Inpatient Case Presentation Dean Keller, M.D., Associate Professor of Medicine Department of Medicine Section of General Internal Medicine February 9, 2004

Objectives and Acknowledgement Review the radiographic features of pneumothorax to include: Upright chest films and how to estimate size Supine film and recognizing deep sulcus sign Tension pneumothorax Conditions mimicking pneumothorax Acknowledgement-Dr. Yandow and his radiology files!

Definition: Radiological diagnosis of a pneumothorax is made when a gas shadow is visible between the peripheral margin of the lung and the chest wall, mediastinum, or diaphragm.

Upright Film: look in ___________________ (50 cc visible) _______________ visceral pleural line , _________ or ________toward chest wall no _________________________ visible beyond visceral pleural edge size ESTIMATION -lateral width of_____ cm between ribs and visceral pleura =__________. >3cm lateral or >4 cm apex consider chest tube Inspiratory and expiratory upright films can be equally sensitive(Reference 1)

Supine chest films: Look in ____________________(500cc visible) Pneumothorax will outline the ________________,_________________(deep sulcus sign), and anteriolateral border of the ____________________ Pleural edge may have a ____________ contour as opposed to the contour on an upright film

Lateral decubitus: As little as ____ cc of pleural gas can be seen, so good to detect small pneumothorax

Tension Pneumothorax Shift of ____________ to the _________ side Flattening or inversion of the ____________ hemidiaphragm Ipsilateral ________ spaces may be widened Accompanies trauma or ___________(PEEP)

Conditions mimicking pneumothorax ______________. Most cases medial border is _____________ to the chest wall. Checking old films can be extremely helpful. (Reference 2) _______________ May see a negative black Mach band. Gradually increasing opacity with abrupt drop off. May extend beyond the rib cage or stop short. Vessels extend beyond the dark edge of skin fold. (Reference 3)

References: Seow A, Kazerooni EA, Cascade PN, Pernicano PG, Neary M. Comparison of Upright Inspiratory and Expiratory Chest Radiographs for Detecting Pneumothoraces. AJR 1996;166:313-316. Jacobson F, Stark P. Critical Care X-ray: Pneumothorax or giant bullae? Clinical Intensive Care 1992;3:188-189. Stark P, Eber C. Critical Care X-ray: Pneumothorax or skin fold? Clinical Intensive Care 1993;4:45-46. Stark P. Imaging of Pneumothorax. Up To Date online 2004 1-3.