Clinical Review

Radiological review of pneumothorax

BMJ 2005; 330 doi: 10.1136/bmj.330.7506.1493 (Published 23 June 2005)
Cite this as: BMJ 2005;330:1493

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  1. A R O'Connor, consultant (angusoconnor@hotmail.com)1,
  2. W E Morgan, consultant2
  1. 1Department of Radiology, Nottingham City Hospital, Nottingham NG5 1PB
  2. 2Department of Thoracic Surgery, Nottingham City Hospital
  1. Correspondence to: A R O'Connor
  • Accepted 3 May 2005

Introduction

Spontaneous pneumothorax is relatively common in the community.1 The incidence of iatrogenic pneumothorax is difficult to assess but is probably increasing due to the more widespread use of mechanical ventilation and interventional procedures such as central line placement and lung biopsy. Correct interpretation of chest radiographs in this clinical setting and knowledge of when to request more complex imaging techniques are essential. In this review we discuss the role of the chest radiograph in the assessment of pneumothorax before and after treatment along with the value of computed tomography and radiologically guided chest drain placement.

Fig 1

(left) Classic appearances of left sided pneumothorax with readily apparent visceral pleural line (arrow)

Fig 2

(right) Supine projection showing air collected at lung base. Absent lung markings anda visceral pleural line (arrow) are still visible (P=pneumothorax). Left basal chest drain is noted

Sources and selection criteria

We reviewed textbooks of chest imaging and radiological normal variants. We also searched Medline for articles relating to both imaging appearances and clinical management of pneumothorax.

Pretreatment evaluation

The radiographic diagnosis of pneumothorax is usually straightforward (fig 1). A visceral pleural line is seen without distal lung markings. Lateral or decubitus views are recommended for equivocal cases.2 On standard lateral views a visceral pleural line may be seen in the retrosternal position or overlying the vertebrae, parallel to the chest wall.3 Shoot-through lateral or decubitus views may be used in ventilated patients or neonates. Although the value of expiratory views is controversial4 many clinicians still find them useful in the detection of small pneumothoraxes when clinical suspicion is high and an inspiratory radiograph appears normal. The British Thoracic Society guidelines2 divide pneumothoraxes into small and large based on the distance from visceral pleural surface (lung edge) to chest wall, with less than 2 cm being small and more than 2 cm …

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