Clinical Presentation and Diagnosis of Pneumothorax

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Official reprint from UpToDate®

www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Clinical presentation and diagnosis of pneumothorax

Author: YC Gary Lee, MBChB, PhD
Section Editors: V Courtney Broaddus, MD, Nestor L Muller, MD, PhD
Deputy Editor: Geraldine Finlay, MD
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
Gas in the pleural space is termed a pneumothorax. Appropriate treatment of pneumothorax is

dictated by the clinical assessment of symptoms, size, and etiology. Thus, prompt recognition
and therapy directed at the pneumothorax and its etiology are important to prevent further
deterioration.
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".)
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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.
Symptoms usually develop when the patient is at rest, although occasionally,

pneumothorax develops during exercise, air travel, scuba diving, or illicit drug use.
Alternatively, symptoms may occur during or following an invasive procedure or trauma to
the chest, neck, gut, or abdomen.
A history of a risk factor or a disorder ( table 1) that can be complicated by

pneumothorax may be present. (See 'Postdiagnosis evaluation' below.)
● Physical examination – In patients with a small pneumothorax, physical examination

findings may not be evident or may be limited to signs of the underlying lung disease, if
present. However, characteristic physical findings when a large pneumothorax is present
include decreased chest excursion on the affected side, enlarged hemithorax on the
affected side, diminished breath sounds, absent tactile or vocal fremitus, and
hyperresonant percussion, as well as, rarely, subcutaneous emphysema. Evidence of
labored breathing, or accessory muscle use suggest a sizeable pneumothorax or a
pneumothorax in a patient with significant underlying lung disease. Tracheal deviation
away from the affected side is a late sign but is not always indicative of tension
pneumothorax. Hemodynamic compromise (eg, tachycardia, hypotension) is an ominous
sign and suggests a tension pneumothorax and/or impending cardiopulmonary collapse.
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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].
Electrocardiography — Electrocardiographic findings are also nonspecific and may reveal a

sinus tachycardia. A more serious rhythm disturbance (eg, bradycardia) may be associated with
severe hypoxemia or indicate tension pneumothorax and impending cardiovascular collapse.
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DIAGNOSTIC IMAGING
The diagnosis of pneumothorax is a radiologic one. The choice of imaging modality is

dependent upon the stability of presentation, the availability of bedside ultrasonography, and
the degree of suspicion for competing diagnoses. In general, while those who are unstable
should have rapid bedside imaging with pleural ultrasonography, those with a stable
presentation can wait for confirmation by chest radiography. Occasionally, chest computed
tomography (CT) is required for those in whom the diagnosis is uncertain, those suspected to
have a loculated pneumothorax, or stable trauma patients who require CT to assess the extent
of other injuries. Incidental pneumothorax may be found on chest CT performed for another
reason.
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'.)
Stable patients — Most patients suspected of having a pneumothorax who are

hemodynamically stable and/or not in severe respiratory distress should undergo routine
bedside chest radiography in the upright position. Inspiratory and expiratory radiographs have
equal sensitivity in detecting pneumothoraces; thus, a standard inspiratory chest radiograph is
sufficient in most cases [5]. Chest radiography is useful even in ultrasonography-identified
pneumothorax since it can reveal other thoracic abnormalities (eg, lung infiltrates) and the size
of a pneumothorax, which, in turn, influences management.
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.)
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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).
Test performance and interpretation
Chest radiography
Pneumothorax appearance and types — Chest radiography (typically performed in the

upright position) is the most common diagnostic imaging modality used for stable patients with
suspected pneumothorax. The presence of a pneumothorax is established by demonstrating a
white visceral pleural line on the chest radiograph. The visceral pleural line defines the interface
between the lung and pleural air ( image 1 and image 2). Bronchovascular markings are
not typically visible beyond the visceral pleural edge unless the pneumothorax is loculated. The
ipsilateral hemithorax size may be increased.
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
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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.
Several other types of pneumothorax can be appreciated on chest radiography:
● 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].
● Pneumothorax from nonexpandable lung (also called pneumothorax ex vacuo) –

Pneumothorax is often seen following pleural fluid removal when the underlying lung fails
to expand due to endobronchial obstruction or a thick fibrous pleural rind. Instead of lung
reexpansion, gas replaces the pleural space occupied by the effusion. (See "Diagnosis and
management of pleural causes of nonexpandable lung" and "Large volume (therapeutic)
thoracentesis: Procedure and complications", section on 'Pneumothorax (including
pneumothorax ex vacuo)'.)
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-
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21]. However, case reports have described bilateral pneumothoraces in patients

without significant lung disease [15,22]. As an example, in one study of 616 cases of
primary spontaneous pneumothorax (PSP), 1.6 percent were bilateral; all patients were
male with a low body mass index and higher height to body weight ratio compared
with patients who had unilateral PSP [22].
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.
Radiologic differential diagnosis — Several conditions can mimic a pneumothorax on

the chest radiograph. When in doubt, a chest CT scan may be needed to distinguish these
entities:
● 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].
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● 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:
● British Thoracic Society (BTS) guidelines – According to the BTS, a pneumothorax is

small, if the distance from the chest wall to the visceral pleural line at the level of the hilum
is <2 cm, and large if the distance is ≥2 cm [26]. A distance of 2 cm roughly correlates with
a 50 percent pneumothorax, which is considered a large pneumothorax [26]. These
guidelines are widely used despite the limitation of a one-dimensional measurement.
Some experts use a 3 cm (and occasionally 4 cm) distance between the apex and chest
wall at the apex as the cutoff to distinguish a small from a large pneumothorax [27].
● 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
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millimeters), divided by three to estimate pneumothorax size as a percentage of the

hemithorax volume ( figure 1 and image 16). This is also called the Rhea method [28].
● 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]:
Percent pneumothorax = 100 – [(average lung diameter3/average hemithorax

diameter3) x 100]
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'.)
The presence of a lung point on pleural ultrasonography is diagnostic of pneumothorax

( movie 1). In partially deflated lung, the lung point is the intermittent and respirophasic
observation of lung sliding at the boundary between the pneumothorax (where there is no
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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.
False-positives of pneumothorax can occur with ultrasonography especially in patients with

underlying diseases (eg, emphysema) [47].
Imaging of pneumothorax on ultrasonography is discussed in more detail separately. (See

"Bedside pleural ultrasonography: Equipment, technique, and the identification of pleural
effusion and pneumothorax", section on 'Evaluation for pneumothorax'.)
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
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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:
● Chest pain or hemoptysis perimenstrually in a young woman with or without a history of

endometriosis might suggest catamenial pneumothorax. (See "Clinical features,
diagnostic approach, and treatment of adults with thoracic endometriosis".)
● A family history of pneumothorax may suggest inheritable disorders such as alpha-1

antitrypsin deficiency or Birt-Hogg-Dubé syndrome, and rarely Marfan or Ehlers Danlos
syndrome. A personal or family history of renal cancer may also support Birt-Hogg-Dubé
syndrome. (See "Clinical manifestations, diagnosis, and natural history of alpha-1
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antitrypsin deficiency" and "Birt-Hogg-Dubé syndrome" and "Clinical manifestations and

diagnosis of Ehlers-Danlos syndromes" and "Genetics, clinical features, and diagnosis of
Marfan syndrome and related disorders".)
● A history of travel (eg, to regions where tuberculosis is endemic) or reason to suspect

underlying human immune deficiency disorder may be sought in those with a possible
infectious reason for pneumothorax. (See "Clinical manifestations and complications of
pulmonary tuberculosis" and "Acute and early HIV infection: Clinical manifestations and
diagnosis" and "Screening and diagnostic testing for HIV infection".)
● 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".)
● Any lucencies or nodules on chest radiography in a young smoking male or nonsmoking

female should prompt CT chest imaging to look for evidence of Langerhans cell
histiocytosis (LCH), subpleural blebs, or LAM. (See "Pulmonary Langerhans cell
histiocytosis" and "Sporadic lymphangioleiomyomatosis: Clinical presentation and
diagnostic evaluation".)
● 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
Chest computed tomography — In the majority of cases, the diagnosis of pneumothorax

is made on chest radiography. If not already performed, a proportion of patients additionally
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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
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.
Other etiology-specific testing — Additional tests are performed when specific

etiologies are being considered based upon clinical and radiologic reevaluation ( table 1).
These might include genetic testing for suspected inheritable syndromes (eg, alpha-1
antitrypsin deficiency, Birt-Hogg-Dubé, Ehlers Danlos syndrome, Marfan syndrome), vascular
endothelial growth factor-D for suspected LAM, and serologic testing for suspected Sjögren
syndrome.
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.
When infection is suspected, microbiologic, serologic testing, and/or bronchoscopy with

bronchoalveolar lavage may also be required.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Pneumothorax".)
INFORMATION FOR PATIENTS
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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 PERSPECTIVE TOPIC
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)".)
SUMMARY AND RECOMMENDATIONS
● Clinical presentation – Pneumothorax (gas in the pleural space) should be suspected in

patients with acute dyspnea and pleuritic chest pain, particularly when an underlying risk
factor is present ( table 1). (See 'Clinical presentation' above.)
• 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.)
• Laboratory and electrocardiography findings are nonspecific. (See 'Laboratory findings'

above and 'Electrocardiography' above.)
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• 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.)
● Diagnostic imaging – The diagnosis of pneumothorax is a radiologic one that is mostly

made in the context of an evaluation for competing diagnoses (eg, acute pulmonary
embolism, pleuritis, pneumonia, myocardial ischemia or infarction, pericarditis, and
musculoskeletal pain). The imaging modality of choice is dependent upon the stability of
presentation, the availability of bedside ultrasonography, and the degree of suspicion for
competing diagnoses:
• Bedside pleural ultrasonography (if available) – For patients with suspected

pneumothorax who are hemodynamically unstable or in severe respiratory distress, we
suggest rapid bedside imaging with pleural ultrasonography, if available, with ongoing
resuscitation efforts focused on stabilizing the airway, breathing, and circulation. The
presence of a lung point on pleural ultrasonography is diagnostic of pneumothorax
( movie 1). A pneumothorax is also suggested if lung sliding ( movie 2 and
movie 3) and/or lung pulse is absent but false positives can occur. In the event that
ultrasonography is unavailable or unhelpful, then an empiric decision to place a chest
tube without confirmatory imaging should be made on clinical assessment alone. (See
'Unstable patients' above and 'Pleural ultrasonography' above and "Approach to shock
in the adult trauma patient", section on 'Tension pneumothorax'.)
• 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
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mediastinum. (See 'Patients with diagnostic uncertainty' above and 'Chest computed
tomography' above.)
● Investigating the underlying etiology – For many patients with pneumothorax, an

underlying cause (eg, trauma or iatrogenic) or underlying lung disorder (eg, chronic
obstructive lung disease [COPD]) ( table 1) is evident at the time of presentation and, in
such cases, no additional testing is typically required unless a second disorder is
suspected. However, in some cases the pneumothorax may not have an apparent cause.
After initial therapy, such patients should be re-evaluated with another detailed history
and examination; chest imaging should also be reexamined with a low threshold to
perform a high resolution chest CT (if not already performed) with or without pulmonary
function testing. If necessary, additional testing (eg, alpha-1 antitrypsin level testing,
genetic testing for Birt-Hogg-Dubé) may be subsequently specifically targeted at
suspected etiologies. (See 'Postdiagnosis evaluation' 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.
Use of UpToDate is subject to the Terms of Use.
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Topic 117242 Version 15.0
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GRAPHICS
Specific diagnostic or management strategies of pneumothorax
Specific diagnostic or management strategies to be

Pneumothorax type
considered
Primary spontaneous Likely benign course with conservative management; drainage of

pneumothorax pleural gas (typically aspiration), VATS for PAL; lower risk of
recurrence.
Secondary spontaneous PAL is more likely; early intervention with pleurodesis (blood,
pneumothorax chemical, surgical) is typically needed; higher risk of recurrence.
COPD Smoking cessation.
CF May consider limited pleurodesis strategies if transplantation

is planned.
Malignancy Chemotherapeutic agents or radiation may be appropriate.

Pneumothorax may not heal and PAL may be likely such that
aggressive surgical strategies may fail.
Infection Antimicrobials are warranted. Pneumothorax may not heal

and PAL may be likely such that aggressive surgical strategies
may fail.
Cystic lung disorders Investigations or therapies targeted at suspected cause may

be warranted (eg, lung biopsy, VEGF-D levels, folliculin gene
analysis, rapamycin*).
Catamenial (endometriosis) Hormonal therapy may be warranted.
Architectural abnormalities May need specific investigations targeted at suspected cause

(eg, Marfan syndrome, Ehlers- (eg, homocysteine levels).
Danlos syndrome,
Homocystinuria)
Iatrogenic Likely benign course (unless patient is mechanically ventilated).

Conservative management with drainage of air is usually
sufficient.
Traumatic May need to co-manage parenchymal trauma and other vascular

and orthopedic aspects of chest trauma.
Miscellaneous
Anorexia Nutrition needs to be addressed, PAL may be likely.
Exercise Likely benign course and conservative management with

drainage of air may be sufficient.
Illicit drug use Cessation of drug use.

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Immunosuppressant drugs Cessation of offending agent, if feasible.
Air travel Avoidance of air travel for short period after definitive
management.
Scuba diving Avoidance of scuba diving until 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.
* Rapamycin, as an immunosuppressant, is a useful therapy for some patients with

lymphangioleiomyomatosis but should not be started until the pneumothorax has healed for
about six weeks. Please refer to the UpToDate topics on sporadic lymphangioleiomyomatosis:
clinical presentation and diagnostic evaluation and sporadic Lymphangioleiomyomatosis: treatment
and prognosis.
Graphic 120903 Version 1.0
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Chest radiograph of spontaneous pneumothorax
Chest radiograph of a 20-year-old male with small spontaneous right pneumothorax

demonstrates the characteristic convex right white visceral pleural line (arrows).
Courtesy of Nestor L Muller, MD, PhD.
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Right simple pneumothorax with complete lung

collapse
Chest radiograph shows spontaneous, simple right-sided

pneumothorax with complete collapse of the right lung
and asymptomatic, non strangulating, uncomplicated, torsion of the
right upper lobe (arrow) and with only minimal contralateral shift of
the mediastinal structures.
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Left hydropneumothorax in a patient with

metastatic osteogenic sarcoma
Chest radiograph in a young patient with metastatic osteogenic

sarcoma, status post right forequarter amputation and left
spontaneous hydropneumothorax. Multiple bilateral pulmonary
nodules are visible and a left basal gas-liquid level is present (arrow).
Courtesy of Paul Stark, MD.
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Chest radiograph of hydropneumothorax
Chest radiograph shows left-sided hydropneumothorax due to a

bronchopleural fistula in a patient with a chronic empyema and prior known
semi-invasive aspergillosis.
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Chest radiograph of hemopneumothorax due to blunt

trauma
Left panel: Supine chest radiograph shows hyperexpansion of the left

hemithorax with filter effect and veil-like opacification due to dorsal blood
and ventral gas. Right panel: After insertion of chest tubes, the dorsal
component of blood has been drained and only the pneumothorax
remains. The contused lung is too rigid and noncompliant to collapse
completely.
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Simple pneumothorax in patient with lung fibrosis
Chest radiograph in a patient with advanced idiopathic pulmonary

fibrosis and spontaneous right apical pneumothorax (arrow).
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Basal pneumothorax in a supine patient
Bedside, supine chest radiograph demonstrates an atypical right

basal pneumothorax in a patient on mechanical ventilation. Note
right basal pleural adhesion that extends towards the right
hemidiaphragm and is outlined by pneumothorax gas.
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Chest radiograph of bilateral pneumothoraces
Patient with ARDS, increased permeability pulmonary edema, and

barotrauma. Supine chest radiograph shows right subpulmonic and
left apicolateral pneumothorax. Streaky lucencies are permeating
the otherwise consolidated lungs as a reflection of interstitial
pulmonary emphysema. Subcutaneous air is also seen in the right
hemithorax. The patient has a tracheostomy tube in place with a
markedly hyperexpanded cuff, due to tracheomalacia.
ARDS: acute respiratory distress syndrome.
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Deep sulcus sign displaying a pneumothorax in a

supine patient
Bedside supine chest radiograph in a trauma patient with left

pneumothorax and deep sulcus sign. Contusion of the left lung
precludes its complete collapse. Pulmonary edema is visible in the
contralateral right lung.
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Left simple pneumothorax with apical bulla
Chest radiograph shows simple, spontaneous pneumothorax on the

left side. The left lung is completely collapsed (arrow) with an apical
bulla (arrowhead) which may have been the source of the air leak.
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Bullae mimicking pneumothorax
Chest radiograph in a patient with bilateral large upper lobe bullae.

The inferomedial contour of the bullae is concave superolaterally
and allows for differentiation from the straight or convex visceral
pleural lines formed by a pneumothorax.
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Giant bullae mimicking pneumothorax with

compressive atelectasis
Chest radiograph in a patient with bilateral giant upper lobe bullae.

The straight or convex visceral pleural line characteristic of a
pneumothorax is absent. The lower lobes on both sides are
retracted caudad.
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Iatrogenic pneumothorax due to chest tube in bulla
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).
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Skin fold mimicking a left simple pneumothorax
Chest radiograph in a patient with left ventricular failure and

pulmonary edema. The left-sided skin fold that was initially mistaken
for a pneumothorax displays a gradual lateral increase in opacity
with an abrupt drop-off and a dark Mach band as its lateral contour
(arrows) instead of a white visceral pleural line. Note the pulmonary
vascular structures and the lung texture extending beyond the skin
fold. These skin folds can develop when technologists insert the
cassette under a supine patient from the opposite side of the skin
fold and bunch up the skin of the back.
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Skin fold mimicking a right simple pneumothorax
Chest radiograph demonstrates a right skin fold superimposed on

the right lung (arrows). This skin fold shows gradual increase in
opacity towards the periphery with an abrupt drop-off and a black
Mach band. Pulmonary vessels extend beyond the edge of the skin
fold towards the periphery. The skin fold was formed during the
insertion of the cassette from left to right.
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Gastric hernia simulating pneumothorax
Chest radiograph demonstrates a herniated, gas-filled stomach

through a rent in the left hemidiaphragm, mimicking a left-sided
tension pneumothorax.
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Pneumothorax size estimated by the average

intrapleural distance
The schematic diagram details the use of the average intrapleural

distance (in millimeters) to estimate the size of a pneumothorax
from a frontal chest radiograph.
Ptx: pneumothorax.
Courtesy of Helga E Stark, MD, PhD.
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Left simple pneumothorax
Chest radiograph shows left simple pneumothorax with arrows

pointing to the site of measurements in order to estimate the
percentage pneumothorax as the average of the three
measurements in millimeters.
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Chest radiograph and computed tomography of pneumothorax due to Birt-Hog

Dubé syndrome
(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.
CT: computed tomography.
Courtesy of Nestor L Muller, MD, PhD.
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Hydropneumothorax with irregular pleural thickening in a

patient with rheumatoid arthritis
Chest radiograph (A) shows an atypical loculated right pneumothorax with

two separate collections of pleural gas in a patient with known rheumatoid
arthritis. CT thorax image (B) shows chronic right hydropneumothorax with
gas-liquid level due to bronchopleural fistula and irregular visceral and
parietal pleural thickening.
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Bullous lung disease and spontaneous pneumothorax
CT thorax in a patient with severe bullous lung disease and a spontaneous

right-sided pneumothorax.
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Right subcutaneous-pleural fistula
(A) Chest frontal radiograph in a patient who underwent a right lower

lobe lobectomy complicated by a postoperative air leak. A large right
basal hydropneumothorax with gas-liquid level is visible. An additional
pocket of gas with a level is seen in the axillary soft tissues of the right
hemithorax. These findings are suggestive of fistula development
between the pleural space and the nearby subcutaneous tissue.
(B) Axial images from chest computed tomography performed in the

same patient confirms the presence of a large right
hydropneumothorax with a right-sided subcutaneous-pleural fistula
due to a postoperative defect in the right side of the rib cage.

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Left spontaneous pneumothorax on computed tomography
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.
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Chest radiograph of a pneumothorax after stab

wound
This plain chest radiograph shows a left apicolateral pneumothorax

with typical convex white visceral pleural line (yellow arrows).
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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
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Clinical Presentation and Diagnosis of Pneumothorax

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Clinical Presentation and Diagnosis of Pneumothorax

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3/30/23, 5:15 PM 117242

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Clinical presentation and diagnosis of pneumothorax

Gas in the pleural space is termed a pneumothorax. Appropriate treatment of pneumothorax is

Symptoms usually develop when the patient is at rest, although occasionally,

A history of a risk factor or a disorder ( table 1) that can be complicated by

● Physical examination – In patients with a small pneumothorax, physical examination

Electrocardiography — Electrocardiographic findings are also nonspecific and may reveal a

The diagnosis of pneumothorax is a radiologic one. The choice of imaging modality is

Stable patients — Most patients suspected of having a pneumothorax who are

Test performance and interpretation

Pneumothorax appearance and types — Chest radiography (typically performed in the

Several other types of pneumothorax can be appreciated on chest radiography:

● Pneumothorax from nonexpandable lung (also called pneumothorax ex vacuo) –

21]. However, case reports have described bilateral pneumothoraces in patients

Radiologic differential diagnosis — Several conditions can mimic a pneumothorax on

● British Thoracic Society (BTS) guidelines – According to the BTS, a pneumothorax is

millimeters), divided by three to estimate pneumothorax size as a percentage of the

Percent pneumothorax = 100 – [(average lung diameter3/average hemithorax

The presence of a lung point on pleural ultrasonography is diagnostic of pneumothorax

False-positives of pneumothorax can occur with ultrasonography especially in patients with

Imaging of pneumothorax on ultrasonography is discussed in more detail separately. (See

● Chest pain or hemoptysis perimenstrually in a young woman with or without a history of

● A family history of pneumothorax may suggest inheritable disorders such as alpha-1

antitrypsin deficiency" and "Birt-Hogg-Dubé syndrome" and "Clinical manifestations and

● A history of travel (eg, to regions where tuberculosis is endemic) or reason to suspect

● Any lucencies or nodules on chest radiography in a young smoking male or nonsmoking

Chest computed tomography — In the majority of cases, the diagnosis of pneumothorax

Other etiology-specific testing — Additional tests are performed when specific

When infection is suspected, microbiologic, serologic testing, and/or bronchoscopy with

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SUMMARY AND RECOMMENDATIONS

● Clinical presentation – Pneumothorax (gas in the pleural space) should be suspected in

• Laboratory and electrocardiography findings are nonspecific. (See 'Laboratory findings'

● Diagnostic imaging – The diagnosis of pneumothorax is a radiologic one that is mostly

• Bedside pleural ultrasonography (if available) – For patients with suspected

● Investigating the underlying etiology – For many patients with pneumothorax, an

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1. Bense L, Wiman LG, Hedenstierna G. Onset of symptoms in spontaneous pneumothorax:

9. Hata Y, Suzuki T, Yokoi M, et al. Simultaneous bilateral spontaneous pneumothorax with

21. Sakurai H, Hada M, Miyashita Y, et al. Simultaneous bilateral spontaneous pneumothorax

38. Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post-interventional

48. Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography

trauma. Chin J Traumatol 2013; 16:351.

Specific diagnostic or management strategies of pneumothorax

Specific diagnostic or management strategies to be

Primary spontaneous Likely benign course with conservative management; drainage of

COPD Smoking cessation.

CF May consider limited pleurodesis strategies if transplantation

Malignancy Chemotherapeutic agents or radiation may be appropriate.

Infection Antimicrobials are warranted. Pneumothorax may not heal

Cystic lung disorders Investigations or therapies targeted at suspected cause may

Catamenial (endometriosis) Hormonal therapy may be warranted.

Architectural abnormalities May need specific investigations targeted at suspected cause

Iatrogenic Likely benign course (unless patient is mechanically ventilated).

Traumatic May need to co-manage parenchymal trauma and other vascular

Anorexia Nutrition needs to be addressed, PAL may be likely.

Exercise Likely benign course and conservative management with

Illicit drug use Cessation of drug use.

Immunosuppressant drugs Cessation of offending agent, if feasible.

Scuba diving Avoidance of scuba diving until definitive management.