Clinical Presentation and Diagnosis of Pneumothorax
Clinical Presentation and Diagnosis of Pneumothorax
Clinical Presentation and Diagnosis of Pneumothorax
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2023. | This topic last updated: Sep 14, 2022.
INTRODUCTION
In this topic review, the clinical presentation and diagnosis of pneumothorax are discussed. The
etiology, epidemiology, and treatment of pneumothorax are reviewed in detail separately. (See
"Treatment of secondary spontaneous pneumothorax in adults" and "Treatment of primary
spontaneous pneumothorax in adults" and "Pneumothorax in adults: Epidemiology and
etiology" and "Pneumothorax: Definitive management and prevention of recurrence".)
CLINICAL PRESENTATION
Pneumothorax should be suspected in patients who present with acute dyspnea and chest pain
(classically pleuritic), particularly in those with an underlying risk factor ( table 1). The major
competing diagnoses include acute pulmonary embolism, pleuritis, pneumonia, myocardial
ischemia or infarction, pericarditis, and musculoskeletal pain. Routine laboratories,
electrocardiography, and chest imaging are usually performed during the diagnostic evaluation
process; it is the identification of a pneumothorax on chest imaging that typically differentiates
pneumothorax from many of these entities. The evaluation of chest pain and dyspnea are
discussed separately. (See "Evaluation of the adult with chest pain in the emergency
department" and "Approach to the adult with dyspnea in the emergency department".)
https://www.uptodate.com/contents/117242/print 1/49
3/30/23, 5:15 PM 117242
Clinical manifestations — Patients with pneumothorax classically present with the following:
● History – Pneumothorax most often presents with sudden onset of dyspnea and pleuritic
chest pain. Since pneumothorax is usually unilateral, the pain is usually felt on the
ipsilateral side, but may be central or bilateral in rare cases where pneumothorax is
bilateral.
The intensity of dyspnea can range from mild to severe. The severity of the symptoms
primarily relates to the volume of air in the pleural space and to the degree of pulmonary
reserve, with dyspnea being more prominent if the pneumothorax is large and/or
underlying disease is present.
Pneumothorax can present at all ages. Patients with primary spontaneous pneumothorax
(PSP; ie, that associated with subpleural blebs in the absence of an underlying disorder) [1]
are typically in their early 20s; PSP is rare after age 40 years and classically occurs in
young, tall, thin, smoking males. In contrast, since most cases of secondary spontaneous
pneumothorax (SSP; ie, that associated with underlying lung disease) are due to
emphysema, these patients tend to be older. However, this finding is not absolute; for
example, pneumothorax in patients with lymphangioleiomyomatosis or thoracic
endometriosis presents in young, nonsmoking females of reproductive age.
Some patients with mild or chronic pneumothorax may be asymptomatic and discovered
incidentally. For example, among women with lymphangioleiomyomatosis who underwent
chest imaging for research purposes after traveling to the National Institutes of Health (NIH),
pneumothorax was discovered in 6 percent of women, among which 57 percent were chronic
and not associated with new symptoms [2]. (See "Pneumothorax and air travel" and "Sporadic
lymphangioleiomyomatosis: Clinical presentation and diagnostic evaluation".)
Patients with pneumothorax on mechanical ventilation (ie, barotrauma) are more likely to
present with acute respiratory distress and elevated pressures, the assessment of which is
discussed separately. (See "Diagnosis, management, and prevention of pulmonary barotrauma
during invasive mechanical ventilation in adults", section on 'Diagnostic evaluation and
management' and "Assessment of respiratory distress in the mechanically ventilated patient".)
Laboratory findings — Laboratory findings of pneumothorax are nonspecific but may reveal a
mild leukocytosis without left shift. Patients who present with pneumothorax may have routine
laboratories performed including D-dimer level and troponin levels to investigate the cause of
dyspnea and chest pain. These laboratory tests can be useful for the detection or exclusion of
competing etiologies such as myocardial ischemia.
Arterial blood gas — In patients with pneumothorax, peripheral oxygen saturation (SpO2) may
be normal in those without underlying lung disease in whom the pneumothorax is small.
However, in patients with sizeable pneumothorax or lung disease, oxygen desaturation is
usually evident.
Arterial blood gases are typically obtained when a patient demonstrates tachypnea, accessory
muscle use, a pulse oxygen saturation <92 percent, or has a history of hypercapnia. Hypoxemia
is common but may be within normal limits if the pneumothorax is small and underlying lung
disease is absent. Pneumothorax typically causes an acute respiratory alkalosis particularly
when pain, anxiety, and/or hypoxemia are substantial. However, acute hypercapnic respiratory
acidosis is unusual because adequate alveolar ventilation can usually be maintained by the
contralateral lung, unless underlying disease such as chronic obstructive lung disease (COPD)
or cardiovascular compromise is present [3]. In one study of patients with SSP, the arterial
oxygen tension (PaO2) was below 55 mmHg in 17 percent of patients and below 45 mmHg in 4
percent, while the arterial tension of carbon dioxide (PaCO2) exceeded 50 mmHg in 16 percent
and exceeded 60 mmHg in 4 percent [4].
https://www.uptodate.com/contents/117242/print 3/49
3/30/23, 5:15 PM 117242
DIAGNOSTIC IMAGING
Unstable patients — Hemodynamically unstable patients and patients with severe respiratory
distress are typically those with a large or tension pneumothorax, patients with extensive
trauma, or patients with significant underlying lung disease. Such patients are resuscitated with
the emphasis on stabilization of the airway, breathing, and circulation. Unstable patients should
also concomitantly undergo rapid bedside imaging, usually initially with ultrasound, to confirm
the diagnosis before undergoing emergent needle or chest tube thoracostomy. In the event
that imaging is unavailable or unhelpful, then an empiric decision to place a chest tube without
confirmatory imaging should be made on clinical assessment alone. (See 'Pleural
ultrasonography' below and "Initial evaluation and management of blunt thoracic trauma in
adults", section on 'Primary survey' and "Approach to shock in the adult trauma patient",
section on 'Tension pneumothorax'.)
Chest radiography may not be needed if patients are undergoing chest CT for another
indication (eg, stable patients with trauma undergoing total body CT for additional injuries or
patients with suspected pulmonary embolism undergoing CT pulmonary angiography). In such
patients, the CT will readily detect pneumothorax. (See 'Chest computed tomography' below.)
https://www.uptodate.com/contents/117242/print 4/49
3/30/23, 5:15 PM 117242
Ultrasonography is being increasingly used in critically ill patients on mechanical ventilation but
chest radiography and CT are also frequently used depending upon the severity of
presentation. (See "Indications for bedside ultrasonography in the critically ill adult patient" and
'Pleural ultrasonography' below.)
Patients with diagnostic uncertainty — Chest CT is reserved for patients in whom the
diagnosis is uncertain following chest radiography (eg, patients with suspected loculated
pneumothorax, complicated bullae, or a complex pleural space).
Chest radiography
Most pneumothoraces are simple pneumothoraces, whereas although uncommon, true tension
pneumothorax is a life-threatening emergency.
● Simple – A simple pneumothorax is one without mediastinal shift to the contralateral side.
Patients are clinically and hemodynamically stable, the definition of which is discussed
separately. (See "Treatment of primary spontaneous pneumothorax in adults", section on
'Definition of stability'.)
● Tension – A tension pneumothorax arises when air in the pleural space builds up enough
pressure to interfere with venous return, leading to hypotension, tachycardia and severe
dyspnea. Tension pneumothorax may be seen in approximately 1 to 2 percent of patients
[6], likely higher in patients with trauma and patients receiving mechanical ventilation; in
the latter group, patients who develop initial signs of pneumothorax are more likely to
rapidly progress to cardiovascular collapse than those who are not on mechanical
ventilation [7].
Traditional teaching suggested that contralateral shift of the trachea and mediastinum,
splaying of the ribs, and flattening of the ipsilateral diaphragm represent radiographic
tension. However, these findings may result from atmospheric intrapleural pressure on
https://www.uptodate.com/contents/117242/print 5/49
3/30/23, 5:15 PM 117242
the side of the pneumothorax while the pleural pressure on the contralateral side remains
negative. Clinical evidence of tachycardia, hypotension, and severe dyspnea is more
indicative of tension. Conversely, patients may have clinical evidence of tension in the
absence of typical radiographic findings of tension. A one-way valve mechanism is
responsible for tension pneumothorax allowing gas to enter the pleural space during
inspiration but not exit fully during expiration. As gas accumulates, pressure increases
within the ipsilateral pleural space resulting in hypotension from reduced venous return,
low cardiac output, and respiratory failure due to compression of the contralateral lung.
Patients with these findings need immediate attention with needle aspiration or chest
tube insertion.
● Hydropneumothorax – This term is used for patients who have evidence of both fluid and
air in the pleural space (eg, trauma patients who have both hemo- and pneumothorax). A
hydropneumothorax can be appreciated by the presence of a liquid-gas level when the
patient is upright ( image 3) and a hazy opacity in a supine patient, that may obscure
the pneumothorax ( image 4 and image 5) [8].
Most pneumothoraces are unilateral but can be bilateral (also known as simultaneous bilateral
spontaneous pneumothoraces [SBSP]):
• Bilateral pneumothoraces may be seen in patients who have a single pleural space.
This phenomenon is rare but can be congenital ("buffalo chest"; buffalo only have one
thoracic cavity [9]) or iatrogenic in nature following thoracic surgery that disrupts the
anterior junction line complex between the right and left thoracic cavities (eg, lung-
and heart-transplant recipients, in patients following esophagectomy) [10-14].
• Bilateral pneumothoraces can also present in patients with severe underlying lung
disease who have two normal intact pleural spaces that do not communicate with each
other (eg, COPD or alpha-1 antitrypsin deficiency, pneumocystis jirovecii, barotrauma
from mechanical ventilation, cystic fibrosis, some drugs, metastatic malignancy) [15-
https://www.uptodate.com/contents/117242/print 6/49
3/30/23, 5:15 PM 117242
Effect of position — Air moves to the least dependent portion of the lung and therefore
the radiographic appearance of a pneumothorax depends upon the patient's position:
● In most cases, chest radiography is performed in the upright position and the
pneumothorax can be appreciated in the apical or apicolateral position ( image 6). It is
estimated that only 50 mL of air in the pleural space is needed for the detection of
pneumothorax in the upright position [23]. The first rib and clavicle can sometimes
interfere with detection of a small pneumothorax in the upright position.
● When the patient is in the supine position (eg, patients who are mechanically ventilated),
pleural gas accumulates anteriorly and in a subpulmonic location ( image 7 and
image 8). This may result in the "deep sulcus" sign (ie, where gas outlines the
costophrenic sulcus) ( image 9). Rarely, pneumothorax can be visualized in the
phrenicovertebral location. In supine patients with pneumomediastinum, a "continuous
diaphragm" sign may be evident (ie, where both leaflets of the diaphragm appear as one).
It is estimated that approximately 500 mL of air in the pleural space is needed for
detection of pneumothorax in the supine position [23].
● For patients in the lateral decubitus position, air rises to the non-dependent lateral
location. Only 5 mL of pleural air may be needed to detect pneumothorax in this position
[23]. However, imaging in this position may be technically difficult and has largely been
supplanted by CT.
● Bullae – Subpleural bullae can mimic a loculated pneumothorax ( image 10). The
distinction is clinically important because the insertion of a chest tube into a bulla can
result in iatrogenic pneumothorax and increase the risk for the development of a
bronchopleural fistula. Similar to a pneumothorax, bullae have a lateral wall that is convex
to the chest wall but unlike pneumothorax, the medial border of a bulla may be
appreciated as concave to the chest wall ( image 11 and image 12A-B) [24].
https://www.uptodate.com/contents/117242/print 7/49
3/30/23, 5:15 PM 117242
● Skin folds – Skin folds (eg, due to obesity or distortion of the skin by the imaging cassette)
may mimic pneumothorax. However, skin folds frequently demonstrate a line (mistakenly
interpreted as the visceral pleural line) that when followed, extends beyond or ends just
before the rib cage. Other findings include an increase in opacification, which ceases at
the distal edge of the skin fold, and the presence of visible bronchovascular markings
beyond the skinfold line. Classically, the edge of the skinfold appears as a black "Mach
band" instead of a thin white pleural line typical of pneumothorax ( image 13 and
image 14).
● Gastric herniation – Herniation of the stomach into the chest (eg, due to diaphragmatic
rupture) can mimic the appearance of a left-sided pneumothorax ( image 15) and, if a
chest tube is inserted, can result in viscus perforation. Intrathoracic stomach air can be
hard to distinguish from pneumothorax but the presence of loops of bowel in the left
hemithorax is supportive of gastric herniation.
Pneumothorax size — Several methods are available to assess the size of pneumothorax
none of which are highly accurate or superior, and many tend to underestimate or overestimate
the size [25]. Such inaccuracy may result when the assessment of size uses a one- or two-
dimensional measurement that does not accurately reflect the three-dimensional nature of the
pleural space; in addition, such measurements also assume that the lung collapses uniformly,
which is not always the case. Despite available methods, considerable variation in practice
exists and many clinicians use gestalt assessment of size in conjunction with symptoms to make
management decisions. (See "Treatment of primary spontaneous pneumothorax in adults",
section on 'Management strategy' and "Treatment of secondary spontaneous pneumothorax in
adults", section on 'Management strategy'.)
Some of the available methods for size assessment, none of which are perfect, include the
following:
● The average interpleural distance (AID) – The AID is the sum of the distances between
the ribs and the visceral pleura at the apex, mid-thorax, and base of the lung (in
https://www.uptodate.com/contents/117242/print 8/49
3/30/23, 5:15 PM 117242
● The Collins method – The Collins method [29] is similar to the Rhea method. Direct
comparisons of both methods have shown high level of agreements [30].
● Formulas – The size of a pneumothorax can be measured using the Light Index [28,31]:
Using the Light index, one study found strong correlation with the volume of air removed
[31], while another found poor correlation with CT volumetrics [25].
Most of these assessments are made on chest radiographs. However, CT is likely the most
accurate modality to assess size. Newer CT-based measurements of the ratio of lung volume to
hemithorax volume may hold promise [32]. Ultrasonography is not typically used to assess
pneumothorax size.
The use of size to determine the therapeutic strategy is discussed separately. (See "Treatment
of primary spontaneous pneumothorax in adults", section on 'Initial management for first
event' and "Treatment of secondary spontaneous pneumothorax in adults", section on 'Initial
management of first event'.)
Pleural ultrasonography — Ultrasound of the pleura is best utilized when bedside rapid
imaging is needed to make the diagnosis of pneumothorax (eg, unstable patients with trauma,
or patients with suspected tension) because ultrasound has been shown to be sensitive
diagnostically [33-43] and ultrasonography is more readily available with shorter wait times
than for bedside chest radiography [44]. It is also typically used for suspected pneumothorax
that follows ultrasound-guided procedures (eg, thoracentesis or central venous catheterization)
and is being increasingly used in critically ill patients. (See "Indications for bedside
ultrasonography in the critically ill adult patient", section on 'Thoracic ultrasonography' and
"Emergency ultrasound in adults with abdominal and thoracic trauma", section on
'Pneumothorax and hemothorax' and "Bedside pleural ultrasonography: Equipment, technique,
and the identification of pleural effusion and pneumothorax" and "Initial evaluation and
management of penetrating thoracic trauma in adults", section on 'E-FAST'.)
https://www.uptodate.com/contents/117242/print 9/49
3/30/23, 5:15 PM 117242
apposition of the pleura, so no lung sliding is seen) and the partially inflated lung (where there
is still apposition of the two pleural surfaces, so lung sliding is seen). A pneumothorax is also
suggested if lung sliding ( movie 2 and movie 3) and/or lung pulse is absent. However, a
lung point may not always be present (eg, complete deflation of the lung) and the absence of
lung sliding or lung pulse is not specific, since it can be seen in other conditions. Thus, a chest
radiograph is always advisable. If ultrasonography shows a pneumothorax, a chest radiography
will help estimate the size of a pneumothorax. If ultrasonography is negative, a chest
radiograph is important to assess for other causes of the patient's presenting complaint(s).
Several studies indicate that ultrasonography may be superior to standard chest radiography
for the detection of pneumothorax [33-43,45]. Several meta-analyses of mostly observational
studies reported sensitivities of ultrasound that were superior to chest radiography (79 to 91
percent versus 40 to 50 percent) [42,43,46]. However, there was significant heterogeneity
among different populations studied; in addition, the sensitivity of chest radiography may have
been underestimated due to the high frequency of supine chest radiographs in many of the
studies.
Chest computed tomography — Chest CT is the best modality for determining the presence,
size, and location of intrapleural gas ( image 17) [39]. Small amounts of air in the pleural
space and pleural pathology including pleural effusions and adhesions as well as loculations
can be better appreciated by CT than chest radiography ( image 18 and image 19 and
image 20 and image 21).
Based upon its superior resolution and observational studies, chest CT is considered more
accurate than either chest radiography [48,49] or ultrasonography [39] for the diagnosis of
pneumothorax. CT can readily distinguish gas from other structures including the lung
parenchyma, the pleural membranes, and the mediastinum, making it the modality of choice
when diagnostic doubt exists.
POSTDIAGNOSIS EVALUATION
https://www.uptodate.com/contents/117242/print 10/49
3/30/23, 5:15 PM 117242
Following initial diagnosis and management, additional steps need to be taken to identify a
potential etiology(s) for pneumothorax. For many patients with pneumothorax, an underlying
cause (eg, trauma or iatrogenic) may be evident or an underlying lung disorder (eg, chronic
obstructive lung disease [COPD], interstitial lung disease, lung cancer, infection) may be known
at the time of presentation. In others, pneumothorax may be the first manifestation of an
unknown disorder (eg, catamenial pneumothorax, lymphangioleiomyomatosis [LAM], Birt-
Hogg-Dubé syndrome). The approach outlined below is based upon our experience since there
are no guidelines or data to help guide the clinician in this matter.
Patients with a clear cause — In many cases, the etiology is evident from the history,
examination, and chest radiography or chest CT findings. For example, patients in this category
would include those with trauma-related pneumothorax, procedural-related pneumothorax (eg,
following central venous catheterization, percutaneous lung biopsy), or patients with a lung
disorder known to be associated with pneumothorax (eg, COPD, cystic fibrosis, malignancy,
LAM, pneumocystis pneumonia). In such cases, no additional testing is typically required unless
a second disorder is suspected.
Patients without a clear cause — In some cases, the pneumothorax may not have an
apparent cause and clinicians need to decide how much testing should be performed to identify
a cause. After initial therapy, these patients should be re-evaluated with another detailed
history and examination and with reexamination of chest imaging to identify abnormalities that
may have been missed during the initial assessment. In many instances, this reevaluation is
performed after initial therapy and discharge and may prompt noncontrast high resolution
chest CT (HRCT), if not already performed, as well as pulmonary function testing. Additional
testing may be subsequently targeted at specific suspected etiologies. (See "Treatment of
primary spontaneous pneumothorax in adults" and "Treatment of secondary spontaneous
pneumothorax in adults".)
Clinical reevaluation — Clinical reevaluation should consider but not be limited to the
following:
https://www.uptodate.com/contents/117242/print 11/49
3/30/23, 5:15 PM 117242
● A joint and skin examination may reveal dry eye and joint disease suggestive of Sjögren
syndrome (which can be complicated by lung cysts), joint hypermobility or hyperextensible
skin consistent with Ehlers Danlos syndrome, or pectus carinatum and disproportionate
tall stature to suggest Marfan syndrome. (See "Diagnosis and classification of Sjögren's
syndrome" and "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes" and
"Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders".)
● A detailed drug history or track marks may suggest illicit drug use or identify
immunosuppressant drugs not previously suspected as an etiology of pneumothorax. (See
"Clinical assessment of substance use disorders" and "Testing for drugs of abuse (DOAs)".)
● A history of weight loss or sweats may suggest occult malignancy. (See "Approach to the
patient with unintentional weight loss".)
● A detailed social history may identify recent air travel or scuba diving as a hobby. (See
"Pneumothorax and air travel" and "Complications of SCUBA diving".)
● Cysts identified on CT should prompt a diagnostic evaluation for cystic lung disorders. (See
"Diagnostic approach to the adult with cystic lung disease".)
Additional testing
https://www.uptodate.com/contents/117242/print 12/49
3/30/23, 5:15 PM 117242
need chest CT when a specific etiology is suspected or the underlying etiology remains
unknown. We typically perform CT in the following:
● Patients with abnormalities on their chest radiograph (eg, lucencies that suggest cysts,
bullae that suggest emphysema), or on clinical evaluation (eg, clubbing, hemoptysis,
systemic symptoms, or basal crackles) that suggest an underlying lung disorder.
● Patients with a suspected etiology for pneumothorax which may be more readily
identified on CT. For example chest CT in:
• A young smoking male may reveal subpleural blebs or nodules or cysts consistent with
LCH. (See "Pulmonary Langerhans cell histiocytosis" and "Sporadic
lymphangioleiomyomatosis: Clinical presentation and diagnostic evaluation" and
"Clinical features, diagnostic approach, and treatment of adults with thoracic
endometriosis".)
• A young non-smoking female may reveal cysts consistent with LAM or pleural and
parenchymal abnormalities that suggest thoracic endometriosis. (See "Pulmonary
Langerhans cell histiocytosis" and "Sporadic lymphangioleiomyomatosis: Clinical
presentation and diagnostic evaluation" and "Clinical features, diagnostic approach,
and treatment of adults with thoracic endometriosis".)
Screening young women with a first spontaneous pneumothorax with chest CT for
underlying cysts is controversial. While some clinicians avoid chest CT screening in this
population based upon the premise that the incidence of pathology is too low, we
advocate having a low threshold to perform chest CT in young (25 to 54 year)
nonsmoking females, in whom the prevalence of LAM, for example, is estimated to be
approximately 5 percent [50,51].
• A cigarette smoker of over 20 pack years, marijuana smoker, or user of illicit drugs may
reveal emphysema, bullous disease, or malignancy. (See "High resolution computed
tomography of the lungs" and "Overview of pulmonary disease in people who inject
drugs", section on 'Pneumothorax and pneumomediastinum'.)
• A young adult with a family history of pneumothorax, skin lesions, or kidney tumors
may reveal lung cysts consistent with Birt-Hogg-Dubé syndrome. (See "Birt-Hogg-Dubé
syndrome".)
● Patients with a history of previous pneumothorax or prolonged air leak on chest tube
drainage where chest CT may reveal underlying cysts or other pathologies that may
https://www.uptodate.com/contents/117242/print 13/49
3/30/23, 5:15 PM 117242
prompt additional testing. (See "Diagnostic approach to the adult with cystic lung
disease".)
● Patients with unusual etiologies for pneumothorax (eg, drugs, anorexia, exercise) in whom
more serious pathologies need to be excluded. (See "Overview of pulmonary disease in
people who inject drugs", section on 'Pneumothorax and pneumomediastinum' and
"Anorexia nervosa in adults and adolescents: Medical complications and their
management", section on 'Pulmonary' and "The benefits and risks of aerobic exercise".)
● Patients with ongoing air leak and/or requiring surgery (as preoperative workup).
Lung function tests — Pulmonary function tests (PFTs) are not routinely performed and
are not valuable at the time of diagnosis or during treatment. However, PFTS may be performed
after recovery (eg, weeks) when underlying lung disease (eg, asthma, COPD, LCH, LAM) is
suspected. PFTs should be performed in stable patients and are not helpful in those in whom a
chest tube is in place or in whom pleurodesis has been recently performed.
Lung biopsy is rarely performed for suspected interstitial lung disease or malignancy. However,
when pleurodesis is being considered for pneumothorax, many surgeons also take tissue for
occult conditions that are not easily detected clinically.
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Pneumothorax".)
https://www.uptodate.com/contents/117242/print 14/49
3/30/23, 5:15 PM 117242
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Pneumothorax (collapsed lung) (The Basics)")
Patient perspectives are provided for selected disorders to help clinicians better understand the
patient experience and patient concerns. These narratives may offer insights into patient values
and preferences not included in other UpToDate topics. (See "Patient perspective:
Lymphangioleiomyomatosis (LAM)".)
• While young, thin, smoking males are more likely to have primary spontaneous
pneumothorax (PSP; ie, that associated with subpleural blebs in the absence of an
underlying disorder) and older patients are more likely to have secondary
pneumothorax (SSP; ie, as a complication of an underlying lung disorder), this division
is not absolute and underlying disorders are not always readily apparent. (See 'Clinical
manifestations' above.)
https://www.uptodate.com/contents/117242/print 15/49
3/30/23, 5:15 PM 117242
• Arterial blood gas analysis may be normal but classically reveals hypoxemia and a
respiratory alkalosis; acute hypercapnic respiratory acidosis can occur rarely and is an
ominous sign. (See 'Arterial blood gas' above.)
• Bedside chest radiography – For most stable patients with suspected pneumothorax,
we suggest bedside chest radiography in the upright position unless chest CT is
planned for another indication or bedside ultrasonography and experts in its
interpretation are readily available (eg, following a procedure, patients who are
mechanically ventilated). On chest radiography, the presence of a pneumothorax is
established by demonstrating a white visceral pleural line on the chest radiograph that
is typically convex towards the chest wall ( image 22 and image 2). However,
imaging characteristics vary with position. (See 'Stable patients' above and 'Chest
radiography' above.)
• Chest CT – For patients in whom the diagnosis is uncertain following chest radiography
(eg, patients with suspected loculated pneumothorax, complicated bullae, complex
pleural space), we suggest chest CT. Chest CT is the most accurate method available for
detection of pneumothorax based upon its superior ability to distinguish gas from
other structures including the lung parenchyma, the pleural membranes, and the
https://www.uptodate.com/contents/117242/print 16/49
3/30/23, 5:15 PM 117242
mediastinum. (See 'Patients with diagnostic uncertainty' above and 'Chest computed
tomography' above.)
ACKNOWLEDGMENTS
The UpToDate editorial staff acknowledges Patricia Tietjen, MD, who contributed to earlier
versions of this topic review.
The UpToDate editorial staff also acknowledges Richard W Light, MD (deceased), who
contributed to earlier versions of this topic.
REFERENCES
2. Taveira-DaSilva AM, Burstein D, Hathaway OM, et al. Pneumothorax after air travel in
lymphangioleiomyomatosis, idiopathic pulmonary fibrosis, and sarcoidosis. Chest 2009;
136:665.
3. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000; 342:868.
4. Light RW, O'Hara VS, Moritz TE, et al. Intrapleural tetracycline for the prevention of
recurrent spontaneous pneumothorax. Results of a Department of Veterans Affairs
cooperative study. JAMA 1990; 264:2224.
https://www.uptodate.com/contents/117242/print 17/49
3/30/23, 5:15 PM 117242
5. Seow A, Kazerooni EA, Pernicano PG, Neary M. Comparison of upright inspiratory and
expiratory chest radiographs for detecting pneumothoraces. AJR Am J Roentgenol 1996;
166:313.
6. Noppen M, De Keukeleire T. Pneumothorax. Respiration 2008; 76:121.
7. Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical Presentation of Patients With Tension
Pneumothorax: A Systematic Review. Ann Surg 2015; 261:1068.
8. Stark P, Leung A. Effects of lobar atelectasis on the distribution of pleural effusion and
pneumothorax. J Thorac Imaging 1996; 11:145.
15. Akcam TI, Kavurmaci O, Ergonul AG, et al. Analysis of the patients with simultaneous
bilateral spontaneous pneumothorax. Clin Respir J 2018; 12:1207.
16. Rivero A, Perez-Camacho I, Lozano F, et al. Etiology of spontaneous pneumothorax in 105
HIV-infected patients without highly active antiretroviral therapy. Eur J Radiol 2009; 71:264.
17. Çelik B, Sürücü ZP, Yılmaz V, Çelik HK. A Case Report of Secondary Simultaneous Bilateral
Pneumothorax Due to Pazopanib Treatment. Turk Thorac J 2018; 19:49.
18. Pedreira DG, Silvério R, Casimiro HJ, Mercier J. Bilateral secondary spontaneous
pneumothorax. BMJ Case Rep 2018; 2018.
19. Martínez García JJ, Rios Osuna MG, Altamirano Álvarez E. [Bilateral spontaneous
pneumothorax as a setting of Langerhans cell histiocytosis]. Arch Argent Pediatr 2014;
112:e113.
20. Mohan K, Ledson MJ, Walshaw MJ, Marchiori E. Simultaneous bilateral spontaneous
pneumothorax in an adult patient with cystic fibrosis. J Bras Pneumol 2009; 35:194.
https://www.uptodate.com/contents/117242/print 18/49
3/30/23, 5:15 PM 117242
30. Kelly AM, Weldon D, Tsang AY, Graham CA. Comparison between two methods for
estimating pneumothorax size from chest X-rays. Respir Med 2006; 100:1356.
31. Noppen M, Alexander P, Driesen P, et al. Quantification of the size of primary spontaneous
pneumothorax: accuracy of the Light index. Respiration 2001; 68:396.
32. Do S, Salvaggio K, Gupta S, et al. Automated quantification of pneumothorax in CT. Comput
Math Methods Med 2012; 2012:736320.
33. Lamb AD, Qadan M, Gray AJ. Detection of occult pneumothoraces in the significantly
injured adult with blunt trauma. Eur J Emerg Med 2007; 14:65.
34. Trupka A, Waydhas C, Hallfeldt KK, et al. Value of thoracic computed tomography in the
first assessment of severely injured patients with blunt chest trauma: results of a
prospective study. J Trauma 1997; 43:405.
https://www.uptodate.com/contents/117242/print 19/49
3/30/23, 5:15 PM 117242
35. Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: diagnostic accuracy of
lung ultrasonography in the emergency department. Chest 2008; 133:204.
36. Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax.
Crit Care Med 2005; 33:1231.
37. Sartori S, Tombesi P, Trevisani L, et al. Accuracy of transthoracic sonography in detection of
pneumothorax after sonographically guided lung biopsy: prospective comparison with
chest radiography. AJR Am J Roentgenol 2007; 188:37.
40. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior
chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg
Med 2010; 17:11.
41. Raja AS, Jacobus CH. How accurate is ultrasonography for excluding pneumothorax? Ann
Emerg Med 2013; 61:207.
42. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection
of pneumothorax: a systematic review and meta-analysis. Chest 2012; 141:703.
43. Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest
radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis.
Crit Care 2013; 17:R208.
44. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest
radiography for evaluation of acute dyspnea in the ED? Chest 2011; 139:1140.
45. Ebrahimi A, Yousefifard M, Mohammad Kazemi H, et al. Diagnostic Accuracy of Chest
Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A
Systematic Review and Meta-Analysis. Tanaffos 2014; 13:29.
46. Chan KK, Joo DA, McRae AD, et al. Chest ultrasonography versus supine chest radiography
for diagnosis of pneumothorax in trauma patients in the emergency department.
Cochrane Database Syst Rev 2020; 7:CD013031.
47. Slater A, Goodwin M, Anderson KE, Gleeson FV. COPD can mimic the appearance of
pneumothorax on thoracic ultrasound. Chest 2006; 129:545.
https://www.uptodate.com/contents/117242/print 20/49
3/30/23, 5:15 PM 117242
51. Gupta N, Langenderfer D, McCormack FX, et al. Chest Computed Tomographic Image
Screening for Cystic Lung Diseases in Patients with Spontaneous Pneumothorax Is Cost
Effective. Ann Am Thorac Soc 2017; 14:17.
Topic 117242 Version 15.0
https://www.uptodate.com/contents/117242/print 21/49
3/30/23, 5:15 PM 117242
GRAPHICS
Secondary spontaneous PAL is more likely; early intervention with pleurodesis (blood,
pneumothorax chemical, surgical) is typically needed; higher risk of recurrence.
Miscellaneous
Air travel Avoidance of air travel for short period after definitive
management.
VATS: video-assisted thoracoscopic surgery; PAL: prolonged (persistent) air leak; COPD: chronic
obstructive pulmonary disease; CF: cystic fibrosis; VEGF-D: vascular endothelial growth factor-D.
https://www.uptodate.com/contents/117242/print 23/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 24/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 25/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 26/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 27/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 28/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 29/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 30/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 31/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 32/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 33/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 34/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 35/49
3/30/23, 5:15 PM 117242
Chest radiograph in the same patient with bilateral giant upper lobe
bullae. A right-sided chest tube was inserted by mistake. Now a
small inferolateral pneumothorax can be seen with a vertical visceral
pleural line visible (arrow).
https://www.uptodate.com/contents/117242/print 36/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 37/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 38/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 39/49
3/30/23, 5:15 PM 117242
Ptx: pneumothorax.
https://www.uptodate.com/contents/117242/print 40/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 41/49
3/30/23, 5:15 PM 117242
(A) Chest radiograph of a 49-year-old female shows left pneumothorax (arrows) and multiple bilateral cystic
lesions involving mainly the lower lung zones.
(B) Coronal reformation of chest CT performed 4 hours later demonstrates large left and small right
(arrowheads) pneumothoraces and multiple bilateral cysts of various sizes including a large cyst at the right
lung base (thick arrows). The patient was subsequently diagnosed as having Birt-Hogg-Dubé syndrome.
https://www.uptodate.com/contents/117242/print 42/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 43/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 44/49
3/30/23, 5:15 PM 117242
Computed tomographic coronal multiplanar reformation image shows a spontaneous small left apical
pneumothorax (arrowhead) and two apical bullae (arrow) in patient with severe paraseptal emphysema
and apical bullae.
https://www.uptodate.com/contents/117242/print 46/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 47/49
3/30/23, 5:15 PM 117242
https://www.uptodate.com/contents/117242/print 48/49
3/30/23, 5:15 PM 117242
Contributor Disclosures
YC Gary Lee, MBChB, PhD Grant/Research/Clinical Trial Support: Rocket Med Plc [Pleural Effusions]. All of
the relevant financial relationships listed have been mitigated. V Courtney Broaddus, MD No relevant
financial relationship(s) with ineligible companies to disclose. Nestor L Muller, MD, PhD No relevant
financial relationship(s) with ineligible companies to disclose. Geraldine Finlay, MD No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
https://www.uptodate.com/contents/117242/print 49/49