eMedicine Specialties > Thoracic Surgery > Trauma

Pneumothorax: Differential Diagnoses & Workup

Author: Rebecca Bascom, MD, MPH, Professor of Medicine, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pennsylvania State College of Medicine, Milton S Hershey Medical Center; Graduate Faculty Member, Pennsylvania State University College of Medicine and The Huck Institutes of the Life Sciences
Coauthor(s): Michael G Benninghoff, MS, DO, Fellow in Pulmonary and Critical Care Medicine, Penn State Hershey Medical Center; Shoaib Alam, MD, Assistant Professor of Medicine, Division of Pulmonary, Allergy and Critical Care, Pennsylvania State University and Hershey Medical Center
Contributor Information and Disclosures

Updated: Feb 10, 2009

Differential Diagnoses

Esophageal Spasm
Myocardial Ischemia
Pericarditis, Acute
Pleurodynia
Pulmonary Embolism

Other Problems to Be Considered

Large bulla can simulate pneumothorax on chest radiographs. CT scan may be required to clarify the diagnosis.

Occasionally, skin folds, the scapula, and bed sheets can mimic the pleural line, falsely suggesting pneumothorax on the chest radiograph.

Workup

Laboratory Studies

  • Arterial blood gas - In patients with severe underlying lung disease and in those with persistent respiratory distress despite treatment
    • Hypoxemia occurs with increased alveolar-arterial oxygen tension gradient.
    • Hypoxemia tends to be more severe in patients with secondary spontaneous pneumothoraces.

Imaging Studies

  • Chest radiograph (confirms pneumothorax)
    • A linear shadow of visceral pleura with lack of lung markings peripheral to the shadow may be observed, indicating collapsed lung.
    • In supine patients, deep sulcus sign with radiolucency along costophrenic sulcus may help to identify occult pneumothorax.
    • Mediastinal shift toward the contralateral lung may also be apparent.
    • Small pleural effusions commonly are present and increase in size if the pneumothorax does not reexpand.
    • Airway or parenchymal abnormalities in the contralateral lung suggest causes of secondary pneumothorax. Evaluation of the parenchyma in the collapsed lung is less reliable.
    • For more information, see eMedicine Radiology article Pneumothorax.
  • Method to estimate the fractional size of pneumothorax
    • Calculate the ratio of the transverse radius of the pneumothorax (cubed) to the transverse radius of the hemithorax (cubed).
    • To express the pneumothorax size as a percentage, multiply the fractional size by 100.
    • The cut-point distinguishing small and large pneumothoraces varies somewhat among professional societies and experts. The British Thoracic Society uses 2 cm as the cut-off,19 the American College of Chest Physicians uses 3 cm as the cut-point,20 and the Light Index uses 15% of the thoracic volume on the posterior-anterior film as the cut point.21
  • Lateral decubitus film
    • Confirmation of a suspected pneumothorax that is not readily observed on standard supine anteroposterior (AP) radiograph can be demonstrated by obtaining a lateral decubitus film with the involved hemithorax positioned uppermost.
  • Rib films
    • Rib films are indicated if the patient has localized rib pain.
    • Rib films are also indicated when evaluating the patient's posttrauma status if nothing is found on the main posteroanterior (PA) and lateral films.
  • CT scan
    • CT scan is not recommended for routine use but can help to accomplish the following:
      • Distinguish between a large bulla and a pneumothorax
      • Indicate underlying emphysema or emphysemalike changes
      • Determine the exact size of the pneumothorax, especially if it is small
      • Confirm the diagnosis of pneumothorax in patients with head trauma who are mechanically ventilated
    • CT is widely used in actual clinical practice to assess the possibility of associated concurrent pulmonary disease because of the inherent superiority of CT scans to visualize the details of lung parenchyma and pleura.
  • Ultrasonography
    • Ultrasonography is increasingly used in the acute care setting as a readily available bedside tool, especially in ICU and emergency departments.
      • Traumatic pneumothorax in the ICU setting can be followed accurately and early (initial 24 hours) with ultrasonography alone for resolution of the lesion.
      • Lung sliding is the terminology for normal pleural movement in patients without pneumothorax.22 One study showed absent lung sliding from an anterior approach indicated pneumothorax (n =9) with 81% sensitivity and 100% specificity.
    • Ultrasonography has high sensitivity (95.65%), specificity (100%), and diagnostic effectiveness (98.91%) for pneumothorax when using CT as the criterion standard. The sensitivity drops in the ICU, especially in patients with acute respiratory distress syndrome (ARDS).23
    • Ultrasonography cannot be used to discriminate between a COPD-associated bleb and pneumothorax.24

More on Pneumothorax

Overview: Pneumothorax
Differential Diagnoses & Workup: Pneumothorax
Treatment & Medication: Pneumothorax
Follow-up: Pneumothorax
Multimedia: Pneumothorax
References
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Further Reading

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Keywords

pneumothorax, primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), iatrogenic pneumothorax, traumatic pneumothorax, parenchymal lung disease, apical pleural blebs, chronic obstructive pulmonary disease, COPD, Pneumocystis jiroveci pneumonia, PCP, hemopneumothorax, bronchopleural fistula, transthoracic needle aspiration, therapeutic thoracentesis, pleural biopsy, central venous catheter insertion, transbronchial biopsy, positive pressure mechanical ventilation, inadvertent intubation of the right mainstem bronchus, diagnostic ultrasound

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Contributor Information and Disclosures

Author

Rebecca Bascom, MD, MPH, Professor of Medicine, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pennsylvania State College of Medicine, Milton S Hershey Medical Center; Graduate Faculty Member, Pennsylvania State University College of Medicine and The Huck Institutes of the Life Sciences
Rebecca Bascom, MD, MPH is a member of the following medical societies: American College of Chest Physicians, American Public Health Association, American Thoracic Society, and Pennsylvania Thoracic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Michael G Benninghoff, MS, DO, Fellow in Pulmonary and Critical Care Medicine, Penn State Hershey Medical Center
Michael G Benninghoff, MS, DO is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Osteopathic Association, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Shoaib Alam, MD, Assistant Professor of Medicine, Division of Pulmonary, Allergy and Critical Care, Pennsylvania State University and Hershey Medical Center
Shoaib Alam, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, European Respiratory Society, International Society for Magnetic Resonance in Medicine, Pennsylvania Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Benson B Roe, MD, Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center
Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Daniel S Schwartz, MD, FACS, Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital
Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association
Disclosure: Nothing to disclose.

 
 
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