J Emerg Trauma Shock. 2012 Jan-Mar; 5(1): 76–81.

doi: 10.4103/0974-2700.93116
PMCID: PMC3299161
PMID: 22416161

Sonographic diagnosis of pneumothorax

Lubna F Husain, Laura Hagopian, Derek Wayman, William E
Baker, and Kristin A Carmody

Author information Article notes Copyright and License

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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.
Keywords: Emergency medicine, pneumothorax, diagnosis, thoracic
ultrasonography
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INTRODUCTION

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 sonographic
artifacts created by the interplay of air and fluid 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]

The diagnosis of a pneumothorax is usually made with a

combination of clinical signs and symptoms, which may be subtle,
and plain chest radiography. Regardless of its presentation, the early
detection and treatment of a pneumothorax is critical. Small- (10%
or less) or medium (11 to 40%)-sized pneumothoraces are generally
not life-threatening and their management varies.[3–5] However, a
delay in the diagnosis and treatment, especially in those 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.’

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’ body
[Figures [Figures2a2a and and2b2b].[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.

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
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

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]

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’
‘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 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
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]
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

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 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
with the presence of ‘A-lines’, the sensitivity and specificity for an
occult pneumothorax is as high as 95 and 94%, respectively.[24]
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

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]

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

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 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]

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

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]
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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.
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Footnotes

Source of Support: Nil.

Conflict of Interest: None declared.

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