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7/25/2019 Recognizing Pneumothorax
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RecognizingA Pneumothorax
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William erring, !"#" $ %&&%
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Remember
'here are two la(ers of pleura) parietal and visceral)the
pleural space between them *ormall( there is no air in the pleural space
'he visceral pleura is inseparable from the lung parench(ma
and moves with the lung
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+isceral
pleura
Parietal
pleura
Pleural space
$ rank *etter, !# *ovartis-
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'he +isceral Pleural White .ine
When air enters the pleural space, the parietal and visceral
pleura separate making the visceral pleura visible
'he thin white line of the visceral pleura is called thevisceral pleural white line
/ou must see the visceral pleural white lineto make
diagnosis of pneumothorax0
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A pneumothorax will bevisible as a thin white
line ) the visceral pleural
white line
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.ung !arkings
.ung markings ma( be absent distal to the visceral pleural
white line
1ut the( 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 pneumothorax0
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.arge bulla in the ..." *ote there is no
visceral pleural white line paralleling the chest wall
ARRS R2 $
Wh( 'he Pleural White .ine
Is Important
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3hest tube erroneousl( inserted into bulla
in .4. produces an intractable pneumothorax"
ARRS R2 $
Wh( 'he Pleural White .ine
Is Important
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'here are diseases other than a pneumothorax that
can cause an absence of lung markingsor example
1ullous disease
.arge c(sts in the lungPulmonar( embolism
Wh( 'he Pleural White .ine
Is Important
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Wh( 'he Pleural White .ine
Is Important
*one of those diseases is treated with a chest
tube
In fact, insertion of a chest tube into a bulla can
produce an intractable pneumothorax
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Skin fold or Pneumothorax
A fold of the patient5s skin ma( become trapped between
the patient and cassetteSkin folds are common
6speciall( in patient5s who have lost a great deal of
weight
'his skin fold can mimic a pneumothorax
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ow can we tell them apart7
Skin oldSkin old Pneumothorax
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'he ke( difference is that a skin fold is an edge
consisting of a densit( 8light9 and then a lucenc( 8dark9
Skin old
#ense
.ucent
'his is an edge
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Whereas the visceral pleural line is a
thin white line with a lucenc( 8darker9 on both sides of it
Pneumothorax
.ucent
#ense
.ucent
'his is a line
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ere the( are again side)b()side: the skin fold is an edge,
the pneumothorax is a line
Skin oldSkin old Pneumothorax
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Which is this7
Skin fold or Pneumothorax
'his is an
edge ;
skin fold
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Which is this7
Skin fold or Pneumothorax
'his is a line ;
pneumothorax
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'(pes of Pneumothoraces
'wo ma
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Simple Pneumothorax
In a simple pneumothorax, there is no shift of
the heart or mediastinal structures 8trachea9
Air in left hemithorax balances the air in the
right hemithorax
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Simple pneumothorax on the left side
*o shift of the heart or trachea
+isceral
pleural white
line
*o shift of
midlinestructures
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'ension Pneumothorax
Progressive loss of air into pleural space causing a
shift of the heart and mediastinal structures awa( from
side of pneumothorax
=pposite lung is compressed
Respirator( function severel( compromised
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'ension Pneumothorax
$ rank *etter, !# *ovartis-
Air enters Right hemithorax either from tear in lung or hole in chest
wall on inspiration> does not exit on expiration
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3omplete right)sided
pneumothorax
.ung is compressedagainst mediastinum
Shift of heart and
trachea to left
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Which is this7Simple or 'ension Pneumothorax
'ension pneumothorax)heart is shifted slightl(
to right b( large left)sided pneumothorax
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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
awa( from side of pneumothorax
'here is never a shift toward the side of a
pneumothorax
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3auses of a Pneumothorax
Spontaneous
Rupture of an apical sub)pleural bleb usuall( in a tall,
thin male
'rauma
'hrough chest wall, e"g" stab wound
Internal, e"g" rupture of a bronchus from a motor vehiclecollision
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3auses of a Pneumothorax
#iseases that decrease lung compliance
3hronic fibrotic diseases, e"g" eosinophilic granuloma
#iseases that stiffen the lung, e"g" h(aline membrane
disease
Rupture of an alveolus or bronchiole
6"g", asthma
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Important Points
/ou must see the visceral pleural white line to
diagnose a pneumothorax
A skin fold is an edge> the visceral pleural line
is a line
'here is a never a shift toward the side of apneumothorax
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Pneumothorax
'he visceral pleural white
line is seen and there are no
lung marking distal to it" 'hisis a simple pneumothorax
since there is no shift"
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*o Pneumothorax
'his is a skin fold" It is an edge,
not a line"
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ARRS R2 $
*o Pneumothorax
'his is a skin
fold" It is an
edge, not a
line"
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'here is a left)sided
tensionpneumothorax with
shift of the heart
and mediastinal
structures to theright"
Pneumothorax