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Where’s the air? Pneumothorax
Case presentation
A 16-year-old male presents with left-sided chest pain for the past week. He states that the pain began during band practice. He plays the trombone and states that he “must have pulled a chest muscle” because he was “playing really loud.” He immediately felt the pain but continued playing. He reports no shortness of breath, but the pain is worse with deep inspiration and he feels like he is breathing faster than usual after marching. He denies recent illness and abdominal or back pain. He was seen by his primary care provider 2 days ago and had an electrocardiogram that was normal. He was told to take ibuprofen which has helped some.
Physical examination reveals a tall, thin, pleasant adolescent in no obvious distress. He is afebrile; his heart rate is 85 beats per minute, respiratory rate is 18 breaths per minute, and blood pressure is 118/70 mm Hg, and he has a pulse oxygenation reading of 93% on room air. He converses easily but does complain of chest pain to the left side. He has slightly diminished breath sounds to the left without crackles or rhonchi. He has no retractions. The remainder of his physical examination is unremarkable.
Imaging considerations
Patients with suspected pneumothorax may have imaging to confirm the diagnosis. In patients with concern for tension pneumothorax or decompensating clinical status, imaging should not delay immediate treatment and stabilization.
Plain radiography
This imaging modality is the initial test of choice for patients when a pneumothorax is a clinical consideration. It is readily available and inexpensive relative to other modalities. The presence of a pleural line and the absence of vascular markings beyond this line are the hallmarks of pneumothorax identification on chest radiography. The deep sulcus sign, which is an area of hyperluncency in a depressed costophrenic angle, is pathognomonic for pneumothorax and seen on nonerect radiographs. Pleural air may also be seen in the subpulmonic and anteromedial areas and laterally. , In an adult meta-analysis, the pooled sensitivity and specificity of chest radiography for pneumothorax were 52% and 100%, respectively. ,
The optimal position of the pediatric patient undergoing radiography for suspected pneumothorax has not been well studied. Traditionally upright inspiratory chest radiographs have been utilized, but this may not be feasible in the pediatric population, since cooperation may be an issue, or in the trauma patient, who may be immobilized. While upright inspiratory films are preferred, supine or lateral decubitus views may be obtained. A chest radiograph should visualize the entire chest and lungs.
Computed tomography (CT)
CT is often used as a follow-up study in patients with recurrent pneumothorax or if there is a clinical concern for pleural bullae/blebs. It is generally not a first-line imaging modality; however, in cases of penetrating thoracic trauma or concern for vascular injury, CT may be utilized.
For patients with chest radiography that reveals large pulmonary bullae or if there is concern for structural anomalies of the lung, CT may be indicated and is often utilized if operative management is being considered. , , CT for first-time spontaneous pneumothorax is not recommended by the American College of Chest Physicians guidelines. , However, there are authors that recommend obtaining CT on all patients with first time primary spontaneous pneumothorax to evaluate for pulmonary abnormalities and to assist in a management plan but this is not universally recommended. In one series of patients, Tsou et al. did not find differences in length of stay, length of operation, or rate of complications in patients who underwent CT prior to thoracoscopic surgical procedures. ,
Ultrasound (US)
The use of ultrasound to identify pneumothorax has gained interest. The advantages are the lack of ionizing radiation, lower expense relative to other advanced modalities, and general availability. There are several findings suggestive of pneumothorax on sonography. The absence of lung sliding and so-called comet tails (grayscale artifacts that are present in normal lung parenchyma) has been shown to have a sensitivity and specificity of 100% and 96.5% for pneumothorax ; the absence of comet tails was found to be present in 100% of patients with pneumothorax.
Magnetic resonance imaging (MRI)
This modality is not indicated for the evaluation of patients with suspected pneumothorax.
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