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Dr. Adrian Tangkilisan, Sp.BTKV

• Pleural ultrasonography (PU) is more sensitive
than chest radiograph (CXR) for diagnosing
pneumothorax and could be useful for
detecting resolution of pneumothorax after
drainage. The aim of this prospective double-
blind observational study was to assess PU
accuracy during pneumothorax follow-up after
• All patients hospitalized with pneumothorax
requiring drainage were eligible. After
drainage, residual pneumothorax was assessed
by CXR and PU
– 24 h after bubbling in the aspiration device had
– 6 h after clamping the pleural catheter, and
– 6 h after removing the pleural catheter.
Pneumothorax indicated by PU but not CXR was
confirmed by CT scan or by aspiration of 10 mL of air.
• Forty-four unilateral pneumothoraces were studied
(primary spontaneous: 70.5%), and 162 pairs of
examinations (CXR and PU) were performed.
Twenty residual pneumothoraces were
detected by both CXR and PU. Furthermore, PU
suspected 14 pneumothoraces that were not
identified by CXR; 13 were confirmed. All of these
pneumothoraces resulted in therapeutic
• Thus, 39% (13/33) of the confirmed residual
pneumothoraces were missed by CXR. In
patients with primary spontaneous
pneumothorax, the positive predictive value
of PU for residual pneumothorax diagnosis
was 100%; for other pneumothoraces, this
value ranged from 90% in the
absence of a lung point to 100% when a lung
point was observed. PU results were
obtained faster than results from CXR (35
34 min vs 71 56 min, P <0001).
• The accuracy of PU is excellent for detecting
residual pneumothorax during pneumothorax
follow-up after drainage.

CHEST 2010; 138(3):648–655

• Chest CT scan is the most accurate way to diagnose
pneumothorax, Conversely, chest radiographs (CXR) miss
30% to 72% of pneumothoraces because of their anterior
location. However, half of these can be with tension.
• Most physicians perform CXR several hours after stopping
the suction device before removing chest tube.
• Despite these precautions, pneumothorax frequently recurs
after clamping or removing the chest tube. Some of these
may be due to residual pneumothorax present before
clamping or removing the chest tube but missed by CXR.
• Lichtenstein et al reported that PU detects all
pneumothoraces in ICU patients, including those
not identified by CXR
• Thus, use of PU rather than CXR for detecting
residual pneumothorax after drainage could
detect more pneumothorax recurrences, save
time, and decrease costs and radiation exposure
• The purpose of this study was to evaluate PU
accuracy in diagnosing residual pneumothorax
after chest tube insertion.
• November 2007 and May 2009 four-bed
intermediate care unit that houses all patients
with pneumothorax requiring drainage in our
tertiary teaching hospital.
• Exclusion criteria were as follows:
– (1) the absence of visualization of the pleural line
on PU because of subcutaneous emphysema,
– (2) use of mechanical ventilation because of
decreased PU specificity.
• End points included the following:
– (1) the number of residual pneumothoraces
diagnosed by PU, including those not identified by
– (2) the therapeutic impact of PU use;
– (3) the time to obtain CXR and PU results;
– (4) the residents learning curve for using PU.
• The success rate for primary spontaneous pneumothorax
is generally better than for other types of pneumothorax.
Thus, pneumothoraces were analyzed according to their
• All pneumothoraces were drained using a
dedicated device, Pleurocath 8 French (Plastimed
division, Prodimed; St-Leu-la- Forêt, France), that
was connected to a one-bottle water seal vacuum
system regulated to generate a depressurization
of 30 cm H 2 O. Nurses assessed pleural catheter
patency every 4 h using 5 mL of saline and noted
whether bubbles were present in the aspiration
device (patients were asked to cough if
• Ultrasound diagnosis of pneumothorax relies
on three signs:
– abolition of lung sliding, the A-line sign, and the
lung point. Before drainage, sensitivity and specifi
city of the abolition of lung sliding are 100% and
91%, respectively

• The A-line sign is defined as the presence of A-

lines without B-lines
• Before drainage, the sensitivity of the A-line sign
is 100%, and its specifcity is 60%. The presence of
B-lines rules out pneumothorax diagnosis.
• The lung point is detected while the probe is
stationary: there is lung sliding during inspiration
(when the lung contacts the wall) that disappears
during expiration (when the lung is not in contact
with the wall). Before drainage, its sensitivity for
diagnosis of pneumothorax is 66%; sensitivity
increases to 79% for pneumothoraces missed by
CXR, 13 whereas its specificity is 100%
( A ) Assessment of lung
sliding on PU in two-
mode. The pleural line is
seen between two ribs. Lung
sliding is abolished when
both the parietal and visceral
pleura do not slide while the
patient is breathing.
B ) Assessment of lung
sliding on PU in time-motion
mode on a patient without
Lung sliding generates a
granular pattern under the
pleural line. Subcutaneous
tissue over the pleural line
does not
move while the patient is
breathing, generating
horizontal lines
C ) Detection of abolition of
lung sliding on PU in time-
motion mode in a patient with
pneumothorax. While the
patient is breathing, the
(normal) granular pattern
under the pleural line is
replaced by horizontal lines,
indicating abolition of lung
A ) The presence of vertical linear artifacts arising from the
pleural line (B-lines or comet-tail artifacts) rules out pneumothorax
in this patient with interstitial syndrome.
B ) The A-line sign: The presence of linear horizontal artifacts at regular intervals
below the pleural line (A-lines) without B-lines. The A-line sign is
part of the ultrasound semiology of the normal lung and pneumothorax.
The Learning Curve for PU Detection of
• Each PU was also performed by one of the ICU
residents, who received 2 h of training that
focused on ultrasonographic diagnosis of
• The Student t test was used to compare how long
it took to obtain results from CXR vs PU.
• Lung point incidence for pneumothoraces
(whether apparent on CXR or not) was compared
using Fisher exact test.
• The residents’ learning curve was determined by
comparing the PU results (% agreement)
obtained by the residents and the primary
investigator. The diagnostic agreement between
the primary investigator and the residents was
assessed by the k coefficient
• Fifty-one patients admitted between November
2007 and May 2009 had pneumothorax requiring
drainage. Five patients were excluded because
they were on mechanical ventilation, and two
were excluded because of important
subcutaneous emphysema that impaired pleural
line visualization on PU. The final analysis
included 44 patients with unilateral
pneumothorax (mean age, 37.5 15.0 years; men,
n =31 [70.5%]).
• Pneumothorax cause was as follows: primary
spontaneous (n=31, 70.5%), traumatic (n=7,
15.9%), secondary to pulmonary emphysema
(n=4, 9.1%), and iatrogenic after placement of
a central venous catheter (n=2, 4.5%).
• Thirty-seven patients were treated
successfully by pleural catheter, whereas
seven patients (15.9%) required surgical
Detection of Residual Pneumothorax
• A total of 162 CXR and PU examinations were
performed during the follow-up of 44
pneumothoraces. CXRs revealed 20 residual
pneumothoraces in 14 patients; all 20 were
also detected by PU. Furthermore, PU
identified 14 suspected pneumothoraces that
were missed by CXR, and and 13 of these were
confirmed in nine patients by CT scan (n =5) or
air aspiration (n=8).
• During follow-up of the 31 primary
spontaneous pneumothoraces, 117 CXR and
PU examinations were performed. The eight
pneumothoraces suspected by PU but not
identified by CXR were all confirmed (six by air
aspiration, two by CT scan).
• The PPV of PU for diagnosing residual
pneumothorax after drainage of primary
spontaneous pneumothorax was 100%.
Time to Obtain CXR and PU Results
• Results of PU were obtained after 35 34 min
whereas results of CXR were obtained after 71
56 min.
• This difference was signifi cant ( P <0.001).
• This is the first study to our knowledge to show that PU is
better than CXR for detecting residual pneumothoraces
after drainage and that 39% of them were not identified by
CXR. PU are obtained more rapidly than results of CXR. the
learning curve showed that naïve residents were able to
perform reliable PU after 2 h of training.
• The lung point is an inconstant sign, but has a specificity of
100% for pneumothorax diagnosis. The fact that the PPV of
PU was still perfect (100%) .
• suggests that PU should be used instead of CXR to assess
the resolution of primary spontaneous pneumothoraces.
• Like every ultrasound examination, the quality of
PU examination results depends to some extent
on the person conducting the examination. The
learning curve of ICU residents in this study
showed that the residents’ results were reliable
after 2 h of training. These results confirm that
for PU, as for echocardiography 41 and general
ultrasonography, 42 training for nonradiologist
physicians is simple and does not take a long
• This study showed that PU diagnostic
performance was excellent for pneumothorax
follow-up after drainage. PU offered several
advantages over CXR, PU diagnosed all
residual pneumothoraces, many of which
were not identified by CXR; PU led to extra
therapeutic interventions; PU gave faster
results than CXR; and PU was performed
competently by naïve physicians after a brief
(2-h) training session.