post-
interventional pneumothorax or hydropneumothorax was
observed. Following TBB and transthoracic tube thora-
costomy, a post-interventional complication developed in
2.9% (1/35 patients) and 16.7% (3/18 patients), respec-
tively. Interestingly, in two patients, a hydropneumothorax
occurred ex vacuo supporting the previous notion that air-
way obstruction (i.e. due to tumour occlusion) increases the
risk of developing a post-interventional hydropneumotho-
rax irrespective of a correctly performed ultrasound-guided
procedure.
The lung is usually considered poorly accessible to ultra-
sound. Indeed, the ultrasound image is herein exclusively
composed of artifacts, because air prevents the transmis-
sion of the ultrasound beam. However, as a vital organ the
respiration-dependent movement of the visceral pleura sur-
face along the parietal pleura synchronous with respiration
(“lung sliding”) can be easily visualised by its characteris-
tic artifacts [24]. The disappearance of this movement was
originally observed in animal and man [8,11,25,26]. Early
sonographic investigations showed that pneumothorax may
be detectable by sonography [8,11]. In these studies, TS
was performed after the diagnosis of pneumothorax had
been established either by X-ray or CT. In contrast, the
present investigation was performed prospectively with the
radiological images being performed after obtaining the
sonographic findings.
The most characteristic sonographic alterations associ-
ated with pneumothorax are the occurrence of reverberation-
artifacts, which are defined as exclusive horizontal echoic
lines. In addition, the “lung point” designated as point of dis-
tinction between aerated lung and area of pneumothorax [15]
has proved to be useful as it confirms the existence of a pneu-
mothorax and provides an estimate of the size of the lung col-
lapse. Further, in patients suffering from diffuse parenchy-
mal lung disease in whom TBB is often performed another
sign can be applied. When examined by TS, these conditions
are characterised by the manifestation of multiple CTAs dis-
tributed over the whole lung surface and combined with a
thickened and irregular and fragmented pleural line [27]. In
pneumothorax, the CTAs disappear. In other words, the de-
tection of CTAs excludes the presence of a pneumothorax.
Although sonographic exclusion of a pneumothorax is
performed with a standard ultrasound unit and equipment,
a few aspects of the examination should be emphasised. A
3.5–5 MHz probe in combination with a high-frequent linear
transducer (within the 7–10 MHz pulse transmission range)
is preferred. The 5 MHz convex probe yields a clearer image
of more distant tissue regions. In contrast, the high-frequent
linear transducer allows a more detailed assessment of the
proximal tissue zones including the chest wall, lung surface
and pleura. In addition, TS scan of the unaffected contralat-
eral lung is strongly recommended to confirm or exclude
the presence of “lung sliding” [28]. This comparison of the
affected site with the respective area of the contralateral un-
affected lung reduces the risk of missing a pneumothorax
[29]. Moreover, the position-dependent location of the air
within the pleural space has to be taken into consideration
during TS examination. Attention should focus on the upper
part of the lung in seated patients and on the ventral lung
regions in supine patients.
There are only limited data available on the use of ul-
trasound in excluding/diagnosing post-interventional pneu-
mothorax. Among the few reports published, no study dealt
 A. Reißig, C. Kroegel / European Journal of Radiology 53 (2005) 463–470
with pneumothorax as a complication following TBB. Ul-
trasound detection of pneumothorax following computed
tomography-guided biopsy of pulmonary lesions was inves-
tigated by Goodman et al. [29]. However, they had failed to
detect five of 13 pneumothoraces because areas distant from
the biopsy site were not examined sonographically. These
data suggest that it is insufficient to restrict sonographic ex-
amination solely to the needle entry site.
A prospective study comparing sonographic with radio-
graphic detection of traumatic pneumothorax on 11 out of
27 patients showed a sensitivity of 100% (36%), a speci-
ficity of 94% (100%) as well as a positive predictive value
of 92% (100%) and a negative predictive value of 100%
(70%), respectively [30]. In contrast, in the present study
a sensitivity of 100% (98%), a specificity of 100% (100%)
as well as an accuracy of 100% (96.3%), respectively, were
calculated for TS compared to postero-anterior CRX from
the results. Thus, the respective estimate for TS deduced in
the present study is in good agreement with that reported
previously [30].
There are several limitations of our study which need to
be considered. First, the relatively small number of pneu-
mothoraces or hydropneumothoraces may lessen generalisa-
tion of the data. Second, due to the small number of patients
enrolled in the study, the frequency of post-interventional
complications may be over- or under-estimated.
Also, a number of situations or co-existing conditions
which limit the diagnostic application of TS for detecting
a pneumothorax need mentioning. On rare occasions, small
pneumothoraces could be present parallel in both sides of
the lung, hampering the diagnostic evaluation by virtue of
the inability to compare the two lung sides. In addition,
the presence of a thoracic wall emphysema causes a “snow
flurry” due to the reverberation echoes caused by subdermal
gas collections and prevents evaluation of the intra-thoracic
regions [13]. Further, although the size of a pneumothorax
can be sonographically approximated by assessing the “lung
point”, the depth of the pulmonary collapse cannot be anal-
ysed. In this case, a CXR is necessary to determine its full
extension. Finally, pachypleuritis with pleural adhesions or
phrenic paralysis may impair lung excursion and obscure
identification of the “gliding sign”. Nevertheless, a carefully
obtained history of pre-existing conditions as well as a thor-
ough sonographic examination should still allow a correct
diagnosis of a pneumothorax.
5. Conclusion
TS is a helpful method for the diagnosis of complica-
tions following thoracic interventions. Chest sonography
represents a cost-effective, safe, and non-invasive method
that allows an immediate exclusion/detection of post-
interventional pneumothorax/hydropneumothorax, thereby
preventing patient exposure to ionising radiation. The pre-
liminary results presented herein suggest, that a complimen-
469
tary CRX would only be required (1) for assessing extent
of the pulmonary collapse or (2) under conditions of dis-
crepancy between the TS-result and the clinical appearance.
However, future prospective studies comparing TS and CRX
in a larger number of patients with pneumothorax/hydrop-
neumothorax are warranted to substantiate our observations.
Acknowledgements
The authors are indebted to N. Kroegel, B.Sc. for review-
ing the manuscript.
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