Tag Archives: Pneumothorax

Student Corner: Air Everywhere

May 19, 2015

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This time, we have an interesting CXR to examine. There are three distinct places in the image below where air is in places it shouldn’t be. Can you identify them?

sp EGD 1


Need a refresher on how to read a CXR? This post will help you out.

Scroll down further for the answer.


PTX, SubQ, Pneumoperitoneum post EGD

Image Key: Blue arrows–supraclavicular subcutaneous emphysema; Purple arrows–pneumothorax; Red arrows = pneumoperitoneum

Pneumothorax: air in the pleural space

On an upright CXR, a pneumothorax is one of the more easily identifiable pathologies in the thoracic cavity. The presence of air separates the parietal pleura and visceral pleura, resulting in the lung tissue being pushed towards midline. This results in the edge of the lung tissue being easily identifiable (purple arrows). The rest of the cavity is devoid of lung markings.

It is important to note that the size of a pneumothorax can vary greatly. Therefore even if the absence of lung markings isn’t as striking as it is in this picture, the edges of the thoracic cavity should always be closely examined to see if there is any evidence of air. On the other extreme is a tension pneumothorax, which is defined as an expanding pocket of air in the thoracic cavity, which causes half of the lung to completely collapse and shift the mediastinal structures in the contralateral direction.

Pneumoperitoneum: air in the abdominal cavity

The presence of air in the abdominal cavity comes from two major sources: outside the body or the GI tract. Air from outside the body enters into the abdominal cavity through either iatrogenic (surgery, peritoneal dialysis) or traumatic (penetrating wound) routes. Air from the GI tract enters if any segment of the bowel is perforated (most commonly secondary to a duodenal ulcer). On an upright CXR, as is shown above, the air rises to the level of the diaphragm and can be identified.

Even though the subdiaphragmatic air in this picture is clearly evident, CXR’s are not the gold standard diagnostic test for pneumoperitoneum. Abdominal CT scans can pick up much smaller amounts of air that may be difficult to visualize on a plain film.

Subcutaneous Emphysema: air in subcutaneous tissue planes

The image above has distinct areas of radiolucency in the supraclavicular area as a result of air tracking in the subcutaneous tissue, which is defined as subcutaneous emphysema. The area is patchy from the infiltration of air into soft tissues.

Similarly to pneumomediastinum, the air comes from either inside the body (secondary to pneumothorax, pneumomediastinum) or outside the body (penetrating trauma, chest tube insertion site). The air travels along fascial planes between the dermal and muscular layers. Another, more serious, cause is necrotizing fasciitis. In this case, however, it is likely that the air entered into the subcutaneous tissues as a result of trauma, which also resulted in a pneumothorax.

Author: Jaymin Patel

Image Contributor: Katren Tyler, M.D.

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Stabbed in the chest…

January 29, 2014


This patient was stabbed in the chest multiple times.  Markers showing the external stab wounds to the lateral chest wall on the right side:

HemoPTX stabbed

This is a classic trauma chest xray with a hemopneumothorax on the right side.  This patient has a great indication for a large-bore chest tube!  Not only to reexpand his lung but to monitor hemothorax output and need for emergent thoracotomy to evaluate the source of bleeding.  Trauma recommendations from the Journal of Trauma in 2010 concerning hemothorax include:

1.  Patient physiology should be the primary indication for surgical intervention rather than absolute numbers of initial or persistent {chest tube} output (Level I recommendation)

2.  1500 ml via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration (Level II recommendation)

3.  All hemothoracies, regardless of size, should be considered for drainage (Level III recommendation)

Please see the EAST Trauma Guidelines for further details:

Mowery NT, et. al.  Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax.  J Trauma 2011; 70 (2): 2011. 

Author:  Russell Jones, MD

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COPD and dyspnea…

October 18, 2013


This patient has a history of COPD (Chronic Obstructive Pulmonary Disease) and presented with acute shortness of breath:


One of the complications of COPD are pulmonary bullae.  Bullae are thin-walled, air-filled spaces that enlarge over months to years.  Sometimes they can burst, causing pneumothoracies.  This Xray demonstrates a pneumothorax on the left side in which a chest tube was placed for reexpansion.  On the right side the patient has multiple large apical bullae which are also at risk of rupture.  The chest tube is in good position with the side-port visualized inside the thoracic cavity and reexpansion of the lung is demonstrated.

Author:  Russell Jones, MD

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PBJ in left mainstem bronchus…

April 28, 2013


A recent patient who presented after choking on a peanut butter and jelly sandwich…

PBJ in L mainstem CTPBJ in L mainstem CXR

This was an interesting case because of the post-intubation conundrum we faced.  The patient came in peri-arrest from hypoxia, GCS was 3 with very poor respiratory effort and oxygen saturation of 60%.  Therefore we were unable to get a great respiratory exam prior to intubation.  Bag-valve mask ventilation with 100% oxygen did not improve the situation and the patient was very difficult to bag due to obviously increased airway pressure.  The intubation was very difficult and as we were checking for bilateral breath sounds post-intubation, we noticed none on the left side.  Capnography color change was good, no gastric sounds were heard, and moisture was in the tube.  Pulling back the endotracheal tube did not change the lack of left sided lung sounds.  The patient continued to be difficult to bag with hypoxia very slowly improving from initial saturations in the 60s now to the mid-70s.  At this point all of our heart rates were around 150 and we had that sinking feeling that occurs when oxygenation doesn’t improve after intubation.

For a few minutes we were concerned about pneumothorax on the left side.  As you can tell from the xray our external landmarks such as tracheal deviation, jugular venous distention were severely limited by body habitus.  Bedside ultrasound using the linear probe was limited as well and no lung-sliding was visualized.  We basically couldn’t identify what we were seeing on ultrasound (later we found out the lung was completely collapsed and we may have been seeing diaphragm, heart, and non-aerated lung).  In the heat-of-the-moment the ED treatment team was perplexed on how to rule out a tension pneumothorax in this situation.

Luckily the patient’s oxygenation creeped above 90% and the patient didn’t have any blood pressure problems.  We took a deep breath, relaxed, and made the decision to obtain the above portable chest xray before performing empiric thoracostomy.  This turned out to be the correct decision as she had a complete obstruction of the left mainstem bronchus from aspiration of a peanut-butter sandwich.  CT chest (above) shows the obstruction at the level of the carina with collapse of the left lung.  Bronchoscopy was performed and a large amount of peanut butter, jelly, and sandwich fragments were removed with improvement in the patient’s chest xray post-procedure.

Moral of the story:  not all patients have pneumothorax or a malpositioned endotracheal tube when lung sounds are absent.

A brief alternative differential diagnosis when a patient has absent lung sounds on one side:

  1. Mainstem bronchus obstruction or compression
  2. Diaphragmatic hernia
  3. Large pleural effusion
  4. History of pneumonectomy

I’ve noticed a trend in ED training toward increased reliance on bedside ultrasound.  It is important to realize that if you are going to use ultrasound in the resuscitation decisions such as this, make sure that you are seeing something that reliably indicates the pathology you are seeking to correct.  We did not see signs that supported or refuted pneumothorax and thus the ultrasound was non-diagnostic.  I apologize for not having the ultrasound images.  We forgot to save them as we all had that panicked feeling when you’ve intubated someone and their pulse ox isn’t improving very fast!

Author:  Russell Jones, MD

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The Chest Xray you never want to see…

April 3, 2013


…but probably most of us have!  One of the senior residents gave me this Chest Xray on a person that came in with cardiac arrest:


This Chest Xray demonstrates a large pneumothorax on the right side with tension phenomena.  Tension Pneumothorax is when the air trapped in the pleural space places pressure on the mediastinal structures and you see a shift of the mediastinum in the opposite direction.

Physiologically this means that the anatomy has changed and blood flow back to the central circulation is limited by not only mechanical obstruction but increased intrathoracic pressure.

After thoracostomy:

T Ptx 2

Remember, tension pneumothorax is one of the 5h’s and 5T’s that cause cardiac arrest.  However, its unclear if this is a post CPR pneumothorax or if this was the cause of the cardiac arrest.  You can see some deformities suspicious for rib fractures mid-way down the right lung fields.  There was no indication of trauma in the patient’s presentation so these may be old or a complication of chest compressions…this could be a source of pneumothorax as well as the positive-pressure from endotracheal intubation.  Incidentally, the chest tube is inserted slightly far with kinking in the upper lung but it appears to be working with reexpansion and relief of the tension phenomena.

Author:  Russell Jones, MD

Image Contributor:  Ryan Hunt, MD

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Good tip for reading CTs…

February 15, 2013


This person came in after a high speed motor vehicle collision.  Their main complaint was neck pain near C-7:

Spine + PTX 1Spine + PTX 3

As you can see under bone windows there is a fracture of C7.  One could stop here and be satisfied that you see the primary pathology in which you were interested.  However, anytime you look at a CT you should pay attention to all parts of the image.  Secondary findings are very common, especially in trauma.  When assessing a CT image, one should change windows on the image to adequately look at all types of tissue that are present.  In a cervical spine CT, the top of the lungs are usually visualized in the catchment area as you get to the upper t-spine.  If you change the window to “lung” windows this is what you’ll see:

Spine + PTX 4

This person also has an anterior, small pneumothorax!  This could have easily been missed if not changing the window to look at the lungs.

One of the basics of CT imaging is to  change windows for all types of tissue.  In the head, your main window change will be from “brain” to “bone” to adequately visualize bony structures of the calavarium.  In the abdomen you should switch to “lungs” to visualize the lungs as well as switch to “bone” to visualize the ribs, pelvis, and spine.  There are many other examples of this principle, but we will leave it at this for now.

Author:  Russell Jones, MD

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Pneumorrhacis. What?

February 4, 2013


I admire radiologists for their medical vocabulary.  I was sent some images from one of my colleagues the other day demonstrating “pneumorrhacis.”  Being a simple minded ER doc, I had to look it up.


Pneumorrhacis:  air in the intra or extra dural space (1).  For a good, concise summary of this rare phenomena see Radiopaedia.org:


This patient was a trauma patient with a pneumothorax as the source of the air.  You can see on the CT there is air everywhere!  Its basically dissecting fasical planes in the neck, chest, and abdominal wall in addition to the extradural space.

Here is a brief review article discussing pneumorrhacis from the European Spine Journal (2).  It is available on PubMed for free download or from this link:

Pneumorrhacis article

Author:  Russell Jones, MD

Image Contributor:  Steve Glocke, MD


1.  Pneumorrhacis.  www.radiopaedia.org

2.  Oertel MF, Kornith MC, Reinges MH, et al.  Pathogenesis, diagnosis, and management of pneumorrhacis.  Eur Spine J (2006) 15 (Suppl. 5):S636–S643

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Blunt Aortic Injury (BAI)

December 17, 2012


One of my colleagues had a patient come in after a high-speed motor vehicle collision (MVC) and the patient turned out to have a blunt aortic injury (BAI).  Luckily she saved the images for EMREMS:

This first image is a portable AP Chest Xray.  There are multiple findings:

1.  The ETT tube is slightly high, this was corrected (see Post Intubation Eval)

2.  Chest tube is inserted in the left side and the patient has subcutaneous emphysema.  The chest tube could have been put in further but seems to be working.

3.  Notice the loss of normal contour of the aortic knob (aka “indistinct aortic knob”).

4.  The trachea is displaced to the patient’s right

5.  The upper mediastinum seems a little wide although not drastically.

6.  There is loss of the aortopulmonary window (AP window)

For comparison I have a normal AP Chest Xray and have arrows pointing to the normal AP window and aortic knob:

The patient’s Chest Xray is worrisome for traumatic aortic dissection.  Here is the patient’s Chest CT which confirms the diagnosis:

In the first image one can see a rough inner surface of the aorta indicating intimal disruption and hematoma.  A dissection flap can be seen in the second image.  Hematoma can be seen on both images surrounding the aorta and tracking in the mediastinum.

What are some other signs on Chest Xray that would get you worried about BAI? (Comments are encouraged)

Stay tuned in the future for a “Radiology Rules” 3X5 card with Chest Xray signs of BAI.

Author:  Russell Jones, MD

Image contributor:  Kendra Grether-Jones, MD

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Rugby is a rough sport…

October 16, 2012


This young woman was playing rugby with “the boys” when she fell on one of the other player’s bent knee.  She has pleuritic chest pain and palpable tenderness along the right chest wall anterior axillary line below the armpit (right about where you’d put a chest tube…hint…hint).

This case demonstrates the power of knowing what you are looking for.  As you probably noticed she has a small, subtle pneumothorax best seen between ribs 3 and 4:

Its always a good idea to take the time when you are ordering radiology studies to help out your radiology friends and describe the area of concern and what you are looking for.  This can help them identify subtle findings such as this small pneumothorax.

The patient was treated with supportive care, observed over night, and discharged the next day after a repeat chest xray showing no significant progression.

Author:  Russell Jones, MD

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69-year-old male fell from a tree…

April 22, 2012


69-year-old male fell from a tree

Contributor:  Russell Jones, MD

Date: 4/25/2012

This guy fell from a tree about 12 feet up…

Here is his Chest X-ray:

What is wrong with this picture?



On the right side of the radiograph subcutaneous air can be seen lateral to the chest wall. Subcutaneous air with no physical exam supporting a puncture or a laceration is highly suspicious of a pneumothorax. Other sources of subcutaneous air can be from tracheal or laryngeal injury but usually this is associated with large subcutaneous air tracking in the area of the neck (but can be extensive).

The radiograph, however, is indicative of a small pneumothorax. The right lung appears to be fully inflated and it doesn’t show a deep sulcus sign.

This guy was seen at a level I trauma center and thus trauma was notified and recommended a CT scan to look for concominant injuries. Specifically their concern was liver injury and multiple occult rib fractures. A CT of the chest and abdomen were ordered with IV contrast to evaluate for these injuries as well as to quantify the severity of the pneumothorax.

CT chest:

On the Chest CT under lung window a small anterior pneumothorax can be seen. Other findings included a small pulmonary contusion in the right lower lobe and 2 non-displaced rib fractures (7 and 8).

The question is…does this guy need a tube thoracostomy (chest tube)?

I’ll leave the management decisions up to you…

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