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

3. 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!

4. 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.

5. 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)

11. 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

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

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

21. 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)

24. 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:
Jacobson F, Stark P. Critical Care X-ray: Pneumothorax or giant bullae? Clinical Intensive Care 1992;3:
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