Symptomatic pneumothorax (summary)

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This is a basic article for medical students and other non-radiologists

Pneumothoraces (singular: pneumothorax) are collections of gas within the pleural space. If the pneumothorax is under pressure, it is called a tension pneumothorax.

Reference article

This is a summary article; read more in our article on pneumothorax.

Summary

  • anatomy
  • epidemiology
    • a wide range of patients present with pneumothoraces
    • epidemiology reflects the many potential causes
  • presentation
    • spontaneous pain
    • post-trauma
  • pathophysiology
    • primary spontaneous
      • no underlying lung disease
      • pleural bleb or bulla rupture
    • secondary spontaneous: underlying lung disease, e.g. asthma, COPD
    • secondary: e.g. car accident, stabbing, gunshot, intervention (post lung biopsy)
  • investigation
    • chest x-ray
      • first line investigation
      • relatively high yield apart from small pneumothoraces
    • CT chest
      • trauma
      • suspicion of small pneumothorax and normal x-ray
  • treatment
    • small pneumothorax with minimal symptoms
      • primary spontaneous pneumothorax: discharge with early outpatient follow-up and advised to return if symptomatic
      • secondary pneumothorax: observe with high-flow oxygen therapy and consider intervention
    • symptomatic pneumothorax

Role of imaging

Imaging is used to answer a number of questions including, whether there is:

  • any evidence of tension pneumothorax?
  • any suggestion of the cause?
  • any features to suggest a complication?

Radiographic features

Chest radiograph

Chest x-rays are the first-line test for confirmation of pneumothorax, assessment of size, initial assessment of any underlying cause, and to look for any complications.

The three main features of a pneumothorax on a chest x-ray are:

  • peripheral lucency
  • visible lung edge
  • the absence of lung markings peripheral to lung edge

On an erect x-ray, pneumothoraces are either apical or a rim around the upper portion of the lung-edge.

CT chest

CT is far more sensitive and tiny pneumothoraces may be found. However, it is only used in specific cases to answer specific questions. CT performed in the trauma situation will often lead the diagnosis of pneumothorax, some of which may be small.

CT can be useful for determining the underlying cause.