William Herring, M.D.

© 2002

Recognizing
A Pneumothorax

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Remember

 There are two layers of pleura- parietal and

visceral-the pleural space between them
 Normally there is no air in the pleural space
 The visceral pleura is inseparable from the
lung parenchyma and moves with the lung
Visceral
pleura

Parietal Pleural
pleura space

© Frank Netter, MD Novartis®

The Visceral Pleural White
Line

 When air enters the pleural space, the

parietal and visceral pleura separate making
the visceral pleura visible
 The thin white line of the visceral pleura is
called the visceral pleural white line
 You must see the visceral pleural white line
to make diagnosis of pneumothorax!
A pneumothorax
will be visible as a
thin white line - the
visceral pleural
white line
 Lung Markings

 Lung markings may be absent distal to the

visceral pleural white line
 But they 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 pneumothorax!
Why The Pleural White Line
Is Important

ARRS R3 ©

Large bulla in the LLL. Note there is no

visceral pleural white line paralleling the chest wall
Why The Pleural White Line
Is Important

ARRS R3 ©

Chest tube erroneously inserted into bulla

in LUL produces an intractable pneumothorax.
Why The Pleural White Line
Is Important

 There are diseases other than a

pneumothorax that can cause an absence of
lung markings
 For example
 Bullous disease
 Large cysts in the lung
 Pulmonary embolism
Why The Pleural White Line
Is Important

 None of those diseases is treated with a

chest tube
 In fact, insertion of a chest tube into a bulla
can produce an intractable pneumothorax
Skin fold or Pneumothorax

 A fold of the patient’s skin may become

trapped between the patient and cassette
 Skin folds are common
 Especially in patient’s who have lost a great deal
of weight
 This skin fold can mimic a pneumothorax
Skin Fold Pneumothorax

How can we tell them apart?

 This is an edge

Dense

Lucent

Skin Fold

The key difference is that a skin fold is an edge

consisting of a density (light) and then a lucency (dark)
 This is a line

Lucent

Dense

Lucent
Pneumothorax

Whereas the visceral pleural line is a

thin white line with a lucency (darker) on both sides of it
 Skin Fold Pneumothorax

Here they are again side-by-side: the skin fold is an edge,

the pneumothorax is a line
Which is this?
Skin fold or Pneumothorax

This is an
edge =
skin fold
Which is this?
Skin fold or Pneumothorax

This is a line =
pneumothorax
Types of Pneumothoraces

 Two major types of pneumothorax

 Simple
 Tension
Simple Pneumothorax

 In a simple pneumothorax, there is no shift of

the heart or mediastinal structures (trachea)
 Air in left hemithorax balances the air in the
right hemithorax
 No shift of
midline
structures

Visceral
pleural white
line

Simple pneumothorax on the left side

No shift of the heart or trachea
 Tension Pneumothorax

 Progressive loss of air into pleural space causing a

shift of the heart and mediastinal structures away
from side of pneumothorax
 Opposite lung is compressed
 Respiratory function severely compromised
Tension Pneumothorax

© Frank Netter, MD Novartis®

Air enters Right hemithorax either from tear in lung or hole in chest
wall on inspiration; does not exit on expiration
 Shift of
Complete right- heart and
sided trachea to
pneumothorax left

Lung is
compressed
against
mediastinum
Which is this?
Simple or Tension Pneumothorax

Tension pneumothorax-heart is shifted slightly

to right by large left-sided pneumothorax
 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 away from side of pneumothorax
 There is never a shift toward the side of a
pneumothorax
Causes of a Pneumothorax

 Spontaneous
 Rupture of an apical sub-pleural bleb usually in a
tall, thin male
 Trauma
 Through chest wall, e.g. stab wound
 Internal, e.g. rupture of a bronchus from a motor
vehicle collision
Causes of a Pneumothorax

 Diseases that decrease lung compliance

 Chronic fibrotic diseases, e.g. eosinophilic
granuloma
 Diseases that stiffen the lung, e.g. hyaline
membrane disease
 Rupture of an alveolus or bronchiole
 E.g., asthma
Important Points

 You must see the visceral pleural white line

to diagnose a pneumothorax
 A skin fold is an edge; the visceral pleural
line is a line
 There is a never a shift toward the side of a
pneumothorax
Which of the following patients
has a pneumothorax?

Click to go forward

Click to go back
Does this patient have a pneumothorax?

Yes

No

Click to go forward
Does this patient have a pneumothorax?

Yes

No

Click to go forward
Does this patient have a pneumothorax?

Yes

No

ARRS R3 ©

Click to go forward
Does this patient have a pneumothorax?

Yes

No

Click to go forward
Correct
There is a Pneumothorax

 The visceral pleural

white line is seen and
there are no lung
marking distal to it.
This is a simple
pneumothorax since
there is no shift.
Click to go forward
Correct
There is No Pneumothorax

This is a skin fold. It is an edge,

not a line.

Click to go forward
Correct
There is No Pneumothorax

This is a skin
fold. It is an
edge, not a
line.

ARRS R3 ©
Click to go forward
Correct
There is a Pneumothorax

There is a left-sided
tension
pneumothorax with
shift of the heart
and mediastinal
structures to the
right.
Click to go forward
Wrong
Look Again

 Remember to look for the 2 signs of a

pneumothorax
 Visceral pleural white line
 Absence of lung marks distal to pleural white
line

Click to go back
Congratulations, You Graduate

You know your

pneumothoraces

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