Inpatient Case Presentation

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Inpatient Case Presentation

• Dean Keller, M.D., Associate Professor of
  Medicine
• Department of Medicine
• Section of General Internal Medicine
• February 9, 2004

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Objectives and Acknowledgement

• Review the radiographic features of pneumothorax
  to include
• Upright chest films and how to estimate size
• Supine film and recognizing deep sulcus sign
• Tension pneumothorax
• Conditions mimicking pneumothorax
• Acknowledgement-Dr. Yandow and his radiology
  files!

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Definition

• Radiological diagnosis of a pneumothorax is made
  when a gas shadow is visible between the
  peripheral margin of the lung and the chest wall,
  mediastinum, or diaphragm.

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Upright Film

1. look in ___________________ (50 cc visible)
2. _______________ visceral pleural line , _________
   or ________toward chest wall
3. no _________________________ visible beyond
   visceral pleural edge
4. size ESTIMATION -lateral width of_____ cm between
   ribs and visceral pleura __________. gt3cm
   lateral or gt4 cm apex consider chest tube
5. Inspiratory and expiratory upright films can be
   equally sensitive(Reference 1)

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Supine chest films

• Look in ____________________(500cc visible)
• Pneumothorax will outline the ________________,___
  ______________(deep sulcus sign), and
  anteriolateral border of the ____________________
• Pleural edge may have a ____________ contour as
  opposed to the contour on an upright film

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Lateral decubitus

1. As little as ____ cc of pleural gas can be seen,
   so good to detect small pneumothorax

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Tension Pneumothorax

1. Shift of ____________ to the _________ side
2. Flattening or inversion of the ____________
   hemidiaphragm
3. Ipsilateral ________ spaces may be widened
4. Accompanies trauma or ___________(PEEP)

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Conditions mimicking pneumothorax

1. ______________. Most cases medial border is
   _____________ to the chest wall. Checking old
   films can be extremely helpful. (Reference 2)
2. _______________ May see a negative black Mach
   band. Gradually increasing opacity with abrupt
   drop off. May extend beyond the rib cage or stop
   short. Vessels extend beyond the dark edge of
   skin fold. (Reference 3)

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References

1. Seow A, Kazerooni EA, Cascade PN, Pernicano PG,
   Neary M. Comparison of Upright Inspiratory and
   Expiratory Chest Radiographs for Detecting
   Pneumothoraces. AJR 1996166313-316.
2. Jacobson F, Stark P. Critical Care X-ray
   Pneumothorax or giant bullae? Clinical Intensive
   Care 19923188-189.
3. Stark P, Eber C. Critical Care X-ray
   Pneumothorax or skin fold? Clinical Intensive
   Care 1993445-46.
4. Stark P. Imaging of Pneumothorax. Up To Date
   online 2004 1-3.