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. 2000 Jul;76(897):399–404. doi: 10.1136/pmj.76.897.399

Diagnosis of pneumothorax in critically ill adults

J Rankine 1, A Thomas 1, D Fluechter 1
PMCID: PMC1741653  PMID: 10878196

Abstract

The diagnosis of pneumothorax is established from the patients' history, physical examination and, where possible, by radiological investigations. Adult respiratory distress syndrome, pneumonia, and trauma are important predictors of pneumothorax, as are various practical procedures including mechanical ventilation, central line insertion, and surgical procedures in the thorax, head, and neck and abdomen. Examination should include an inspection of the ventilator observations and chest drainage systems as well as the patient's cardiovascular and respiratory systems.
Radiological diagnosis is normally confined to plain frontal radiographs in the critically ill patient, although lateral images and computed tomography are also important. Situations are described where an abnormal lucency or an apparent lung edge may be confused with a pneumothorax. These may arise from outside the thoracic cavity or from lung abnormalities or abdominal viscera inside the chest.


Keywords: pneumothorax; adult respiratory distress syndrome; critical care; radiography

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Selected References

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  1. Albelda S. M., Gefter W. B., Kelley M. A., Epstein D. M., Miller W. T. Ventilator-induced subpleural air cysts: clinical, radiographic, and pathologic significance. Am Rev Respir Dis. 1983 Mar;127(3):360–365. doi: 10.1164/arrd.1983.127.3.360. [DOI] [PubMed] [Google Scholar]
  2. Baldt M. M., Bankier A. A., Germann P. S., Pöschl G. P., Skrbensky G. T., Herold C. J. Complications after emergency tube thoracostomy: assessment with CT. Radiology. 1995 May;195(2):539–543. doi: 10.1148/radiology.195.2.7724780. [DOI] [PubMed] [Google Scholar]
  3. Berrouschot J., Oeken J., Steiniger L., Schneider D. Perioperative complications of percutaneous dilational tracheostomy. Laryngoscope. 1997 Nov;107(11 Pt 1):1538–1544. doi: 10.1097/00005537-199711000-00021. [DOI] [PubMed] [Google Scholar]
  4. Capellier G., Beuret P., Clement G., Depardieu F., Ract C., Regnard J., Robert D., Barale F. Oxygen tolerance in patients with acute respiratory failure. Intensive Care Med. 1998 May;24(5):422–428. doi: 10.1007/s001340050590. [DOI] [PubMed] [Google Scholar]
  5. Carr J. J., Reed J. C., Choplin R. H., Pope T. L., Jr, Case L. D. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology. 1992 Apr;183(1):193–199. doi: 10.1148/radiology.183.1.1549671. [DOI] [PubMed] [Google Scholar]
  6. Chen S. C., Markmann J. F., Kauder D. R., Schwab C. W. Hemopneumothorax missed by auscultation in penetrating chest injury. J Trauma. 1997 Jan;42(1):86–89. doi: 10.1097/00005373-199701000-00015. [DOI] [PubMed] [Google Scholar]
  7. Fernández-Mondéjar E., Vazquez-Mata G. PEEP: more than just support? Intensive Care Med. 1998 Jan;24(1):1–2. doi: 10.1007/s001340050506. [DOI] [PubMed] [Google Scholar]
  8. Fisher J. K. Skin fold versus pneumothorax. AJR Am J Roentgenol. 1978 Apr;130(4):791–792. doi: 10.2214/ajr.130.4.791. [DOI] [PubMed] [Google Scholar]
  9. Flynn A. E., Thomas A. N., Schecter W. P. Acute tracheobronchial injury. J Trauma. 1989 Oct;29(10):1326–1330. doi: 10.1097/00005373-198910000-00005. [DOI] [PubMed] [Google Scholar]
  10. Frassinelli P., Pasquale M. D., Cipolle M. D., Rhodes M. Utility of chest radiographs after guidewire exchanges of central venous catheters. Crit Care Med. 1998 Mar;26(3):611–615. doi: 10.1097/00003246-199803000-00040. [DOI] [PubMed] [Google Scholar]
  11. Gammon R. B., Shin M. S., Groves R. H., Jr, Hardin J. M., Hsu C., Buchalter S. E. Clinical risk factors for pulmonary barotrauma: a multivariate analysis. Am J Respir Crit Care Med. 1995 Oct;152(4 Pt 1):1235–1240. doi: 10.1164/ajrccm.152.4.7551376. [DOI] [PubMed] [Google Scholar]
  12. George R. B., Herbert S. J., Shames J. M., Ellithorpe D. B., Weill H., Ziskind M. M. Pneumothorax complicating pulmonary emphysema. JAMA. 1975 Oct 27;234(4):389–393. [PubMed] [Google Scholar]
  13. Gerard P. S., Kaldawi E., Litani V., Lenora R. A., Tessler S. Right-sided pneumothorax as a result of a left-sided chest tube. Chest. 1993 May;103(5):1602–1603. doi: 10.1378/chest.103.5.1602. [DOI] [PubMed] [Google Scholar]
  14. Gordon R. The deep sulcus sign. Radiology. 1980 Jul;136(1):25–27. doi: 10.1148/radiology.136.1.7384513. [DOI] [PubMed] [Google Scholar]
  15. Heffner J. E., McDonald J., Barbieri C. Recurrent pneumothoraces in ventilated patients despite ipsilateral chest tubes. Chest. 1995 Oct;108(4):1053–1058. doi: 10.1378/chest.108.4.1053. [DOI] [PubMed] [Google Scholar]
  16. Ho H. C., Burchell S., Morris P., Yu M. Colon perforation, bilateral pneumothoraces, pneumopericardium, pneumomediastinum, and subcutaneous emphysema complicating endoscopic polypectomy: anatomic and management considerations. Am Surg. 1996 Sep;62(9):770–774. [PubMed] [Google Scholar]
  17. Kam A. C., O'Brien M., Kam P. C. Pleural drainage systems. Anaesthesia. 1993 Feb;48(2):154–161. doi: 10.1111/j.1365-2044.1993.tb06859.x. [DOI] [PubMed] [Google Scholar]
  18. Layton T. R., DiMarco R. F., Pellegrini R. V. Tracheoesophageal fistula from nonpenetrating trauma. J Trauma. 1980 Sep;20(9):802–805. doi: 10.1097/00005373-198009000-00017. [DOI] [PubMed] [Google Scholar]
  19. Lichter I., Gwynne J. F. Spontaneous pneumothorax in young subjects. A clinical and pathological study. Thorax. 1971 Jul;26(4):409–417. doi: 10.1136/thx.26.4.409. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Luce J. M. Acute lung injury and the acute respiratory distress syndrome. Crit Care Med. 1998 Feb;26(2):369–376. doi: 10.1097/00003246-199802000-00043. [DOI] [PubMed] [Google Scholar]
  21. Manning H. L. Peak airway pressure: why the fuss? Chest. 1994 Jan;105(1):242–247. doi: 10.1378/chest.105.1.242. [DOI] [PubMed] [Google Scholar]
  22. Maunder R. J., Pierson D. J., Hudson L. D. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med. 1984 Jul;144(7):1447–1453. [PubMed] [Google Scholar]
  23. Pastores S. M., Garay S. M., Naidich D. P., Rom W. N. Review: pneumothorax in patients with AIDS-related Pneumocystis carinii pneumonia. Am J Med Sci. 1996 Nov;312(5):229–234. doi: 10.1097/00000441-199611000-00008. [DOI] [PubMed] [Google Scholar]
  24. Perez J. E., Alberts W. M., Mamel J. J. Delayed tension pneumothorax after laparoscopy. Surg Laparosc Endosc. 1997 Feb;7(1):70–72. [PubMed] [Google Scholar]
  25. Petersen G. W., Baier H. Incidence of pulmonary barotrauma in a medical ICU. Crit Care Med. 1983 Feb;11(2):67–69. doi: 10.1097/00003246-198302000-00002. [DOI] [PubMed] [Google Scholar]
  26. Ross I. B., Fleiszer D. M., Brown R. A. Localized tension pneumothorax in patients with adult respiratory distress syndrome. Can J Surg. 1994 Oct;37(5):415–419. [PubMed] [Google Scholar]
  27. Shackelford D., Casani J. A. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumothorax after dental extraction. Ann Emerg Med. 1993 Feb;22(2):248–250. doi: 10.1016/s0196-0644(05)80214-8. [DOI] [PubMed] [Google Scholar]
  28. Shorr R. M., Crittenden M., Indeck M., Hartunian S. L., Rodriguez A. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg. 1987 Aug;206(2):200–205. doi: 10.1097/00000658-198708000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Stewart T. E., Meade M. O., Cook D. J., Granton J. T., Hodder R. V., Lapinsky S. E., Mazer C. D., McLean R. F., Rogovein T. S., Schouten B. D. Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and Volume-Limited Ventilation Strategy Group. N Engl J Med. 1998 Feb 5;338(6):355–361. doi: 10.1056/NEJM199802053380603. [DOI] [PubMed] [Google Scholar]
  30. Tagliabue M., Casella T. C., Zincone G. E., Fumagalli R., Salvini E. CT and chest radiography in the evaluation of adult respiratory distress syndrome. Acta Radiol. 1994 May;35(3):230–234. [PubMed] [Google Scholar]
  31. Tarnoff M., Moncure M., Jones F., Ross S., Goodman M. The value of routine posttracheostomy chest radiography. Chest. 1998 Jun;113(6):1647–1649. doi: 10.1378/chest.113.6.1647. [DOI] [PubMed] [Google Scholar]
  32. Tocino I. M., Miller M. H., Fairfax W. R. Distribution of pneumothorax in the supine and semirecumbent critically ill adult. AJR Am J Roentgenol. 1985 May;144(5):901–905. doi: 10.2214/ajr.144.5.901. [DOI] [PubMed] [Google Scholar]
  33. Tomlinson M. A., Treasure T. Insertion of a chest drain: how to do it. Br J Hosp Med. 1997 Sep 17;58(6):248–252. [PubMed] [Google Scholar]
  34. Webb T. Pneumothorax and pneumomediastinum during colonoscopy. Anaesth Intensive Care. 1998 Jun;26(3):302–304. doi: 10.1177/0310057X9802600313. [DOI] [PubMed] [Google Scholar]
  35. Wilson A. J., Krous H. F. Lung perforation during chest tube placement in the stiff lung syndrome. J Pediatr Surg. 1974 Apr;9(2):213–216. doi: 10.1016/s0022-3468(74)80124-7. [DOI] [PubMed] [Google Scholar]
  36. Yilmazlar A., Bilgin H., Korfali G., Eren A., Ozkan U. Complications of 1303 central venous cannulations. J R Soc Med. 1997 Jun;90(6):319–321. doi: 10.1177/014107689709000607. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Yu P. Y., Lee L. W. Pulmonary artery pressures with tension pneumothorax. Can J Anaesth. 1990 Jul;37(5):584–586. doi: 10.1007/BF03006331. [DOI] [PubMed] [Google Scholar]

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