Pneumothorax
Daniel J. Podberesky, MD
DIFFERENTIAL DIAGNOSIS
Common
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Pulmonary Hypoplasia
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Surfactant Deficiency Disease
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Meconium Aspiration Syndrome
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Pulmonary Interstitial Emphysema
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Asthma
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Cystic Fibrosis, Lung
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Iatrogenic
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Spontaneous
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Trauma
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Skin Fold (Mimic)
Less Common
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Langerhans Cell Histiocytosis
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Tuberous Sclerosis Complex
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Ruptured Bulla/Blebs
Rare but Important
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Metastatic Neoplasm
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Infection
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Marfan Syndrome
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Ehlers-Danlos Syndrome
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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History is extremely helpful in determining possible source of pneumothorax
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Is there history of trauma? asthma? recent instrumentation?
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Appearance of pneumothorax depends on position of patient and amount of pleural gas
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In supine patient, air collects anteromedially
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Sharp, well-delineated cardiac and mediastinal borders
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In upright patient, air collects laterally and apically
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Radiolucent space lacking pulmonary vascular markings
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White pleural line visible
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Size of pneumothorax difficult to accurately estimate on chest x-ray
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Signs of tension pneumothorax
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Depressed/inverted hemidiaphragm
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Contralateral shift of mediastinum
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Expansion of spaces between ribs
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Expiratory, decubitus, and cross-table lateral views may all aid in diagnosis in equivocal cases
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Skin folds and pneumomediastinum can mimic pneumothorax
Helpful Clues for Common Diagnoses
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Pulmonary Hypoplasia
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Potter syndrome
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Oligohydramnios related to fetal urinary system problems
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Resultant pulmonary aplasia and typical abnormal facies
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Pneumothorax may result from progressive air leaks &/or mechanical ventilation
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Surfactant Deficiency Disease
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Premature neonates
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Reticulogranular opacities
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Air leak from alveolar rupture can lead to pneumothorax
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Meconium Aspiration Syndrome
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History of meconium-stained amniotic fluid helpful
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Coarse interstitial and patchy opacities
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Hyperinflation
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Pneumothorax may result from air-trapping and alveolar rupture
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Pulmonary Interstitial Emphysema
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Premature neonates
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Barotrauma from mechanical ventilation
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Reticular and cystic opacities
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Alveolar rupture results in pneumothorax
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Asthma
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Airway narrowing and mucous plugging leads to air-trapping and alveolar rupture
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History of asthma exacerbation helpful
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Hyperinflated lungs
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Cystic Fibrosis, Lung
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Chronic lung disease can lead to airway obstruction and alveolar rupture
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Superimposed infection increases pneumothorax risk
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Pneumothorax indicates poor prognosis
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Bronchiectasis, bronchial wall thickening, mucus plugging, hyperinflation, prominent hila
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Iatrogenic
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Mechanical ventilation
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Instrumentation, such as central line placement or thoracentesis
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Postoperative patients
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History helpful
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Spontaneous
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Diagnosis of exclusion
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No distinguishing radiologic features
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Trauma
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Pneumothorax may result from acute blunt or penetrating trauma
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May also result from rupture of pneumatocele from old trauma
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Motor vehicle crashes, falls, sports injuries
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Other signs of trauma
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Fractures
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Pulmonary contusions
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Mediastinal injuries
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Pleural effusions
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Skin Fold (Mimic)
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Frequently seen in neonates in NICU
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Can be difficult to differentiate from pneumothorax
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Linear interface with Mach line
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No white pleural line
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Consider decubitus or cross-table lateral views in equivocal cases
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Helpful Clues for Less Common Diagnoses
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Langerhans Cell Histiocytosis
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Small pulmonary nodules and parenchymal lung cysts
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Apical reticulonodular pattern
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Lung cysts may rupture and result in pneumothorax
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Tuberous Sclerosis Complex
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Lymphangioleiomyomatosis
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Small parenchymal cysts
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Chylous pleural effusion
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Pneumothorax in ˜ 70%
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Ruptured Bulla/Blebs
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Small pleural blebs and parenchymal bulla may spontaneously rupture and lead to pneumothorax
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CT can be very helpful in these cases
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Helpful Clues for Rare Diagnoses
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Metastatic Neoplasm
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Pneumothorax may occur in presence of metastases, especially when present on pleural surface
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Seen in children with osteosarcoma and Wilms tumor
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Infection
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Any infection that causes alveolar destruction can lead to pneumothorax
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Particularly seen with tuberculosis and Pneumocystis infection
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Marfan Syndrome
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Autosomal dominant connective tissue disorder
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At risk for spontaneous pneumothorax
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Look for associated findings
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Aortic aneurysms
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Kyphoscoliosis
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Arachnodactyly
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Ehlers-Danlos Syndrome
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Connective tissue disorder
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At risk for spontaneous pneumothorax
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Image Gallery
![]() (Left) Frontal radiograph shows bilateral pneumothoraces in this neonate with meconium aspiration. Note the bilateral, coarse, interstitial lung opacities. The left pneumothorax is loculated
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