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Trapped lung

Article · August 2016

DOI: 10.1594/EURORAD/CASE.13940

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 Case 13940
Trapped lung

Locklin, Jasmine N MD; Taylor, Susan D DO; Thomson, Norman B MD; Keshavamurthy, Jayanth
H

Augusta University Medical Center,

Medical College of GA;
1120 15th St
30912 Augusta;
Email:sustaylor@augusta.edu
Augusta University Medical Center

Section: Chest Imaging

Published: 2016, Aug. 5
Patient: 63 year(s), male

Clinical History
63-year-old man with past medical history of renal cell carcinoma s/p bilateral nephrectomy on
haemodialysis, hypertension, and type II diabetes mellitus presented after a syncopal episode with
left flank and rib pain. The patient had decreased breath sounds of the right lung base, crackles of
the left lung base.

Imaging Findings
Presentation chest X-ray showed a large right pleural effusion with compressive atelectasis (Fig. 1);
thoracentesis was suggested and performed. Immediately following thoracentesis, the patient's chest
X-ray showed development of a hydropneumothorax. The pneumothorax component did not change
with inspiration or expiration (Fig. 2). A right-sided chest tube was placed a few days later without
successful lung expansion (Fig. 3), although it did resolve the pleural effusion; this chest tube was
likely unwarranted as the diagnosis of trapped lung was apparent from the chest X rays immediately
following thoracentesis.

Discussion
A. Background: A trapped lung occurs when there is pleural space inflammation resulting in
visceral pleural encasement with a fibrous peel preventing the lung from expanding in the chest
wall during fluid removal. A negative pressure gradient is created causing a chronic fluid-filled
pleural space [2]. The fibrous visceral pleura from chronic inflammation results in separation from
the parietal pleura and the space fills with fluid resulting in a hydropneumothorax. When the fluid is
 removed there is a resulting pneumothorax since the lung cannot expand [1].

B. Clinical Perspective: Clinical presentations of trapped lung include chest pain, dyspnoea on
exertion and decreased breath sounds on the affected side. However, patients may be asymptomatic
or have minimal dyspnoea with exertion. To diagnose trapped lung, there must be no active pleural
inflammatory or malignant process and the lack of expansion must be stable over time [3]. Imaging
is needed to make the proper diagnosis and distinguish trapped lung from other process with similar
presentations such as lung entrapment which is a complication of active pleural inflammation,
malignancy or haemothorax [4].

C. Imaging Perspective: Computed tomography and plain film radiographs can be used to assist in
the diagnosis of trapped lung. Trapped lung does not appear larger on expiration than on inspiration
in comparison to pneumothorax. The visceral pleural line delineates the scarred lung contour.
Visceral pleural peel, pneumothoraces and lobar atelectasis may be visualized on radiography of
trapped lung distinguishing it from other entities [2]. Manometry has also been used to assist in the
diagnosis of trapped lung [4].

D. Outcome: The therapeutic approach to treating trapped lung depends on the clinical situation.
The definitive treatment is surgery including pleurectomy and decortication to remove the fibrosed
visceral pleura from the lung to relieve pressure and allow for expansion of the trapped lung [1].
Extended drainage by pleural catheter is another treatment option usually reserved for patients that
are symptomatic but are poor surgical candidates [2].

E. Take Home Message: Trapped lung should be included in the differential diagnosis of a patient
with a radiographically stable pneumothorax after pleural fluid drainage, when lung expansion
would be expected. Other clinical entities can initially mimic trapped lung such as lung entrapment
and further imaging and other diagnostic tests such as manometry can determine the clinical
diagnosis. Making the proper diagnosis initially will help guide management.

Final Diagnosis
Trapped lung (pneumothorax ex vacuo)

Differential Diagnosis List

Post-procedural pneumothorax, Obstructing bronchogenic carcinoma, Cryptogenic organizing
pneumonia, Bronchiolitis obliterans organizing pneumonia

Figures

Figure 1 Presentation chest X-ray

 Posteroanterior radiograph of the chest demonstrates a large right pleural effusion with
compressive atelectasis.
© Augusta University Medical Center, Augusta University Department of Radiology, Augusta University, Augusta, GA, USA.

Area of Interest: Lung;

Imaging Technique: Conventional radiography;
Procedure: Education;
Special Focus: Acute;

Figure 2 Chest X-rays following thoracentesis

Inspiratory posteroanterior radiograph of the chest demonstrates smaller right pleural

effusion with pneumothorax.
© Augusta University Medical Center, Augusta University Department of Radiology, Augusta University, Augusta, GA, USA
 Area of Interest: Lung;
Imaging Technique: Conventional radiography;
Procedure: Diagnostic procedure;
Special Focus: Biological effects;

Expiratory posteroanterior radiograph shows no change of the pneumothorax when

compared to inspiratory radiograph. Right pleural effusion is also unchanged from
inspiratory radiograph.
© Augusta University Medical Center, Augusta University Department of Radiology, Augusta University, Augusta, GA, USA

Area of Interest: Lung;

Imaging Technique: Conventional radiography;
Procedure: Diagnostic procedure;
Special Focus: Biological effects;

Figure 3 Chest X-ray following chest tube placement

 Posteroanterior radiograph of the chest shows interval placement of a right chest tube with
successful evacuation of right pleural effusion, but no significant expansion of the right lung
consistent with trapped lung.
© Augusta University Medical Center, Augusta University Department of Radiology, Augusta University, Augusta, GA, USA

Area of Interest: Lung;

Imaging Technique: Conventional radiography;
Procedure: Treatment effects;
Special Focus: Biological effects;

References
[1] Albores J, Wang T. (2015) Images in clinical medicine. Trapped lung. New England Journal of
Medicine 372(19):e25.

[2] Khan H, Fernandez-Perez ER, Caples SM (2007) Post-thoracentesis trapped lung Journal of
Postgraduate Medicine 53.2: 119-120

[3] Huggins JT, Sahn SA, Heidecker J, Ravenel JG, Doelken P (2007) Characteristics of Trapped
Lung Chest 131.1: 206-213

[4] Huggins JT, Doelken P, Sahn SA (2010) The Unexpandable Lung F1000 Medicine Reports
2.77:1-3

Citation
Locklin, Jasmine N MD; Taylor, Susan D DO; Thomson, Norman B MD; Keshavamurthy, Jayanth
H

Augusta University Medical Center,

 Medical College of GA;
1120 15th St
30912 Augusta;
Email:sustaylor@augusta.edu (2016, Aug. 5)
Trapped lung {Online}
URL: http://www.eurorad.org/case.php?id=13940

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