Symposium

Sonographic diagnosis of pneumothorax

Lubna F Husain, Laura Hagopian, Derek Wayman, William E Baker,
Kristin A Carmody
Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA

ABSTRACT
Lung sonography has rapidly emerged as a reliable technique in the evaluation of various thoracic diseases. One important,
well-established application is the diagnosis of a pneumothorax. Prompt and accurate diagnosis of a pneumothorax in
the management of a critical patient can prevent the progression into a life-threatening situation. Sonographic signs,
including ‘lung sliding’, ‘B-lines’ or ‘comet tail artifacts’, ‘A-lines’, and ‘the lung point sign’ can help in the diagnosis of a
pneumothorax. Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for
the detection of a pneumothorax. Small occult pneumothoraces may be missed on CXR during a busy trauma scenario,
and CXR may not always be feasible in critically ill patients. Computed tomography, the gold standard for the detection
of pneumothorax, requires patients to be transported out of the clinical area, compromising their hemodynamic stability
and delaying the diagnosis. As ultrasound machines have become more portable and easier to use, lung sonography now
allows a rapid evaluation of an unstable patient, at the bedside. These advantages combined with the low cost and ease of
use, have allowed thoracic sonography to become a useful modality in many clinical settings.

Key Words: Emergency medicine, pneumothorax, diagnosis, thoracic ultrasonography

INTRODUCTION sonographic artifacts created by the interplay of air and fluid

The use of ultrasound (US) in the diagnosis and treatment of
patients is a well-established modality that has existed for many
years. Thoracic sonography is fairly new in comparison to other
accepted ultrasound applications, and is still rapidly evolving. The
use of thoracic ultrasound has gained slow acceptance due to the
traditional teaching that the air-filled lungs are not ultrasound
friendly. Poor imaging is a result of the confinement of air
between the lung and the chest wall, preventing diffusion of the
ultrasound beam into the parietal pleura and deep lung structures,
leading to a production of artifacts. Over the past decade, bedside
lung sonography has developed an established role in literature
for the diagnosis of thoracic diseases. This development is
based on an improved understanding and appreciation of the
Address for correspondence:
Dr. Lubna Farooq Husain, E-mail: lubna.farooq@bmc.org
in the lungs. The first reported use of ultrasound to detect
pneumothorax in humans was by Wernecke et al., in 1987.[1]
The Focused Assessment with Sonography in Trauma (FAST)
examination has now been modified to include lung imaging as
part of the evaluation in a trauma patient. The application has
been renamed as the E-FAST examination, with ‘E’ standing for
extended, including the standard lung views.
A pneumothorax can be divided into two broad categories: traumatic
(including iatrogenic) or atraumatic. Atraumatic pneumothorax
can further be categorized as primary spontaneous or secondary
spontaneous. Pneumothorax is commonly associated with both
blunt and penetrating chest injury and is a leading cause of
preventable morbidity and mortality. Traumatic pneumothorax,
the most common life-threatening outcome in blunt chest trauma,
occurs in over 20% of patients with blunt injuries and about 40%
with penetrating chest injuries.[2]

Access this article online The diagnosis of a pneumothorax is usually made with a
Quick Response Code:
Website:
combination of clinical signs and symptoms, which may be subtle,
www.onlinejets.org and plain chest radiography. Regardless of its presentation, the
early detection and treatment of a pneumothorax is critical. Small-
DOI:
(10% or less) or medium (11 to 40%)-sized pneumothoraces are
10.4103/0974-2700.93116 generally not life-threatening and their management varies.[3-5]
However, a delay in the diagnosis and treatment, especially in those
76 Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012

who are mechanically ventilated, may lead to the progression of a
pneumothorax and resultant hemodynamic instability.[6,7] In these
critical situations where a subtle pneumothorax may be missed,
a quick bedside lung ultrasound may expedite the diagnosis,
treatment, and resuscitation of a patient who may have otherwise
decompensated.
Ultrasound has a well-known established role in the diagnosis
of a traumatic pneumothorax. In one prospective study a
hand-held ultrasound device was used by trauma surgeons
to perform the E-FAST examination in patients with blunt
or penetrating trauma.[8] The utility of thoracic ultrasound
for diagnosing a pneumothorax was compared to chest x-ray
(CXR) alone, a composite standard (CXR, chest, and abdomen
Computed tomography (CT) scans, clinical course, and invasive
interventions), and to the gold standard CT scan (CT only). Their
results showed that the E-FAST examination had a sensitivity of
58.9% with a positive likelihood ratio of 69.7 and a specificity
of 99.1% when compared to the composite standard. The
E-FAST was also compared to CXR, using CT scan as the gold
standard, showing that ultrasound had a higher sensitivity than
CXR, 48.8 and 20.9%, respectively, and a similar specificity of
99.6 and 98.7%, respectively. In addition, they noted that 63%
of all pneumothoraces diagnosed were occult. Traditionally,
these would end up getting diagnosed later on a CT scan.
Although CT scan remains the gold standard, they concluded
that ultrasound was more sensitive in identifying occult traumatic
pneumathoraces compared to CXR.
Similarly, a prospective study by Ball et al., noted that up to 76%
of all traumatic pneumothoraces were missed by the standard
supine AP chest film when interpreted by the trauma team.[9]
This number was much higher than their prior retrospective
study (55%), where image interpretation relied on radiologists.
This stressed the poor sensitivity of CXR in a rushed trauma
scenario and the utility of performing a rapid bedside ultrasound,
to possibly aid in the diagnosis, prior to sending a patient for a
CT scan.[10]
Several other studies highlight the utility of ultrasound compared
to CXR for the diagnosis of pneumothorax in the Emergency
Department.[11-14] The sensitivity of ultrasound in certain studies
has been similar to that found in CT scan, which is still considered
to be the gold standard for the detection of a pneumothorax.[11,15]
Lichtenstein et al., have shown that ultrasound has a sensitivity of
95.3% and a specificity of 91.1% for detecting pneumothorax in
intensive care unit (ICU) patients.[16] However, in this particular
article, the authors cite that the underlying lung process may
have affected the accuracy of ultrasound, resulting in both false-
positive and false-negative cases.
Relevant English language articles and case reports were searched
by using PubMed and Google Scholar (1984–2011). The following
search terms were used: ‘Ultrasonography’, ‘chest sonography,’
‘bedside lung ultrasound,’ ‘pneumothorax,’ and ‘emergency
medicine.’
Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012
Husain, et al.: Sonographic diagnosis of pneumothorax
Probe selection and equipment
The bedside sonographic diagnosis of pneumothorax can be
performed with most ultrasound machines without the need of
any sophisticated functions. Most machines are now portable and
can be brought to the bedside, which is especially helpful in the
critically ill and hemodynamically unstable patient, as it obviates
the need for transport. Also, the physician performing the scan
can interpret the results of the bedside ultrasound immediately.
A straight linear array high frequency probe (5–13 MHz) may
be most helpful in analyzing superficial structures such as the
pleural line and providing better resolution.[17] A microconvex
or curvilinear array probe may be more suitable for deeper lung
imaging as it provides better penetration (1–8 MHz), at the cost of
less resolution. Finally, some advocate the use of the phased array
probe, generally used in cardiac imaging (2–8 MHz), as its flat and
smaller footprint is better suited for imaging in between the ribs.
Technique and normal anatomy
A pneumothorax contains air and no fluid, and therefore, will
rise to the least dependent area of the chest. In a supine patient
this area corresponds to the anterior region of the chest at
approximately the second to fourth intercostal spaces in the
mid-clavicular line. This location will identify the majority of
significant pneumothoraces in the supine patient, which makes
it the recommended initial area for investigation in a trauma.[17,18]
In contrast, air will accumulate in an apicolateral location in an
upright patient.[19]
Based on the above, patients are scanned in a supine or near-to-
supine position. The probe should be placed in a sagittal position
(indicator pointing cephalad) on the anterior chest wall at about
the second intercostal space, in the mid-clavicular line [Figure 1].
The sonographer should first identify the landmarks of two ribs
with posterior shadowing behind them and visualize the pleural
line in between them. This is typically called ‘the bat sign’ where
the periosteum of the ribs represents the wings and the bright
hyperechoic pleural line in between them represents the bats’
Figure 1: Correct probe positioning in the initial evaluation of a
pneumothorax. The probe is placed on the anterior chest wall
in a sagittal orientation, pointing toward the patient’s head at
approximately the second intercostal space in the mid-clavicular line
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Husain, et al.: Sonographic diagnosis of pneumothorax
body [Figures 2a and 2b].[20] If the ribs are not visualized the
probe should be slowly moved in a caudal direction (inferiorly)
until two ribs appear on the screen. It is in between these two
rib landmarks that the two layers of pleura, parietal and visceral,
are seen sliding across one another. As stated earlier, air will rise
to the anterior chest wall, and therefore a pneumothorax that is
large enough to require a chest tube will appear with this simple
technique.
The presence of pleural sliding is the most important finding
in normal aerated lung. The sonographer should visualize
the hyperechoic pleural line in between two ribs moving or
shimmering back and forth. Lung sliding corresponds to the
to-and-fro movement of the visceral pleura on the parietal
pleura that occurs with respiration. It is a dynamic sign and can
be identified on ultrasound as horizontal movement along the
pleural line.[21] Sliding is best seen at the lung apex in a supine
patient.[21] The use of M-mode, which detects motion over
time, provides more evidence that the pleural line is sliding. It is
beneficial in patients where sliding may be subtle, such as, in the
elderly or in patients with poor pulmonary reserve, who are not
taking large breaths. The M-mode cursor is placed over the pleural
line and two different patterns are displayed on the screen: The
motionless portion of the chest above the pleural line creates
horizontal ‘waves,’ and the sliding below the pleural line creates a
granular pattern, the ‘sand’ [Figure 3]. The resultant picture is one
that resembles waves crashing in onto the sand and is therefore
called the ‘seashore sign’ and is present in normal lung.[13,22,23]
‘B-lines’ or ‘comet-tail artifacts’ are reverberation artifacts that
appear as hyperechoic vertical lines that extend from the pleura
to the edge of the screen without fading [Figure 4]. 'Comet-tail
artifacts' move synchronously with lung sliding and respiratory
movements.[21] A few visualized ‘B-lines’ in dependent regions
are expected in normal aerated lung and are visualized moving
along with the sliding pleura. These artifacts are seen in normal
lung due to the acoustic impedance differences between water
and air.[22] Excessive ‘B-lines’, especially in the anterior lung, are
abnormal and are usually indicative of interstitial edema.
Figure 2: (a) ‘The bat sign.’ Two ribs with posterior shadowing represents the wings of the bat, and the hyperechoic pleural line, its
body (b) A sagittal scan at the upper intercostal spaces depicting normal anatomy
78
The average time to perform this examination varies from two to
three minutes; less than one minute to rule out a pneumothorax
and several minutes to rule it in.[8,12]
Sonographic signs of pneumothorax
Absence of lung sliding
In a pneumothorax, there is air present that separates the visceral
and parietal pleura and prevents visualization of the visceral
pleura. In this situation, lung sliding is absent. This lack of lung
sliding can be visualized by identifying the landmarks discussed
earlier. Two ribs should be identified with the pleural line in
between them. The typical to-and-fro movement or shimmering
of the pleural line will not be present. The same technique using
M-mode can be used to confirm a lack of sliding. The resultant
M-mode tracing in a pneumothorax will only display one pattern
of parallel horizontal lines above and below the pleural line,
exemplifying the lack of movement. This pattern resembles a
‘barcode’ and is often called the ‘stratosphere sign’ [Figure 5].[22,23]
The negative predictive value for lung sliding is reported as
99.2–100%, indicating that the presence of sliding effectively
rules out a pneumothorax.[11,16,24] However, the absence of
lung sliding does not necessarily indicate that a pneumothorax
is present. Lung sliding is abolished in a variety of conditions
other than pneumothorax, including acute respiratory distress
syndrome (ARDS), pulmonary fibrosis, large consolidations,
pleural adhesions, atelectasis, right mainstem intubation, and
phrenic nerve paralysis.[21,25,26] Specificity values range from
60 –99% depending on the patient population, with higher values
in the general population and lower values in the Intensive Care
Unit and in those with ARDS.[11,16,21,24] Although the absence of
lung sliding is not specific for pneumothorax, the combination
of this with other signs improves the accuracy of the diagnosis.
Comet tail artifacts or ‘B-lines’
Ultrasound demonstrates the loss of ‘comet-tail artifacts’ in
patients with a pneumothorax. These reverberation artifacts
are lost due to air accumulating within the pleural space, which
hinders the propagation of sound waves and eliminates the
Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012

Figure 3: M-mode illustrating the ‘seashore sign.’ The pleural
line divides the image in half: The motionless portion above the
pleural line creates horizontal ‘waves,’ and the sliding line below
it creates granular pattern, the ‘sand’
Figure 5: M-mode and the absence of lung sliding are shown
as the ‘stratosphere sign’: Parallel horizontal lines above and
below the pleural line, resemble a ‘barcode.’ This sign indicates
a pneumothorax at this intercoastal space
Figure 7: ‘Lung point sign.’ (Right) B-mode depicting the lung
point: Sliding lung touching the chest wall. (Left) The ‘seashore
sign’ (white arrow) and the ‘stratosphere sign’ (dotted arrow) as
the lung intermittently contacts the chest wall
Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012
Husain, et al.: Sonographic diagnosis of pneumothorax
Figure 4: ‘B-lines’ or ‘comet-tail artifacts’ are seen originating from
the bright white hyperechoic pleural line, extending vertically to
the edge of the screen. ‘B-lines’ move in synchrony with the sliding
pleura in a normal well-aerated lung
Figure 6: ‘A-lines’, a type of reverberation artifact, are horizontal,
equally spaced lines seen originating from the bright white
hyperechoic pleural line. If ‘B-lines’ are present, they extend out
from the pleural line and erase the ‘A-lines’ in their path
acoustic impedance gradient.[20] In addition, ‘comet–tail’ artifacts
are generated by the visceral pleura, which is not visualized in
a pneumothorax, therefore, these artifacts are not generated.[24]
The negative predictive value for this artifact is high, reported
at 98–100%, such that visualization of even one comet-tail
essentially rules out the diagnosis of a pneumothorax.[21,24,27]
‘A-lines’ are other important thoracic artifacts that can help in
the diagnosis of a pneumothorax. These are also reverberation
artifacts appearing as equally spaced repetitive horizontal
hyperechoic lines reflecting off of the pleura [Figure 6].
The space in between each A-line corresponds to the same
distance between the skin surface and the parietal pleura. In the
normal patient, when ‘B-lines’ are present, they extend from
the pleural line and erase ‘A-lines’, as they emanate out to the
edge of the screen. ‘A-lines’ will be present in a patient with a
pneumothorax, but ‘B-lines’ will not. If lung sliding is absent
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Husain, et al.: Sonographic diagnosis of pneumothorax
with the presence of ‘A-lines’, the sensitivity and specificity for
an occult pneumothorax is as high as 95 and 94%, respectively.[24]
Lung-point sign
The ‘lung-point sign’ occurs at the border of a pneumothorax.
It is due to sliding lung intermittently coming into contact with
the chest wall during inspiration and is helpful in determining
the actual size of the pneumothorax. This sign can further
be delineated using M-mode where alternating ‘seashore’ and
‘stratosphere’ patterns are depicted over time [Figure 7]. The
‘lung-point sign’ is 100% specific for pneumothorax and defines
its border.[21,28] The location of the lung point is beneficial in
determining the size of the pneumothorax. If a lack of lung
sliding is visualized anteriorly, the probe can progressively be
moved to more lateral and posterior positions on the chest wall
searching for the location of the lung-point. The more lateral
or posterior the ‘lung-point sign’ is identified, the larger the
pneumothorax. Therefore, if the ‘lung-point sign’ is seen in
an anterior location on the chest wall, the sonographer can be
assured that the pneumothorax is relatively small.[11,24,29] Although
the specificity is high, the sensitivity of the ‘lung-point sign’
is relatively low (reported at 66%) and is not seen in cases of
total lung collapse.[28] Studies have shown concordance between
pneumothorax size on ultrasound and CT scan, reportedly
within 1.9–2.3 cm.[15,26,29] The determination of the size of a
pneumothorax is important for clinical decision-making, as larger
pneumothoraces are more likely to require thoracostomy.[11,24]
Other signs
The ‘Power Slide’ refers to the use of power (angiography)
Doppler to help identify lung sliding. Power Doppler is very
sensitive and picks up subtle flow and movement. If there is
lung sliding present, power Doppler will light up the sliding
pleural line with color flow [Figure 8]. This technique can be
helpful in cases of subtle sliding when direct visualization may
be difficult. The disadvantage of this type of Doppler is that
due to its increased sensitivity, the probe needs to be held in a
Figure 8: ‘Power slide’ in normal sliding lung. Power (angiography)
Doppler is used at the pleural line, which is visualized lighting up
with color flow as subtle sliding is detected. The probe must be
steady to avoid unwanted color artifacts
80
steady manner and the patient has to be motionless in order to
prevent artifact and erroneous color flow over the pleural line,
when sliding is actually absent.[23,30]
The ‘lung pulse’ refers to the rhythmic movement of the pleura
in synchrony with the cardiac rhythm. It is best viewed in areas
of the lung adjacent to the heart, at the pleural line. The ‘lung
pulse’ is a result of cardiac vibrations being transmitted to the
lung pleura in poorly aerated lung. Cardiac activity is essentially
detected at the pleural line when there is absent lung sliding. In
normal well-aerated lung, the ‘lung pulse’ is not present, as lung
sliding becomes dominant and resistant to cardiac vibrations. [21]
CONCLUSIONS
Thoracic sonography for the detection of pneumothorax has
become a well-established modality in the acute care setting. It
is indispensible in the blunt or penetrating chest trauma patient,
where the identification of a pneumothorax can prevent life-
threatening consequences. The ease of use and portability of
newer machines, combined with the improved training among
physicians has allowed thoracic ultrasound to become a useful
bedside tool in patients with respiratory complaints. The
traditional upright AP radiograph has become less important due
to its poor sensitivity in diagnosing a pneumothorax compared
to ultrasound. Although CT scan remains the gold standard and
may still catch smaller occult pneumothoraces that ultrasound
misses, its disadvantages are becoming more apparent. Bedside
ultrasound obviates the need for patient transport in unstable
situations, it eliminates radiation exposure, it is quicker to perform
and is immediately interpreted at the bedside without unnecessary
delays. In addition, it is more cost-effective and can be repeated
multiple times during a resuscitation.
In addition, ultrasound is the perfect modality in the emergency
and critical care setting after performing certain procedures, such
as a thoracentesis or the placement of a central line, to quickly
confirm the presence of lung-sliding and to rule out an iatrogenic
pneumothorax. It has also been found to be beneficial in the
post-intubation scenario, where a confirmation of bilateral lung
sliding rules out a right mainstem intubation.
The increasing portability of newer ultrasound machines makes
them easier to use in first responder and disaster settings, wilderness
medicine, air medical transport, rural medicine, and even space
explorations. Studies indicate that the recognition of key artifacts
in thoracic ultrasound is readily teachable to both physicians as
well as non-physician health care providers and its uses continue
to expand in the out-of-hospital setting.[31,32]
This article offers a review of the current evidence for the use of
thoracic ultrasound in the diagnosis of a pneumothorax, reviews
the proper techniques used, and highlights its clinical utility.
We conducted a literature search for the latest scientific evidence
on this topic in English language articles and case studies
(1984 - 2011) using PubMed and Google Scholar.
Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 2012

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How to cite this article: Husain LF, Hagopian L, Wayman D,
Baker WE, Carmody KA. Sonographic diagnosis of pneumothorax.
J Emerg Trauma Shock 2012;5:76-81.
Received: 01.06.11. Accepted: 06.06.11.
Source of Support: Nil. Conflict of Interest: None declared.
81
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