What are limitations of chest radiographs in the evaluation of pneumothorax?

Updated: Apr 28, 2020
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Chest radiographs may fail to reveal pneumothorax or radiologists or interpreting physicians may fail to recognize the presence of the pneumothorax. Other disadvantages are as follows:

  • In patients with underlying pulmonary disease, the classic visceral pleural line may be harder to detect, because the lung is hyperlucent, and little difference exists in the radiographic density between the pneumothorax and the emphysematous lung
  • A vertical skin line can be mistaken for a pneumothorax, leading to unnecessary and possibly harmful therapy
  • Large bulla can simulate pneumothorax on chest radiographs, so that CT may be required to clarify the diagnosis.
  • Occasionally, skin folds, the scapula, and bed sheets can mimic the pleural line, falsely suggesting pneumothorax on the chest radiograph; unlike pneumothoraces, skin folds usually continue beyond the chest wall, and lung markings can be seen peripheral to the skin fold line; viewing the film under the hot lamp may be necessary to discern obscure peripheral lung markings

As ultrasonography becomes increasingly available in emergency situations, the already limited role of radiography in tension pneumothorax will be further minimized. Multiple recent studies have shown bedside ultrasonography to be more accurate than supine chest radiography in detecting and quantifying the presence of pneumothorax, including traumatic pneumothorax.

Go to Radiologic Diagnosis of Pneumothorax for complete information on this topic.

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