William Herring, M.D.

© 2002

Recognizing
A Pneumothorax

In Slide Show mode, to advance slides, press spacebar

or click left mouse button
 Remember

 There are two layers of pleura- parietal and visceral-the

pleural space between them
 Normally there is no air in the pleural space
 The visceral pleura is inseparable from the lung parenchyma
and moves with the lung
Visceral
pleura

Parietal Pleural space

pleura

© Frank Netter, MD Novartis®

The Visceral Pleural White Line

When air enters the pleural space, the parietal and visceral
pleura separate making the visceral pleura visible
The thin white line of the visceral pleura is called the
visceral pleural white line
You must see the visceral pleural white line to make
diagnosis of pneumothorax!
A pneumothorax will be
visible as a thin white
line - the visceral pleural
white line
 Lung Markings

Lung markings may be absent distal to the visceral pleural



white line
But they can be seen distal to the visceral pleural white line
even with a pneumothorax if lung is folded on itself
Absence of lung markings is not sufficient to make diagnosis
of pneumothorax!
Why The Pleural White Line
Is Important

ARRS R3 ©

Large bulla in the LLL. Note there is no

visceral pleural white line paralleling the chest wall
Why The Pleural White Line
Is Important

ARRS R3 ©

Chest tube erroneously inserted into bulla

in LUL produces an intractable pneumothorax.
 Why The Pleural White Line
Is Important

There are diseases other than a pneumothorax that

can cause an absence of lung markings
 For example
 Bullous disease
 Large cysts in the lung
 Pulmonary embolism
 Why The Pleural White Line
Is Important

None of those diseases is treated with a chest

tube
In fact, insertion of a chest tube into a bulla can
produce an intractable pneumothorax
Skin fold or Pneumothorax

A fold of the patient’s skin may become trapped between

the patient and cassette
 Skin folds are common
Especially in patient’s who have lost a great deal of


weight
 This skin fold can mimic a pneumothorax
Skin Fold Pneumothorax

How can we tell them apart?

 This is an edge

Dense

Lucent

Skin Fold

The key difference is that a skin fold is an edge

consisting of a density (light) and then a lucency (dark)
 This is a line

Lucent

Dense

Lucent
Pneumothorax

Whereas the visceral pleural line is a

thin white line with a lucency (darker) on both sides of it
 Skin Fold Pneumothorax

Here they are again side-by-side: the skin fold is an edge,

the pneumothorax is a line
 Which is this?
Skin fold or Pneumothorax

This is an
edge =
skin fold
 Which is this?
Skin fold or Pneumothorax

This is a line =
pneumothorax
Types of Pneumothoraces

 Two major types of pneumothorax

 Simple
 Tension
 Simple Pneumothorax

In a simple pneumothorax, there is no shift of

the heart or mediastinal structures (trachea)
Air in left hemithorax balances the air in the
right hemithorax
 No shift of
midline
structures

Visceral
pleural white
line

Simple pneumothorax on the left side

No shift of the heart or trachea
 Tension Pneumothorax

Progressive loss of air into pleural space causing a

shift of the heart and mediastinal structures away from
side of pneumothorax
 Opposite lung is compressed
 Respiratory function severely compromised
 Tension Pneumothorax

© Frank Netter, MD Novartis®

Air enters Right hemithorax either from tear in lung or hole in chest
wall on inspiration; does not exit on expiration
 Shift of heart and
trachea to left
Complete right-sided
pneumothorax
Lung is compressed
against mediastinum
 Which is this?
Simple or Tension Pneumothorax

Tension pneumothorax-heart is shifted slightly

to right by large left-sided pneumothorax
Shifts with a Pneumothorax

 If simple, there is no shift of heart and/or trachea

If tension, there is a shift of heart and/or trachea
away from side of pneumothorax
There is never a shift toward the side of a
pneumothorax
Causes of a Pneumothorax

 Spontaneous
Rupture of an apical sub-pleural bleb usually in a tall,
thin male
 Trauma
 Through chest wall, e.g. stab wound
Internal, e.g. rupture of a bronchus from a motor vehicle
collision
Causes of a Pneumothorax

 Diseases that decrease lung compliance

 Chronic fibrotic diseases, e.g. eosinophilic granuloma
Diseases that stiffen the lung, e.g. hyaline membrane
disease
 Rupture of an alveolus or bronchiole
 E.g., asthma
 Important Points

You must see the visceral pleural white line to

diagnose a pneumothorax
A skin fold is an edge; the visceral pleural line
is a line
There is a never a shift toward the side of a
pneumothorax
Pneumothorax

The visceral pleural white

line is seen and there are no
lung marking distal to it. This
is a simple pneumothorax
since there is no shift.
No Pneumothorax

This is a skin fold. It is an edge,

not a line.
 No Pneumothorax

This is a skin
fold. It is an
edge, not a
line.

ARRS R3 ©
Pneumothorax

There is a left-sided
tension
pneumothorax with
shift of the heart
and mediastinal
structures to the
right.