Log in | Register

Sonographic diagnosis of pneumothorax

Giovanni Volpicelli
Review
Volume 37, Issue 2 / February , 2011

Pages 224 - 232

Abstract

Purpose

Over the last decade, the use of ultrasound as a technique to look for pneumothorax has rapidly evolved. This review aims to analyze and synthesize current knowledge on lung ultrasound targeted at the diagnosis of pneumothorax. The technique and its usefulness in different scenarios are explained, and its merits over conventional radiology are highlighted.

Methods

A systematic literature search (1995–2010) was performed, involving PubMed, to describe the more recent scientific evidence on the topic. Moreover, this review is also a synopsis of experts’ opinion and personal clinical experience.

Results and conclusions

Ultrasound diagnosis of pneumothorax relies on the recognition of four sonographic artifact signs: the lung sliding, the B lines, the lung point, and the lung pulse. Combining these few signs, it is possible to accurately rule in or rule out pneumothorax at the bedside in several different clinical scenarios. Sensitivity of a lung ultrasound in the detection of pneumothorax is higher than that of conventional anterior–posterior chest radiography, and similar to that of computerized tomography. A major benefit of a lung ultrasound is that it can be used quickly to diagnose pneumothorax at the bedside in any critical situation, like cardiac arrest and hemodynamically unstable patients. Moreover, it can be used to detect radio-occult pneumothorax and to quantify the extension of the air layer. Advantages in terms of reduced complexity, feasibility at the bedside, and absence of exposure to ionizing radiation make lung ultrasound the method of choice in several common clinical situations.

Keywords

References

  1. Lichtenstein DA (2007) Ultrasound in the management of thoracic disease. Crit Care Med 35:S250–S261
    • View reference on publisher's website
    • View reference on PubMed
  2. Bouhemad B, Zhang M, Lu Q, Rouby JJ (2007) Clinical review: bedside lung ultrasound in critical care practice. Crit Care 11:205
    • View reference on publisher's website
    • View reference on PubMed
  3. Reissig A, Gorg C, Mathis G (2009) Transthoracic sonography in the diagnosis of pulmonary diseases. Ultraschall Med 30:438–458
    • View reference on publisher's website
    • View reference on PubMed
  4. Volpicelli G, Cardinale L, Garofalo G, Veltri A (2008) Usefulness of lung ultrasound in the bedside distinction between pulmonary edema and exacerbation of COPD. Emerg Radiol 15:145–151
    • View reference on publisher's website
    • View reference on PubMed
  5. Volpicelli G, Silva F, Radeos M (2010) Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department. Eur J Emerg Med 17:63–72
    • View reference on publisher's website
    • View reference on PubMed
  6. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ (2004) Comparative diagnostic performances of auscultation, chest radiography and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 100:9–15
    • View reference on publisher's website
    • View reference on PubMed
  7. Soldati G, Testa A, Pignataro G, Portale G, Biasucci DG, Leone A, Gentiloni Silveri N (2006) The ultrasonographic deep sulcus sign in traumatic pneumothorax. Ultrasound Med Biol 32:1157–1163
    • View reference on publisher's website
    • View reference on PubMed
  8. Ball CG, Kirkpatrick AW, Laupland KB et al (2005) Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces. Am J Surg 189:541–546
    • View reference on publisher's website
    • View reference on PubMed
  9. Tocino IM, Miller MH, Fairfax WR (1985) Distribution of pneumothorax in the supine and semi-recumbent critically ill adult. AJR Am J Roentgenol 144:901–905
    • View reference on PubMed
  10. Lichtenstein DA, Menu Y (1995) A bedside ultrasound sign ruling-out pneumothorax in the critically ill. Lung sliding. Chest 108:1345–1348
    • View reference on publisher's website
    • View reference on PubMed
  11. Noble VE, Lamhaut L, Capp R, Bosson N, Liteplo A, Marx JS, Carli P (2009) Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers. BMC Med Educ 9:3
    • View reference on publisher's website
    • View reference on PubMed
  12. Monti JD, Younggren B, Blankenship R (2009) Ultrasound detection of pneumothorax with minimally trained sonographers: a preliminary study. J Spec Oper Med 9:43–46
    • View reference on PubMed
  13. Cunningham J, Kirpatrick AW, Nicolaou S, Liu D, Hamilton DR, Lawless B, Lee M, Brown DR, Simons RK (2002) Enhanced recognition of lung sliding with power color Doppler imaging in the diagnosis of pneumothorax. J Trauma 52:769–771
    • View reference on publisher's website
    • View reference on PubMed
  14. Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, Hameed SM, Brown R, Simons R, Dulchavsky SA, Hamiilton DR, Nicolaou S (2004) Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST). J Trauma 57:288–295
    • View reference on publisher's website
    • View reference on PubMed
  15. Lichtenstein DA, Lascols N, Prin S, Mezière G (2003) The lung pulse: an early ultrasound sign of complete atelectasis. Intensive Care Med 29:2187–2192
  16. Lichtenstein DA, Mezière G, Biderman P, Gepner A (2000) The lung point: an ultrasound sign specific to pneumothorax. Intensive Care Med 26:1434–1440
  17. Lichtenstein DA, Mezière GA (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 134:117–125
    • View reference on publisher's website
    • View reference on PubMed
  18. Lichtenstein DA, Mezière G, Lascols N, Biderman P, Courret JP, Gepner A, Goldstein I, Tenoudji-Cohen M (2005) Ultrasound diagnosis of occult pneumothorax. Crit Care Med 33:1231–1238
    • View reference on publisher's website
    • View reference on PubMed
  19. Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, Fava C, Frascisco M (2006) Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med 24:689–696
    • View reference on publisher's website
    • View reference on PubMed
  20. Reissig A, Kroegel C (2003) Transthoracic sonography of diffuse parenchymal lung disease. The role of comet tail artifacts. J Ultrasound Med 22:173–180
    • View reference on PubMed
  21. Soldati G, Copetti R, Sher S (2009) Sonographic interstitial syndrome. The sound of lung water. J Ultrasound Med 28:163–174
    • View reference on PubMed
  22. Agricola E, Bove T, Oppizzi M, Marino G, Zangrillo A, Margonato A, Picano E (2005) Ultrasound comet-tail images: a marker of pulmonary edema. A comparative study with wedge pressure and extravascular lung water. Chest 127:1690–1695
    • View reference on publisher's website
    • View reference on PubMed
  23. Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJR, Liteplo A (2009) Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. Chest 135:1433–1439
    • View reference on publisher's website
    • View reference on PubMed
  24. Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF (2008) Bedside ultrasound for the monitoring of acute decompensated heart failure. Am J Emerg Med 26:585–591
    • View reference on publisher's website
    • View reference on PubMed
  25. Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF (2008) Detection of sonographic B-lines in patients with normal lung or radiographic alveolar consolidation. Med Sci Monit 14:CR122–CR128
    • View reference on PubMed
  26. Lichtenstein D, Meziere G, Biderman P, Gepner A (1999) The comet-tail artifact, an ultrasound sign ruling out pneumothorax. Intensive Care Med 25:383–388
  27. Chun R, Kirkpatrick AW, Sirois M, Sargasyn AE, Melton S, Hamilton DR, Dulchavsky S (2004) Where’s the tube? Evaluation of hand-held ultrasound in confirming endotracheal tube placement. Prehosp Disast Med 19:366–369
  28. Blaivas M, Lyon M, Duggal S (2005) A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 12:844–849
    • View reference on publisher's website
    • View reference on PubMed
  29. Zhang M, Liu ZH, Yang JX, Gan JX, Xu SW, You XD, Giang GY (2006) Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma. Crit Care 10:R112
    • View reference on publisher's website
    • View reference on PubMed
  30. Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Gentiloni Silveri N (2008) Occult traumatic pneumothorax. Diagnostic accuracy of ultrasonography in the emergency department. Chest 133:204–211
    • View reference on publisher's website
    • View reference on PubMed
  31. Volpicelli G (2010) Usefulness of emergency ultrasound in non traumatic cardiac arrest. Am J Emerg Med. doi: 10.1016/j.ajem.2009.03.018
  32. Niendorff DF, Rassias AJ, Palac R, Beach ML, Costa S, Greenberg M (2005) Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers. Resuscitation 67:81–87
    • View reference on publisher's website
    • View reference on PubMed
  33. Breitkreutz R, Walcher F, Seeger FH (2007) Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm. Crit Care Med 35(5 Suppl):S150–S161
    • View reference on publisher's website
    • View reference on PubMed
  34. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J (2008) CAUSE: cardiac arrest ultra-sound exam—a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 76:198–206
    • View reference on publisher's website
    • View reference on PubMed
  35. Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ (2005) Value of high-resolution ultrasound in detecting a pneumothorax. Eur Radiol 15:930–935
    • View reference on publisher's website
    • View reference on PubMed
  36. Garofalo G, Busso M, Perotto F, De Pascale A, Fava C (2006) Ultrasound diagnosis of pneumothorax. Radiol Med 111:516–525
    • View reference on publisher's website
    • View reference on PubMed
  37. Reissig A, Kroegel C (2005) Accuracy of transthoracic sonography in excluding post-interventional pneumothorax and hydropneumothorax. Comparison to chest radiography. Eur J Radiol 53:463–470
    • View reference on PubMed
  38. Rowan KR, Kirkpatick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S (2002) Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT: initial experience. Radiology 225:210–214
    • View reference on publisher's website
    • View reference on PubMed
  39. Sartori S, Tombesi P, Trevisani L, Nielsen I, Tassinari D, Abbasciano V (2007) Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography. AJR Am J Roentgenol 188:37–41
    • View reference on publisher's website
    • View reference on PubMed
  40. Gobien RP, Reines HD, Schabel SI (1982) Localized tension pneumothorax: unrecognized form of barotrauma in ARDS. Radiology 142:15–19
    • View reference on PubMed
  41. Hill SL, Edmisten T, Holtzman G, Wright A (1999) The occult pneumothorax: an increasing diagnostic entity in trauma. Am Surg 65:254–258
    • View reference on PubMed
  42. Ball CG, Kirkpatrick AW, Feliciano DV (2009) The occult pneumothorax: what have we learned? Can J Surg 52:E173–E179
    • View reference on PubMed
  43. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA (2001) Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 119:590–602
    • View reference on publisher's website
    • View reference on PubMed
  44. Henry M, Arnold T, Harvey J (2003) BTS guidelines for the management of spontaneous pneumothorax. Thorax 58(Suppl II):ii39–ii52
    • View reference on PubMed
  45. De Leyn P, Lismonde M, Ninana V, Noppen M, Slabbynck H, Van Meerhaeghe A, Van Schil P, Vermassen F (2005) Guidelines Belgian Society of Pulmonology. Guidelines on the management of spontaneous pneumothorax. Acta Chir Belg 105:265–267
    • View reference on PubMed
  46. Baumann MH, Noppen M (2004) Pneumothorax. Respirology 9:157–164
    • View reference on publisher's website
    • View reference on PubMed
  47. Engdahl O, Toft T, Boe J (1993) Chest radiograph: a poor method for determining the size of a pneumothorax. Chest 103:26–29
    • View reference on publisher's website
    • View reference on PubMed
  48. Dulchavsky SA, Schwarz KL, Kirkpatrick AW, Billica RD, Williams DR, Diebel NL, Campbell MR, Sargysan AE, Hamilton DR (2001) Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 50:201–205
    • View reference on publisher's website
    • View reference on PubMed
  49. Kirkpatrick AW, Nicolau S, Rowan K, Liu D, Cunningham J, Sargsyan AE, Hamilton D, Dulchavsky SA (2005) Thoracic sonography for pneumothorax: the clinical evaluation of an operational space medicine spin-off. Acta Astronaut 56:831–838
    • View reference on publisher's website
    • View reference on PubMed
  50. Volpicelli G (2008) Towards an appropriate use of ultrasound in resuscitation. Resuscitation 79:341–342
    • View reference on publisher's website
    • View reference on PubMed
  51. Volpicelli G, Audino B (2010) The double lung point: an unusual sonographic sign of juvenile spontaneous pneumothorax. Am J Emerg Med. doi: 10.1016/j.ajem.2010.03.020
  52. Soldati G, Sher S, Copetti R (2010) If you see the contusion, there is no pneumothorax. Am J Emerg Med 28:106–107
    • View reference on publisher's website
    • View reference on PubMed

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement