Pediatric Pneumothorax

Etiology: Barotrauma, blunt thoracic trauma
Imaging CXR upright: gravity drops lung inferiorly and medially and shows distinct pleural edge with no lung markings lateral to it
Imaging CXR decubitus: Gravity drops lung inferiorly and shows distinct pleural edge with no lung markings superior to it
Imaging CXR cross-table lateral: Gravity drops lung inferiorly and may show pleural edge with no lung markings anterior to it – but does not tell you which side the pneumothorax is on
Imaging CXR supine: Gravity drops lung posteriorly and usually fails to reveal pleural edge, air accumulates anteromedially so pneumothorax can manifest itself as increased lucency throughout hemithorax or sharp heart border or deep sulcus sign = increased lucency in costophrenic angle or asymmetrical lucency of lungs
Imaging CT: Most sensitive for detection of pneumothorax, useful in patients who can only lie supine, excellent for determining chest tube position
Note: If you suspect small pneumothorax on CXR supine get decubitus image with suspected side up to confirm
Note: Tension pneumothorax is medical emergency and is diagnosed when there is mediastinal shift which implies underlying tension, other findings of tension pneumothorax are flattening of ipsilateral hemidiaphragm and widening of ipsilateral ribs
Note: In bilateral tension pneumothorax look for flattening of both hemidiaphragms and tubularization of heart
Note: Subpulmonic pnemothorax can occur in patients who have prior pulmonary scarring
DDX: Skin fold
Complications: Tension pneumothorax causes torquing of great vessels leading to vascular compromise and therefore requires immediate treatment
Treatment:
Clinical: In premature infant lungs are stiff (noncompliant) so don’t collapse like adult lung

Radiology Cases of Pneumothorax

Radiology Cases of Pneumothorax on Upright CXR

CXR of pneumomediastinum — CXR AP+lateral shows air around the thymus superiorly and air around the heart inferiorly. The diaphragm can be traced continuously across both images. There is also a small amount of air in the apex of the right pleural space.

CXR of pneumothorax — Upright CXR shows a distinct right pleural edge with no lung markings lateral to it and the right lung collapsing inferiorly and medially.

Radiology Cases of Pneumothorax on Decubitus CXR

CXR of pneumothorax — Left lateral decubitus CXR shows a distinct left pleural edge with no lung markings superior to it and the left lung collapsing inferiorly.

CXR of respiratory syncytial virus pneumonia / RSV — CXR AP and lateral (above) shows right upper lobe collapse and air outlining the inferior border of the heart (continuous diaphragm sign). Left lateral decubitus CXR (below) shows a small right pneumothorax.

Radiology Cases of Pneumothorax on Cross-Table Lateral CXR

CXR of pneumothorax — Cross-table lateral CXR shows air collecting anteriorly in the thorax without a clear pleural edge. The thymus is also outlined by air.

Radiology Cases of Pneumothorax on Supine CXR

CXR of tension pneumothorax — AP CXR (above) shows increased lucency in the left hemithorax when compared to the right and a deep sulcus sign is seen. There is mediastinal shift to the right implying underlying tension. Right lateral decubitus CXR (below) shows a clear pleural edge.

CXR of pneumothorax — Supine CXR shows a large amount of air in the right pleural space with inversion of the right hemidiaphragm and mediastinal shift to the left. There is also evidence of pulmonary interstitial emphysema in the right lung.

CXR of pulmonary interstitial emphysema — CXR AP shows a branching bubbly appearance to the right lung and a large amount of air in the right pleural space.

CXR of a pneumothorax and a skin fold simulating a pneumothorax in a patient with respiratory distress syndrome — CXR AP shows a small amount of increased lucency laterally in the right lung base and increased lucency in the left lung apex and base. There is also a straight line running at an angle across the lower lateral left chest.

CXR of small bilateral pneumothoraces in patient with respiratory distress syndrome — CXR AP shows diffuse symmetrical ground glass opacity throughout the lungs along with increased lucency in the right lung base laterally and increased lucency distinctly outlining the left cardiomediastinal silhouette.

CXR of basilar pneumothorax in a patient with respiratory distress syndrome — CXR AP shows a large amount of lucency in the left lung base and over the left hemidiaphragm with a chest tube in the center of it.

CXR of pneumothorax in a patient with respiratory distress syndrome — CXR AP shows symmetrical ground glass appearance to the right lung and increased lucency throughout the left hemithorax with a suggestion of a left pleural edge laterally while the cross-table lateral CXR shows a large amount of lucency anterior to the heart.

CXR of tension pneumothorax in patient with respiratory distress syndrome — CXR AP shows a large amount of lucency in the right pleural space and there is mediastinal shift to the left.

CXR of bilateral tension pneumothoraces in a patient with respiratory distress syndrome — CXR AP shows a large amount of lucency in the lung bases bilaterally while the cardiac silhouette is very narrow and small in size. The mediastinum remains in the midline.

CXR of bilateral tension pneumothoraces and pneumomediastinum — CXR AP shows a large amount of lucency in the pleural spaces laterally and inferiorly to the right lung and superiorly and inferiorly to the left lung. There is air outlining the thymus and in the neck. The mediastinum remains in the midline.

CXR of chest tube malfunction with chest tube in the subcutaneous tissues of the chest wall — CXR AP shows diffuse ground glass opacity throughout the lungs and a large amount of air in the right pleural space causing mediastinal shift to the left while the right-sided chest tube courses through the subcutaneous tissues of the right chest wall and never enters the right pleural space.

CXR of endotracheal tube in the right mainstem bronchus and pneumothorax in a patient with respiratory distress syndrome — CXR AP shows an endotracheal tube with its tip projecting deep within the right mainstem bronchus. There is complete atelectasis of the left lung with no mediastinal shift. There is diffuse lucency in the right hemithorax which is also surrounding the right upper lobe.

CXR of esophageal perforation from nasogastric tube placement — CXR AP shows air outlining the heart in the pericardial space, air outlining the thymus in the mediastinum, and air in the bilateral pleural spaces.

CXR of pneumothorax — Supine CXR shows multiple left-sided rib fractures and the deep sulcus sign which is increased lucency in the left costophrenic angle. No definite pleural edge is seen.

CXR of pneumothorax — Supine CXR shows the left mediastinal and cardiac border is much more sharp in appearance than the right mediastinal and cardiac border.

CXR and CT of pneumothorax and pulmonary contusion and rib fracture — CXR AP shows a widened mediastinum and a small right-sided pneumothorax. Axial CT with contrast of the chest with lung (above) and bone (below) windows shows air in the pleural space anterior to the right lung and fluid in the pleural space posterior to the right lung as well as airspace disease in the right lower lobe and a cortical disruption through one of the right ribs posteriorly.

CXR of tracheobronchial injury of left mainstem bronchus — CXR AP shows air in the superior mediastinum and neck, airspace disease in the left upper lobe, and a small amount of air in the left pleural space.

CT of chest tube malposition with chest tube in the lung parenchyma — Axial and coronal and sagittal CT with contrast of the chest shows a large amount of air in the left pleural space. The left chest tube is clearly located within the air space disease in the posterior left lung parenchyma in all three planes.

AXR of feeding tube in mainstem bronchus, lung and pleural space with tension pneumothorax — AXR obtained immediately after feeding tube placement (left) shows a feeding tube going down the left mainstem bronchus and then turning up into the lung and increased lucency in the left costophrenic angle presumably due to the feeding tube entering the left pleural space. AXR obtained a minute later after feeding tube repositioning (right) shows the tip of the feeding tube in the antrum of the stomach and a large left pleural air collection with mediastinal shift to the right.

Radiology Cases of Tension Pneumothorax

CXR of tension pneumothorax in patient with respiratory distress syndrome — CXR AP shows a large amount of lucency in the right pleural space and there is mediastinal shift to the left.

CXR of pneumothorax — Supine CXR shows a large amount of air in the right pleural space with inversion of the right hemidiaphragm and mediastinal shift to the left. There is also evidence of pulmonary interstitial emphysema in the right lung.

CXR of pneumopericardium and right pulmonary interstitial emphysema which resulted in a right tension pneumothorax — CXR AP at 2 days of age (above) shows air surrounding the heart and not rising above the great vessels. Air is also present in the right pulmonary interstitium in a branching pattern from the hilum to the periphery. CXR AP at 3 days of age (below) shows air no longer surrounding the heart and interval development of a large amount of lucency in the right pleural space with mediastinal shift to the left.

Radiology Cases of Tension Pneumothorax Due to Nasogastric Tube Placement

CXR of nasogastric tube placement into lung resulting in tension pneumothorax — Initial CXR AP (left) shows the course of the nasogastric tube to project over the right lung and the tip of the nasogastric tube projects over the liver and is probably in the right costophrenic sulcus. The remaining tubes and lines are in appropriate position. CXR AP obtained after removal of the nasogastric tube (right) shows a large amount of air in the right pleural space and there is mediastinal shift to the left.

Radiology Cases of Pneumothorax and Pneumoperitoneum

CT of congenital diaphragmatic hernia — CXR (left) shows massive pneumoperitoneum and right pneumothorax which outlines a mass in the lower right chest which is causing mediastinal shift to the left. Coronal CT with contrast of the chest (above right) shows liver herniating through a lateral defect in the diaphragm into the lower right chest and lying above the right diaphragm (below right).

Gross Pathology Cases of Pneumothorax

CXR of chest tube malposition with chest tube in the lung parenchyma — CXR AP (left) shows chronic interstitial fibrosis and scarring in the lungs, a left-sided chest tube, and a moderately-sized basilar left pleural air collection manifesting as a deep sulcus sign. Gross pathological specimen (right) shows the left chest tube entering the upper lobe of the left lung.