Anatomical distribution of traumatic pneumothoraces on chest computed tomography: implications for ultrasound screening in the ED

Published:September 12, 2011DOI:



      We sought to assess the anatomical distribution of traumatic pneumothoraces (PTXs) on chest computed tomography (CT) to develop an optimized protocol for PTX screening with ultrasound in the emergency department (ED).


      We performed a retrospective review of all chest CTs performed in one ED between January 2005 and December 2008 according to presence, location, and size of PTX. Pneumothoraces were then measured and categorized into 14 anatomical regions for each hemithorax.


      A total of 277 (3.8%) PTXs were identified, with 26 bilateral PTX, on 3636 chest CTs performed during the study period. Etiology was blunt (85%) or penetrating trauma (15%). Eighty-three (45%) PTXs were radiographically occult on initial chest x-ray. One hundred eighty-three (66%) PTX had no chest tube at the time of CT. For both hemithoraces, the distribution demonstrated increasing PTX frequency and size from lateral to medial and from superior to inferior. Region 12 (parasternal, intercostal spaces [ICS] 7-8) was involved in 68% of PTX on either side; region 9 (parasternal, ICS 5-6), in 67% on the left and in 52% on the right; and region 11 (lateral to midclavicular line, ICS 7-8), in 46% on the left and in 53% on the right. The largest anterior-to-posterior PTX dimension was seen in region 12.


      Our results indicate that 80.4% of right- and 83.7% of left-sided traumatic PTXs would be identified by scanning regions 9, 11, and 12. These findings suggest that a standardized protocol for PTX screening with ultrasound should include these regions.
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        • Di Bartolomeo S.
        • Sanson G.
        • Nardi G.
        • et al.
        A population-based study on pneumothorax in severely traumatized patients.
        J Trauma. 2001; 51: 677-682
        • Farooq U.
        • Raza W.
        • Zia N.
        • et al.
        Classification and management of chest trauma.
        J Coll Physicians Surg Pak. 2006; 16: 101-103
        • Wustner A.
        • Gehmacher O.
        • Hammerle S.
        • et al.
        Ultrasound diagnosis in blunt thoracic trauma.
        Ultraschall Med. 2005; 26: 285-290
        • Dulchavsky S.A.
        • Schwarz K.L.
        • Kirkpatrick A.W.
        • et al.
        Prospective evaluation of thoracic ultrasound in the detection of pneumothorax.
        J Trauma. 2001; 50: 201-205
        • Zhang M.
        • Liu Z.H.
        • Yang J.X.
        • et al.
        Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma.
        Crit Care. 2006; 10: R112
        • Ball C.G.
        • Kirkpatrick A.W.
        • Laupland K.B.
        • et al.
        Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces.
        Am J Surg. 2005; 189: 541-546
        • Chung M.J.
        • Goo J.M.
        • Im J.G.
        • et al.
        Value of high-resolution ultrasound in detecting a pneumothorax.
        Eur Radiol. 2005; 15: 930-935
        • Soldati G.
        • Testa A.
        • Sher S.
        • et al.
        Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department.
        Chest. 2008; 133: 204-211
        • Lichtenstein D.A.
        • Meziere G.
        • Lascols N.
        • et al.
        Ultrasound diagnosis of occult pneumothorax.
        Crit Care Med. 2005; 33: 1231-1238
        • Lichtenstein D.A.
        Ultrasound in the management of thoracic disease.
        Crit Care Med. 2007; 35: S250-S261
        • Dulchavsky S.A.
        • Hamilton D.R.
        • Diebel L.N.
        • et al.
        Thoracic ultrasound diagnosis of pneumothorax.
        J Trauma. 1999; 47: 970-971
        • Rowan K.R.
        • Kirkpatrick A.W.
        • Liu D.
        • et al.
        Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT—initial experience.
        Radiology. 2002; 225: 210-214
        • Blaivas M.
        • Lyon M.
        • Duggal S.
        A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax.
        Acad Emerg Med. 2005; 12: 844-849
        • Kirkpatrick A.W.
        • Sirois M.
        • Laupland K.B.
        • et al.
        Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST).
        J Trauma. 2004; 57: 288-295
        • Knudtson J.L.
        • Dort J.M.
        • Helmer S.D.
        • et al.
        Surgeon-performed ultrasound for pneumothorax in the trauma suite.
        J Trauma. 2004; 56: 527-530
        • Chan S.S.
        Pneumothorax detection with thoracic US: more research is needed.
        Radiology. 2003; 227: 905-906
        • Yiadom M.Y.
        • Platz E.
        • Brown D.F.
        • et al.
        Pneumothorax in a blunt trauma patient.
        J Emerg Med. 2008; 35: 199-203
        • McGonigal M.D.
        • Schwab C.W.
        • Kauder D.R.
        • et al.
        Supplemental emergent chest computed tomography in the management of blunt torso trauma.
        J Trauma. 1990; 30: 1431-1434
        • Neff M.A.
        • Monk Jr., J.S.
        • Peters K.
        • et al.
        Detection of occult pneumothoraces on abdominal computed tomographic scans in trauma patients.
        J Trauma. 2000; 49: 281-285
        • Cai W.
        • Tabbara M.
        • Takata N.
        • et al.
        MDCT for automated detection and measurement of pneumothoraces in trauma patients.
        AJR Am J Roentgenol. 2009; 192: 830-836
        • Wernecke K.
        • Galanski M.
        • Peters P.E.
        • et al.
        Pneumothorax: evaluation by ultrasound—preliminary results.
        J Thorac Imaging. 1987; 2: 76-78
        • Lichtenstein D.A.
        • Menu Y.
        A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding.
        Chest. 1995; 108: 1345-1348
        • Brook O.R.
        • Beck-Razi N.
        • Abadi S.
        • et al.
        Sonographic detection of pneumothorax by radiology residents as part of extended focused assessment with sonography for trauma.
        J Ultrasound Med. 2009; 28: 749-755
        • Dente C.J.
        • Ustin J.
        • Feliciano D.V.
        • et al.
        The accuracy of thoracic ultrasound for detection of pneumothorax is not sustained over time: a preliminary study.
        J Trauma. 2007; 62: 1384-1389
        • Soldati G.
        • Testa A.
        • Pignataro G.
        • et al.
        The ultrasonographic deep sulcus sign in traumatic pneumothorax.
        Ultrasound Med Biol. 2006; 32: 1157-1163
        • Trupka A
        • Waydhas C
        • Hallfeldt KK
        • et al.
        Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study.
        J Trauma. 1997; 43: 405-411
        • Berrington de Gonzalez A.
        • Mahesh M.
        • Kim K.P.
        • et al.
        Projected cancer risks from computed tomographic scans performed in the United States in 2007.
        Arch Intern Med. 2009; 169: 2071-2077
        • Wilson H.
        • Ellsmere J.
        • Tallon J.
        • et al.
        Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation?.
        Injury. 2009; 40: 928-931
        • Barrios C.
        • Tran T.
        • Malinoski D.
        • et al.
        Successful management of occult pneumothorax without tube thoracostomy despite positive pressure ventilation.
        Am Surg. 2008; 74: 958-961
        • Wolfman N.T.
        • Myers W.S.
        • Glauser S.J.
        • et al.
        Validity of CT classification on management of occult pneumothorax: a prospective study.
        AJR Am J Roentgenol. 1998; 171: 1317-1320
        • Sistrom C.L.
        • Reiheld C.T.
        • Gay S.B.
        • et al.
        Detection and estimation of the volume of pneumothorax using real-time sonography: efficacy determined by receiver operating characteristic analysis.
        AJR Am J Roentgenol. 1996; 166: 317-321