Pneumothorax: An Emergency! How Do I Diagnose in a Primary Setup? A Systematic Approach to Read X-Rays Pneumothorax: An Emergency! How Do I Diagnose in a Primary Setup? A Systematic Approach to Read X-Rays

Abstract

Background: Pneumothorax can be an important diagnosis in patient presenting with sudden onset shortness of breath. Timely diagnosis can be confirmed by a radiograph. Aim: This review is an attempt to make a systematic and highly informative algorithm to read and analyse a radiograph in patient with pneumothorax. Methods: Authors have combined their rich experience in the field with available standard text to make a simple and useful approach to radiographs with pneumothorax. The text is liberally illustrated for readers to get insight into radiographic approach which can be extremely useful in clinical practice. Results: Correct interpretations of chest radiographs in the clinical setting can be lifesaving. Proper interpretation of Xray Chest can reveal about underlying lung, aetiology and associated life threatening conditions. Abstract-Background : Pneumothorax can be an important diagnosis in patient presenting with sudden onset shortness of breath. Timely diagnosis can be confirmed by a radiograph.

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© 2015. Raghavendra Bhat, Dr. Parul Kodan, Dr. Gita Bhat, Dr. Sanmath Shetty, Dr. Meenakshi Shetty & Dr. Nita Bhat. This is a
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Global Journal of Medical Research: D
Radiology, Diagnostic Imaging and Instrumentation
Volume 15 Issue 1 Version 1.0 Year 2015
Type: Double Blind Peer Reviewed International Research Journal
Publisher: Global Journals Inc. (USA)
Online ISSN: 2249-4618 & Print ISSN: 0975-5888
Pneumothorax: An Emergency! How Do I Diagnose in a Primary
Setup?
A Systematic Approach to Read X-Rays
By Raghavendra Bhat, Dr. Parul Kodan, Dr. Gita Bhat, Dr. Sanmath Shetty,
Dr. Meenakshi Shetty & Dr. Nita Bhat
Manipal University, India
Abstract-
Background: Pneumothorax can be an important diagnosis in patient presenting with sudden
onset shortness of breath. Timely diagnosis can be confirmed by a radiograph.
Aim: This review is an attempt to make a systematic and highly informative algorithm to read and analyse
a radiograph in patient with pneumothorax.
Methods: Authors have combined their rich experience in the field with available standard text to make a
simple and useful approach to radiographs with pneumothorax. The text is liberally illustrated for readers
to get insight into radiographic approach which can be extremely useful in clinical practice.
Results: Correct interpretations of chest radiographs in the clinical setting can be lifesaving. Proper
interpretation of Xray Chest can reveal about underlying lung, aetiology and associated life threatening
conditions.
Keywords: pneumothorax, hyperlucency, x ray.
GJMR-D Classification : NLMC Code: WF 746
PneumothoraxAnEmergencyHowDoIDiagnoseinaPrimarySetupASystematicApproachtoReadXRays
Strictly as per the compliance and regulations of:

Pneumothorax: An Emergency! How Do I
Diagnose in a Primary Setup?
A Systematic Approach to Read X-Rays
Abstract- Background :
Pneumothorax can be an important
diagnosis in patient presenting with sudden onset shortness of
breath. Timely diagnosis can be confirmed by a radiograph.
Aim:
This review is an attempt to make a systematic and
highly informative algorithm to read and analyse a radiograph
in patient with pneumothorax.
Methods:
Authors have combined their rich experience in the
field with available standard text to make a simple and useful
approach to radiographs with pneumothorax. The text is
liberally illustrated for readers to get insight into radiographic
approach which can be extremely useful in clinical practice.
Results:
Correct interpretations of chest radiographs in the
clinical setting can be lifesaving. Proper interpretation of Xray
Chest can reveal about underlying lung, aetiology and
associated life threatening conditions.
Keywords: pneumothorax, hyperlucency, x ray.
I. Review Article
neumothorax represents a common clinical
problem.1The development of a pneumothorax
with ensuing hypoxia and hypercapnia can be
potentially life-threatening event. 2Correct interpretations
of chest radiographs in the clinical setting can be
lifesaving! On x ray chest pneumothorax is seen as
hyperlucency without lung markings (pulmonary
vasculature) and the positive presence of the visceral
pleural margin of the partially collapsed lung. A visceral
pleural line is seen without distal lung markings. Lateral
or decubitus views are recommended for equivocal
cases.3
All that glitters is not gold – similarly all
situations with hyperlucency are however not
pneumothorax. There are many other causes for
hyperlucency on a chest x ray and differentiating them
from pneumothorax is crucial. A stepwise approach in
reading a chest x ray with hyperlucency will avoid wrong
diagnosis and facilitate correct and timely treatment.
Hence it is important for the clinicians to be able
to navigate through various causes of hyperlucency. The
following flow chart is made specially to help this.
In any x ray start by looking for hyperlucency,
absence of lung markings, visceral pleural margin and
any fluid level. For example look for figure 1 and analyze
the following:
Figure 1
1. Hyperlucency on the right side
2. Absence of lung markings
3. Visceral pleural margin of the collapsed lung seen at
the hilum. Note that the lung may almost
completely be collapsed like a cricket ball to the
hilum indicating that the underlying lung is unlikely
to have major illness.
4. Observe a small fluid level in costophrenic angle
(Hydropneumothorax on the right side).
Once pneumothorax is recognized, a careful
look at x ray may reveal a lot of information about the
cause, associated conditions and unravel about
underlying lung. 4 However, when we recognizes the
presence of pneumothorax we must have a streamlined
approach for that. An approach is suggested below.
‘Drill’ for seeing an X-ray with pneumothorax:
A. Things to look for on the same side of
pneumothorax.
B. Things to look for on the opposite side of
pneumothorax.
C. Things to look for on both sides.
D. Things to look for under a pneumothorax.
P
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Raghavendra Bhat α, Dr. Parul Kodan σ, Dr. Gita Bhat ρ, Dr. Sanmath Shetty Ѡ,
Dr. Meenakshi Shetty ¥& Dr. Nita Bhat§
Author σ :Kasturba Medical College, Mangalore, Manipal University.
e-mail: parulkodan@yahoo.com

a) Things To Look For On The SAME SIDE Of
Pneumothorax
1. Air in soft tissue: Surgical emphysema (due to the
cause of pneumothorax or introduced during the
insertion of the intercostal tube.
2. Rib fracture: Traumatic (including pathological
fractures)
3. Intercostal tube May indicate severity and also
suggest as coexisting empyema or haemothorax.
May be the source of air.
4. Costophrenic angle obliteration (suggesting
associated pleural effusion+ Hydropneumothorax
Fluid level
5. Is the collapse of the lung complete Collapses like
a ball to hilum (major underlying lung disease in
the almost completely collapsed lung is unlikely.
6. Is the collapse of the lung partial? There must be
some reason for preventing complete collapse:
Look Outside the lung for: Fibrous strands , small
pneumothorax. Look Inside the lung for: T. B.
infiltration, malignancy.
7. Pleural thickening Old lesion.
Figure 2 : Observe
1. Surgical emphysema on both sides.
2. Pneumothorax on the right side.
3. Intercostal tube on the right side.
4. Calcification on left side indicating possible old
tubercular foci.
i. Observe
− Chest tube - used to treat the pneumothorax.
− Surgical emphysema - air in subcutaneous
tissues, seen bilaterally, probably as a result of
a chest tube (intercostal tube) introduction.
Look for a rib fracture whenever there is surgical
emphysema.
Clinical clue: crepitus in the muscle planes
overlying the surgical emphysema.
Figure 3 : In see the collapsed lung.
Lung tends to collapse like a cricket ball
towards the hilum (compression collapse). Unlike the x
ray in fig 1, the lung has failed to collapse to the hilum
indicates the possibility of an underlying pathology.
Figure 4
The most obvious finding in this Chest X ray in
figure 4 is a horizontal fluid which is because of
simultaneous presence of fluid and air in the thoracic
Pneumothorax: An Emergency! How Do I Diagnose in aPrimary Setup?
A Systematic Approach to Read X-Rays
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cavity outside the pleura. The hyperlucency is situated
lateral to the margin of the collapsed lung (outlined by
the visceral pleura). Therefore this hyperlucency is
clearly due to presence of free air in the pleural cavity.
The simultaneous presence of air and fluid indicated by
a horizontal fluid level, helps to identify this situation as a
hydropneumothorax. Note that the visible portion of the
partially collapsed lung is not healthy- there is an apical
cavity. The opposite lung also shows evidence of
infiltration. The overall picture strongly suggests
possibility of underlying tuberculosis as evidenced by
the cavity, whose rupture is most likely the cause of
pneumothorax.
Figure 5
There is a clearly seen horizontal fluid level in
the lateral view in Figure 5. Above the fluid level there is
an area of hyperlucency without lung markings (free air).
Margin of the collapsed lung though faintly visible is not
seen as clearly as in the PA view.
Figure 6 :
Observe in figure 6 that the lung underlying the
pneumothorax on the right side has partially collapsed.
The upper and the middle lobes are having
consolidation preventing a total collapse. This is an
example of collapse consolidation.
b) Things to Look for on the Opposite Side of
Pneumothorax
1. Air in a soft tissue: Surgical emphysema.
2. Trachea If shifted to the opposite side indicate
3. Heart a substantial pneumothorax possibly with
air under pressure
4. Lung fields: Cavity, cotton wool infiltrates (T.B)
Figure 7
Figure 7 is an example of tension pneumothorax.
There is a lot of free air outside the lung which has
collapsed like a deflated balloon to thehilum of the
lung(which also shows evidence of some underlying
disease). The free air has resulted in hyperlucency
without lung markings obviously because the vessels
(which would have resulted in visible lung markings)
have collapsed to the hilum with the lung. There is lot of
free air outside the lung exerting pressure on
neighborhood structures resulting in flattening of
diaphragm, shift of mediastinum to the opposite side.
The pressure can also be exerted on the great
vessels for which the veins (superior and inferior vena
cavae) are more vulnerable (than aorta). This can
explain the hypotension and shock which can
complicate the tension pneumothorax.
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Pneumothorax: An Emergency! How Do I Diagnose in aPrimary Setup?
A Systematic Approach to Read X-Rays

Figure 8
In Figure 8 observe:
1. Hyperlucency (unilateral on right side +no lung
markings +
2. Margin of the partially collapsed lung.
3. Cavities inside the partially collapsed lung.
4. Tracheal shift to the opposite side.
5. Infiltration in the opposite lung.
6. Cardiac shift to the opposite side.
Note of caution: The scapular margin seen on the left
side can erroneously be considered to be margin of the
collapsed lung.
c) Things to Look for on Both Sides
1. Bilateral pneumothorax: TB, connective tissue
disorders. like Marfan’s syndrome
2. Look for mediastinal emphysema, surgical
emphysema.
Figure 9
Observe in figure 9:
1. Hyperlucency
2. Absent lung markings Bilateral
3. Margin of the collapsed lung
4. Fluid level - on right side only
5. Hydropneumothorax on the right side
Pneumothorax on left side. Most likely cause:
bilateral tuberculosis - that’s probably why the
underlying lung has not collapsed completely. It is
a wonder how the patient is alive!
Figure 10
Observe in figure 10 ,the smooth outlining of the
heart with a radiolucent shadow. This is suggestive of
mediastinal emphysema .Also observe infiltration in both
lungs.
d) Things to Look for “Under” the Pneumothorax
1. Visible lesions can be Infiltration, cavity, in a
partially collapsed lung, emphysema(sometimes
seen after expansion), bulla etc.
2. “Invisible” lesions: Bulla, sub pleural lesions.
Figure 11
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Pneumothorax: An Emergency! How Do I Diagnose in aPrimary Setup?
A Systematic Approach to Read X-Rays

Observe in figure 11 ,COPD changes in this
long term male smoker of 60 years age.
Notice the pneumothorax at the right lower
zone. Though it is a small pneumothorax it is clearly
visible – Hyperlucency without lung markings laterally
and margin of the collapsed lung covered by the
visceral pleura medially. Note the blunted costophrenic
angle.
What caused this pneumothorax?
Look at the lower zone on the other side (red
arrow) – you will observe a hyperlucent circular area but
no pneumothorax- a Bulla, which can sometimes mimic
a cavity or a pneumothorax.
A similar bulla on the right side must have resulted in the
Pneumothorax.
Beware of the effects that could have happened
but have not:Large pneumothorax + trachea/ Look for a
lesion causing heart not shifted to opposite side volume
loss in the disorder shifted to the same side eased lung:
eg: fibrosis, tumour (an ominous sign when it is due to a
tumour).
II. Localised Pneumothorax
Figure 12
Please note that in this x ray (figure 12 ) the
outline of the collapsed lung margin on the right side is
very faint.
This is an example of localized apical
pneumothorax. A prominent cardiomegaly and a
prominent medial border of the scapula on the left side
is two distracting features in this x ray.
Figure 13
In figure 13 we can see close up view of the
localized apical pneumothorax. Please observe that free
air in the pleural cavity (pneumothorax) is situated
between the two (visceral and parietal) layers of pleura.
The visceral layer outlines the outer border of the
collapsed lung.
The treatment of the pneumothorax and its
cause has to be individualized for each patient and is
out of scope of this article. However underlying etiology,
associated conditions and other information revealed by
a X ray can be essential guiding tool in deciding the
treatment.
III. Conclusion
A close look at x-ray can be highly informative
and revealing. To diagnose pneumothorax timely can be
life saving. This approach is an attempt to help students
and physicians to systematically approach
pneumothorax.
References Références Referencias
1. Noppen M, DeKeukeleireT.Pneumothorax.Respirati
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2. EsraArunOzer, Ali YukselErgin, Sumer Sutcuoglu,
Can Ozturk, and Ali Yurtseven, .Is Pneumothorax
Size on Chest X-Ray a Predictor of Neonatal
Mortality? Iran J Pediatr. Oct 2013; 23(5): 541–545.
3. Henry M, Arnold T, Harvey J. BTS guidelines for the
management of spontaneous pneumothorax.
Thorax 2003;58(Suppl 2):ii39-52.
4. Sutton D(2003). Textbook of radiology and
imaging(7th ed).ChurchillLivingstone. p. 93-6. ]
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Pneumothorax: An Emergency! How Do I Diagnose in aPrimary Setup?
A Systematic Approach to Read X-Rays