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Small pneumothoraces are often not visible on supine screening chest radiographs because they develop anteriorly
to the lung. These pneumothoraces are termed occult. Occult pneumothoraces account for an astonishingly high
52% to 63% of all traumatic pneumothoraces. A 19-year-old obese woman was involved in a head-on car accident.
The admission anteroposterior chest radiographs were unremarkable. Because of the presence of right chest
tenderness and an abrasion, we suspected the presence of a pneumothorax. Thus, we decided to take a supine
oblique chest radiograph of the right side of the thorax, which clearly revealed a visceral pleural line, consistent
with a diagnosis of traumatic pneumothorax. A pneumothorax may be present when a supine chest radiograph
reveals either an apparent deepening of the costophrenic angle (the deep sulcus sign) or the presence of 2
diaphragm-lung interfaces (the double diaphragm sign). However, in practice, supine chest radiographs have poor
sensitivity for occult pneumothoraces. Oblique chest radiograph is a useful and fast screening tool that should be
considered for cases of blunt chest trauma, especially when transport of critically ill patients to the computed
tomographic suite is dangerous or when imminent transfer to another hospital is being arranged and early
diagnosis of an occult pneumothorax is essential. [Ann Emerg Med. 2011;57:378-381.]
Figure. A, We created this method to detect occult pneumothoraces by supine oblique chest radiography without the need
for a CT scan. OPX, Occult pneumothorax. B, Anteroposterior supine radiograph shows no abnormality. Indeed, a left-sided
pneumothorax appears unlikely. C, Oblique supine chest radiograph on the right side clearly reveals a distinct visceral
pleural line (arrowheads). D, CT scan proves the existence of an occult pneumothorax on the right side. The pneumothorax
size is about 19% of the pleural cavity. E, Supine oblique chest radiographs are easily performed in our trauma
resuscitation area.
the right side of the thorax, clearly revealing a visceral pleural DISCUSSION
line, which allowed us to make a diagnosis of traumatic The most common intrathoracic injury after a blunt trauma
pneumothorax (Figure, C). is a pneumothorax, which is caused by air being trapped within
Because this was our first experience with this technique (Figure,
the pleural space. Occult pneumothoraces account for a high
E), we confirmed the pneumothorax by CT scan of the chest,
percentage of traumatic pneumothoraces. Detecting a small
which clearly revealed the anterior pneumothorax with lung
pneumothorax by clinical examination or with a supine
contusions and rib fractures. The pneumothorax was limited to the
anterior pleural cavity. The air pocket was almost 2.5 cm thick on anteroposterior chest radiograph is difficult.3 The sensitivity and
the greatest CT slice (Figure, D). The patient had stable vital signs specificity of supine chest radiographs are 12% to 24% and
and needed no positive-pressure ventilation, so we chose not to 89% to 100%, respectively.8 Free air in the pleural space usually
perform a thoracostomy. The patient was admitted to the ICU for migrates to the most nondependent portion. In an upright
observation and monitoring. A follow-up anteroposterior chest patient, a pneumothorax is usually most visible at the apex of
radiograph on the following day revealed an obvious the chest. Erect chest radiographs are superior to supine chest
pneumothorax. We concluded that the pneumothorax had radiographs for detecting pneumothoraces, with sensitivities of
progressed and thus inserted a chest tube. 92% and 50%, respectively.9 In addition, MacEwan et al10
reported the use of a lateral decubitus radiograph for a supine pleural motion (lung sliding). Kirkpatrick et al5 reported that
pneumothorax.10 However, most trauma victims must remain the extended focused assessment with sonography for trauma
in a supine position because of fear of spinal cord injury or is useful for the detection of occult pneumothoraces. We
pelvic fracture. The utility of a supine oblique radiograph was agree that ultrasonography is useful for detecting
discussed by Galanski et al,11 who argued that this technique pneumothoraces, used in conjunction with focused
offers the advantage of not needing to turn critically ill patients. assessment with sonography for trauma directed solely at
In our literature search, we were unable to find a identifying the presence of free intraperitoneal or pericardial
thorough comparison of the merits of upright, decubitus, or fluid. But potential impediments to ultrasonography are
oblique chest radiograph for detecting traumatic pleural adhesions, thoracic skin defects, and emphysematous
pneumothoraces. In a supine patient, the anterior, inferior, bullae.15 Furthermore, ultrasonography is operator
and medial portions of the pleural space are the most dependent. Moreover, ultrasonography is difficult for obese
nondependent; free pleural air is directly positioned over the patients such as the present patient. In cases such as these,
aerated lung. The incident radiographic beam of an diagnosis by oblique chest radiograph is simpler and easier.
anteroposterior radiograph is vertical, not parallel to the That said, we are not proposing oblique chest radiograph as a
visceral pleura, which is the boundary between the replacement for ultrasonography. Rather, oblique chest
pneumothorax and the underlying lung. Thus, the boundary radiograph may be used alongside other techniques or alone
line of an occult pneumothorax cannot be seen on an when there are no other methods available.
anteroposterior radiograph. A supine oblique chest In recent years, CT has gained importance in the early
radiograph may therefore be a useful method for detecting diagnostic phase of trauma care. For many institutions, it has
occult pneumothoraces. become an essential part of the imaging of severe trauma
It is thought that a pneumothorax may be suspected when a patients who are at risk for occult pneumothoraces.
supine chest radiograph reveals an apparent deepening of the However, critical patients in severe shock are difficult to
costophrenic angle (the deep sulcus sign) or the presence of 2 transport to the CT suite, and many hospitals in developing
diaphragm-lung interfaces (the double diaphragm sign). countries do not have access to CT. Thus, we think this is a
However, chest radiographs have a poor sensitivity (12% to valuable and novel technique.
24%) for the detection of occult pneumothoraces, and they We conclude that oblique chest radiograph is an additional
have poor interobserver agreement.8 useful and fast screening tool to be considered in blunt chest
Because supine chest radiographs have poor sensitivity for trauma, especially when transport of critically ill patients to the
detecting occult pneumothoraces, it is important to find a CT suite is dangerous or when imminent transfer to another
more sensitive technique. Ball et al12 reported that hospital is being arranged and early diagnosis of an occult
subcutaneous emphysema, pulmonary contusions, and rib pneumothorax is essential.
fractures are clinical risk factors for the presence of an occult
pneumothorax.12 Misthos et al13 also observed that
Supervising editor: Amy H. Kaji, MD, PhD
associated chest wall muscle contusions are present in 79% of
patients with occult pneumothoraces.13 Thus, in cases in Funding and support: By Annals policy, all authors are required
which there are certain clinical markets but no evidence of a to disclose any and all commercial, financial, and other
pneumothorax on a supine chest radiograph, an oblique relationships in any way related to the subject of this article
that might create any potential conflict of interest. The authors
chest radiograph may be a useful technique for detecting an
have stated that no such relationships exist. See the
occult pneumothorax.
Manuscript Submission Agreement in this issue for examples
In the present case, there were no suspicious signs on the of specific conflicts covered by this statement.
initial radiograph (Figure, B) and there was no consensus
among our team after the physical examination. In this case, Publication dates: Received for publication March 27, 2010.
the oblique chest radiograph revealed an occult Revisions received July 29, 2010, and August 2, 2010.
pneumothorax that was limited to the anterior pleural cavity. Accepted for publication August 6, 2010. Available online
September 22, 2010.
The air pocket was almost 2.5 cm on CT. It may be difficult
to detect extremely small pneumothoraces with this Presented at 13th International Conference on Emergency
technique; however, the true utility of this technique will Medicine, June 2010.
have to be confirmed in future studies. Reprints not available from the authors.
Several authors have reported that ultrasonography is a
useful way to detect pneumothoraces.5,14,15 The diagnostic Address for correspondence: Shokei Matsumoto, MD,
sensitivity and specificity of this technique for detecting Department of Trauma and Emergency Surgery, Saiseikai
Yokohama-shi Tobu Hospital, 3-6-1 Shimosueyoshi Tsurumi-ku
pneumothoraces range from 58.9% to 100% and 94% to
Yokohama-shi, Kanagawa 230-0012, Japan; 81-45-576-3000,
100%, respectively.5,14,15 The ultrasonographic diagnosis of fax 81-45-576-3586; E-mail m-shokei@feel.ocn.ne.jp.
pneumothoraces is mainly based on the inability to detect
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