1978, British Journal of Radiology, 51, 494-497

Subpulmonary pneumothorax
By A. Schulman, M.R.C.P., F.R.C.R., and R. B. Dalrymple, M.B., Ch.B., D.M.R.D., F.F.RAD(D) (S.A.)
Departments of Radiology, Groote Schuur Hospital and University of Cape Town, South Africa
{Received October, 1977 and in revised form February, 1978)

ABSTRACT lucency without septa or lung markings paralleling

Seven cases of subpulmonary pneumothorax are pre- the upper surface of the hemi-diaphragm and sep-
sented : four due to penetrating injury, two to blunt trauma
and one to osteosarcoma metastasis. arated from the lung by a thin hair-line representing
The typical and diagnostic appearance is a basal band of the basal visceral pleura (Figs. 1-3).
radiolucency bounded above by the thin hair-line of visceral
pleura paralleling the dome of the hemi-diaphragm. When Two cases, due to penetrating and blunt trauma
partially clotted blood is also present, the appearance respectively, were atypical presumably due to the
becomes less typical and has to be differentiated from additional presence of blood in the pleural space. In
traumatic diaphragmatic herniation of bowel and from
traumatic pneumatocoele by barium studies and by decu-
bitus radiographs respectively.
It is the bridge-like disposition of the pleural cavity
between the dome of the hemi-diaphragm and the hollowed
concavity of the lung base which allows pneumothorax to
collect in it. It is rarely seen because blebs and bullae which
are the commonest causes of pneumothorax are most often
located in the upper zones.

A recent report of four cases of subpulmonary

pneumothorax (Christensen and Dietz, 1976) stres-
sed the importance of pleural adhesions in the upper
pleural space causing the pneumothorax to localize
in a basal position. We wish to emphasize that sub-
pulmonary pneumothorax can probably occur with-
out pleural adhesions, that it may be especially
common with basal penetrating trauma and that the
thoracic bases and not simply the apices must be
diligently searched for early small pneumothoraces.

MATERIALS AND METHODS

During a recent period of eight months, we have
seen seven cases of pneumothorax presenting in-
itially in an entirely subpulmonary situation. Four of (A) Erect P.A. film.
them were due to penetrating stab wounds of the
left lower chest, two to blunt assault on the left side
of the chest without radiographic or clinical evidence
of fractured ribs, and one to pulmonary metastases
from a femoral osteosarcoma.
One patient had treated, healed tuberculosis in
both upper lobes, but none of the others had
clinical or radiographic evidence of pre-existing lung
or pleural disease.
In five cases, at least some of the subpulmonary
air later moved into more common sites, lateral or
medial to the lung and even eventually up to the (B) Erect lateral film.
apex; this occurred after lying the patient on his side FIG. 1. Case 1.
for decubitus radiographs or simply with the passage A 26-year old man received two stab wounds in posterior
of 24 to 48 hours. aspect of left hemithorax causing small subpulmonary
In five cases, the subpulmonary pneumothorax pneumothorax. See line of visceral pleura (arrow-heads).
Later the same day, a repeat film showed that the air had
showed the typical appearance, i.e. a band of radio- moved to the apex.
494
 Subpulmonary pneumothorax

FIG. 2. Case 2.
Erect P.A. film. A 31-year old man stabbed in back of left
hemithorax causing small subpulmonary pneumothorax.
Paralleling upper surface of diaphragm is the thin line of
visceral pleura (arrows).

FIG. 3. Case 3.
Erect P.A. film. A 17-year old boy seven months after
amputation for femoral osteosarcoma. The pneumothorax
on the left is purely subpulmonary (white triangles), that on
the right is all around the lung. Whole lung tomography
confirmed that the opacity at the left base (arrow-heads) was
a metastasis projecting inwards from the visceral pleura and
that there were multiple metastases in both lungs; proven by
thoracotomy and histology.

one, the blood and air formed a rounded collection

with a fluid level above the stomach bubble (Figs.
4A & B). Barium examination of the stomach was
entirely normal, while decubitus radiographs showed
that the gas moved freely within the pleural space,

FIG. 4. Case 4.
A 25-year old woman received four stab wounds in back of
chest inflicted with screwdriver. In A and B, note the air-fluid
collection (straight black arrows) at the left base above the
stomach bubble (arrow-heads). Diagnosis—subpulmonary
haemopneumothorax?, traumatic pneumatocoele?, trau-
matic hernia? Barium meal showed no gastric herniation.
Decubitus film (c) shows the air moving freely upwards in
the pleural cavity (open arrows) and the blood freely down-
wards (curved arrows). Diagnosis—subpulmonary haemo- ^Bfapi
pneumothorax. (c) Left lateral decubitus film with barium in stomach.
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A. Schulman and R. B. Dalrymple
thus excluding both traumatic herniation of the gas-
tric fundus and traumatic pneumatocoele (Fig. 4c).
In the other case (Fig. 5), the air collection at the
base was crossed by numerous septa causing it to re-
semble bowel. Again, traumatic herniation was con-
sidered but barium examinations of stomach and
colon were normal. Following drainage of the sub-
pulmonary pneumothorax, chest radiographs were
normal.
The patient with osteosarcoma metastases had
been treated by amputation, radio-therapy and cyto-
toxic drugs. Routine chest radiographs were normal
until seven months after amputation when, although
the patient was asymptomatic, there were bilateral
pneumothoraces and pulmonary metastases on the
FIG. 5. Case 5.
Erect PA film, left basal detail. A 24-year old man was
assaulted receiving blunt skull and facial injuries with
amnesia. No clinical or radiographic evidence of fractured
ribs but this multi-septate air collection appeared at the left
base. Contrast studies of stomach, jejunum and colon were
normal, excluding traumatic herniation. Following basal
pleural aspiration, chest radiographs became normal. Diag-
nosis—subpulmonary haemopneumothorax.
496
visceral pleura (Fig. 3). The right sided pneumo-
thorax encircled the lung while that on the left side
was purely subpulmonary.
DISCUSSION
Radiologists are trained to look meticulously at the
apices for the earliest evidence of small pneumo-
thorax, and recent text books (Fraser and Pare,
1970; Crofton and Douglas, 1975; Harris and
Harris, 1975) make no mention of pneumothorax
located in the initial stages below the lung base even
in erect patients. Our series indicates that, especially
in cases of penetrating trauma, one should look most
carefully for the fine hair-line of visceral pleura
pushed upwards from the hemi-diaphragm by a
subpulmonary pneumothorax.
It is presumably the bridge-like disposition of the
pleural space between the dome of the hemi-
diaphragm and the hollowed out base of the lung
that allows pneumothorax, arising from injury or
disease of this part of the lung, to collect here. Part of
the reason why this is seen so seldom is that the
major causes of pneumothorax, i.e. pleural blebs and
emphysematous bullae, are situated most commonly
in the upper parts (Crofton and Douglas, 1975).
Neonatal pneumomediastinum is occasionally as-
sociated with air loculated below the lung and this is
thought to be extra-pleural, between the parietal
pleura and the hemi-diaphragm (Lillard and Allen,
1965; Caffey, 1972). However, none of our patients
had pneumomediastinum and in five of them, some
or all of the subpulmonary air later moved into more
typical intrapleural sites around or above the lung
after some time or after lying the patient on his side
for decubitus radiographs. Indeed, it would be
difficult for air to track far beneath the parietal
pleura as it is found to be firmly adherent to under-
lying tissue during thoracic surgical dissections.
It is also unnecessary to postulate the presence of
pleural adhesions higher up causing a subpulmonary
situation (Christensen and Dietz, 1976) as in six of
our cases there was nothing to suggest previous
pulmonary or pleural disease and again because of
the later movement of some of the air into higher
parts of the pleural space.
The typical appearance of subpulmonary pneu-
mothorax is a radiolucent zone without bronchovas-
cular markings or septa lying on the hemi-diaphragm
and bounded above by the thin hair-line of the
visceral pleura paralleling the dome of the hemi-
diaphragm (Figs. 1-3). This appearance should be
diagnostic but can be confirmed by the free move-
ment of the air into other parts of the pleural space
after lying the patient on his side.

Subpulmonary pneumothorax
A subpulmonary pneumothorax crossed by strands
of partially clotted blood producing a multiseptate
appearance (Fig. 5) can resemble basal bullae or the
fold or haustral pattern of bowel herniated through a
diaphragmatic laceration. The latter is easily ex-
cluded by barium study of stomach and colon
(Fataar and Schulman, 1978). If the blood produces
a fluid level within the loculated air (Figs. 4A and B)
it can again resemble traumatic herniation as well as
traumatic pneumatocoele (Fagan and Swischuk,
1976; Freed, 1977) but decubitus radiographs show
independent movement of the air upward and the
blood downward to opposite extremities of the
pleural space thus proving that the collection is
intrapleural and not intrapulmonary.
The visceral pleura is much thinner than the
hemi-diaphragm so that subpulmonary air should
not be mistaken for subdiaphragmatic air.
We are unable to account for the fact that all
seven of our cases were left sided. It can be argued
that when facing a right handed assailant, the left
side of the chest is more likely to receive the stab
wound. However, in three of the four cases of stab
wounds, they were in fact in the back of the chest.
Pulmonary metastases are a known cause of pneu-
mothorax which for obvious reasons may be bilateral
(Janetos and Ochner, 1963; Wright, 1976; Winter,
1976; Kai-Yui Yeung and Bonnet, 1977). The
majority of published cases have been due to sar-
comas of various origins, the commonest being
osteosarcoma and most frequently in children and
adolescents. Subpulmonary pneumothorax has not
been reported.
Our two cases due to blunt trauma had a pneu-
mothorax in spite of no evidence of rib fracture or
penetrating injury. The presence of rib fractures is
JULY 1978
underestimated by radiological examination but even
in the absence of fractures, blunt trauma can pro-
duce both lung damage and pneumothorax (Gerblich
and Kleinerman, 1977).
REFERENCES
CAFFEY, J., 1972. Pediatric x-ray diagnosis, Vol. I, 6th edn.
pp. 431-434 (Year Book Medical Publishers).
CHRISTENSEN, E. E., and DIETZ, G. W., 1976. Subpulmonic
pneumothorax in patients with chronic obstructive pul-
monary disease. Radiology, 121, 33—37.
CROFTON, J., and DOUGLAS, A., 1975. Respiratory diseases,
2nd edn. pp. 350-359 and 478-487 (Blackwell Scientific
Publications, Oxford).
FAGAN, C. J., and SWISCHUK, L. E., 1976. Traumatic lung
and para-mediastinal pneumatocoeles. Radiology, 120,
11-18.
FATAAR, S., and SCHULMAN, A., 1978. The diagnosis of
diaphragmatic tears. British Journal of Radiology (in
press).
FRASER, R. G., and PARE, J. A. P., 1970. Diagnosis of diseases
of the chest, Vol. 1, pp. 371-376 (W. B. Saunders Company,
Philadelphia).
FREED, C , 1977. Traumatic lung cysts after penetrating
chest injury (report of three cases). South African Medical
Journal, 51,720-722.
GERBLICH, A. A., and KLEINERMAN, J., 1977. Blunt chest
trauma and the lung (editorial). American Review of
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HARRIS, J. H., and HARRIS, W. H., 1975. The radiology of
emergency medicine, pp. 226-230. (Williams and Wilkins,
Baltimore).
JANETOS, G. P., and OCHNER, S. F., 1963. Bilateral pneu-
mothorax in metastatic osteogenic sarcoma. American
Review of Respiratory Diseases, 88, 73-76.
KAI-YUI YEUNG and BONNET, J. D., 1977. Spontaneous
pneumothorax with metastatic malignant melanoma.
Chest, 71, 435-436.
LILLARD, R. L., and ALLEN, R. P., 1965. The extrapleural
air sign in pneumomediastinum. Radiology, 85, 1093-
1098.
WINTER, W. G., 1976. Spontaneous pneumothorax heralding
metastasis of adamantinoma of tibia. The Journal of Bone
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WRIGHT, F. W., 1976. Spontaneous pneumothorax and
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211-222.

Book review
Computerised cranial tomography. Edited by B. Felson,
pp. 146, illus., 1977 (New York; Grune and Stratton Inc.)
$18.5O/£13-15.
This book presents a collection of papers which were
originally published in seminar in Radiolgoy Vol. 12. Each
of the major papers is a good, well illustrated review of its
subject. The presentation on equipment and physics by
Tor-Pogossian stands out as a model of clarity in explaining
this difficult field to diagnostic radiologists.
This book is not meant to be comprehensive and there are
obvious omissions as for example, the lack of consideration
of hydrocephalus or the effects of surgery and other therapy.
The defects are covered to some extent in the good selection
of references.
It is recommended as an authorative introduction to
cranial computed tomography.
B. E. KENDALL.

497