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Although evaluating trauma patients with ultrasound instability, especially in patients receiving positive-
(US) is not a new concept, the detection of pneumo- pressure ventilation.6 Traditional imaging for a po-
thorax is a novel application of US for many clini- tential traumatic pneumothorax initially begins with
cians.1–4 Patients who have sustained blunt or chest radiography. However, due to the limitations of
penetrating thoracic and abdominal trauma are at spinal immobilization in trauma patients, this exam-
risk for a wide variety of injuries. Although typically ination often consists of anteroposterior (AP) supine
not immediately life-threatening unless a tension films, in which radiographic features of pneumo-
pneumothorax is present, early identification of a thorax may be quite subtle.7 Recent literature reveals
traumatic pneumothorax is essential.5 Even a small that small penumothoraxes are initially missed on
pneumothorax may progress to cause hemodynamic clinical examination, or by admission chest radiogra-
phy, in 30% to 50% of trauma patients.7 Computed
tomography (CT) is much more sensitive for pneu-
From the Section of Emergency Ultrasound, Department of Emer-
gency Medicine, Medical College of Georgia (MB, ML, SD),
mothorax, but requires the patient to be removed
Augusta, GA. from the emergency department (ED) environment
Received February 19, 2005; revision received May 2, 2005; accepted and its resuscitative capability.8
May 3, 2005. Although a more frequent use of US in chest trauma
Address for correspondence and reprints: Michael Blaivas, MD, is the evaluation for traumatic pericardial or pleural
RDMS, Department of Emergency Medicine, Medical College of
Georgia, 1120 15th Street, AF-2039, Augusta, GA 30912-4007;
effusion, research has shown that US of the thorax
e-mail: blaivas@pyro.net. is highly accurate for the diagnosis of pneumo-
doi:10.1197/j.aem.2005.05.005 thorax.1,9,10 Many of these prior studies, however, did
ACAD EMERG MED d September 2005, Vol. 12, No. 9 d www.aemj.org 845
METHODS
Study Design. This was a prospective, single-blind
study with convenience sampling, based on re-
searcher availability, of blunt trauma patients at a Figure 1. A still image of the pleural interfaces, which are seen
as a bright line (arrows). With breathing, the pleura slide past
Level 1 trauma center with an annual census of 75,000 each other and two separate lines are seen sliding.
patients. The study was approved by the institutional
review board with waiver of informed consent, since
it is the standard practice in our ED to use US in the
evaluation of trauma patients, and contemporaneous the case of a pneumothorax, were to seep in between
collection of data did not require follow-up or iden- the parietal and visceral pleura, the deeper pleural
tifying information. layer would not be visualized due to the inability of
medical US to penetrate through air (Figure 2A, B).
Study Setting and Population. The study was Thus, since half of the sliding component is invisible,
conducted from September 2003 to May 2004. Enroll- no sliding lung sign is seen.
ment criteria were blunt trauma patients more than Ultrasound images were obtained parallel to ribs at
17 years of age receiving a focused assessment with the rib interspaces. Depth settings were minimized to
sonography for trauma (FAST) examination followed approximately 5 cm to optimize magnification of the
by chest radiography and CT of the chest and/or superficial structures being imaged. Power Doppler
abdomen and pelvis (which includes lung windows was utilized to enhance the sonologist’s ability to
at our institution). Patients in whom the examination identify pleural sliding whenever the sliding lung
could not be completed for any reason were excluded. sign was not easily detected. Study physicians de-
Patients who had chest tube placement prior to CT cided on the presence and size of pneumothorax.
scan were included in the analysis, and the presence When the sliding lung sign was absent at the
of pneumothorax was considered to be verified if a midclavicular point anteriorly or at the fourth inter-
rush of air was heard when the chest tube was inserted. space at the anterior axillary line, a small pneumo-
thorax was thought to be present. When it was absent
Study Protocol. Patients were classified as trauma at the midaxillary line, a medium pneumothorax was
patients based on mechanism, loss of consciousness, noted. When sliding lung sign was absent in the
apparent injury at the scene, and vital signs. During posterior axillary line, a large pneumothorax was
the initial evaluation of patients meeting trauma believed to be present. Pneumothorax sizes were
criteria, attending emergency physicians performed defined as small (10% or less), medium (11% to
bedside US examinations of the chest using a SonoSite 40%), and large (over 40%).13 Portable, supine AP
180PLUS (Bothell, WA) using a 4- to 2-MHz micro- chest radiographs were obtained immediately after
convex broadband transducer. Protocol views con- US evaluation. CT examination using a multigated
sisted of four locations of each hemithorax (anterior scanner was obtained at the discretion of the treating
second intercostal space at the midclavicular line, physician, and consisted of using 5-mm thick slices.
fourth intercostal space at the anterior axillary line, All examinations (US, CT, radiography) were per-
sixth intercostal space at the midaxillary line, and formed with the patient in the supine position.
sixth intercostal space at the posterior axillary line) to A total of five emergency physicians participated in
assess for the presence of a sliding lung sign to rule study enrollment. All had emergency US credentialing
out pneumothorax. In the normal lung, the parietal through the hospital in accordance with American
and visceral surfaces can be visualized by US as College of Emergency Physicians training and
bright interfaces or echogenic lines. With respiration, credentialing guidelines.14 The physicians were trained
these two bright lines slide past each other (Figure 1).1 to perform thoracic US for the detection and ruling
This sliding is seen on US deep to the ribs. If air, as in out of pneumothorax by the emergency ultrasound
846 Blaivas et al. d ULTRASOUND FOR DIAGNOSIS OF PNEUMOTHORAX
Figure 2. A sliding lung sign is seen on the left side, with the movement of the pleura denoted by a blush of color on the power
Doppler setting, A. No sliding lung sign is seen on the opposite (right) side, with no movement picked up on power Doppler, B.
TABLE 1. Sensitivity, Specificity, and Positive and Negative Predictive Values for Ultrasound and
Chest Radiography
Ultrasound (95% CI) Chest Radiography (95% CI)
Sensitivity 98.1% (89.9%, 99.9%) 75.5% (61.7%, 86.2%)
Specificity 99.2% (95.6%, 99.9%) 100% (97.1%, 100%)
Positive predictive value 98.1% (89.3%, 99.9%) 100% (91.2%, 100%)
Negative predictive value 99.2% (95.6%, 99.9%) 90.4% (84.2%, 94.8%)
tube placement. All discrepancies between US and CT pneumothoraxes in 225 trauma patients, most of
for pneumothorax size occurred with medium-sized whom were suffering from blunt trauma.17 The authors
pneumothoraxes, as estimated by US. utilized a different ultrasound transducer from the one
we used in our study. The use of a linear ultrasound
transducer should have provided for greater accuracy
DISCUSSION over the microconvex transducer we utilized. Further,
The use of US in the diagnosis of pneumothorax was the linear transducer may not be available on many
first reported in a veterinary journal in 1986.15 Since ultrasound units used just for trauma evaluation. Thus,
that time, multiple case reports and several studies our study was more practical, despite using somewhat
have explored the use of US in the diagnosis of inferior technology for visualization of the sliding lung
pneumothorax. The primary means used to diagnose sign. Kirkpatrick et al. noted that 63% of all pneumo-
the presence of air between the visceral and parietal thoraxes were missed on trauma chest radiography.
pleura is the absence of the sliding lung sign. When This was a higher percentage of misses for chest
present, the sliding lung sign has been shown to be a radiography than in our study, but its significance is
good negative predictor for the presence of a pneu- the same: that trauma chest radiographs are not reliable
mothorax, with Dulchavsky et al. reporting a true- for detecting pneumothoraxes. However, as in our
negative rate of 100% for ruling out a pneumothorax study, Kirkpatrick noted that occult or small pneumo-
when compared with standard radiography.10 Addi- thoraxes were most likely to be missed by chest radi-
tionally, the sensitivity of lung US in the detection of ography. The authors reported a sensitivity of 58.9% for
pneumothorax is comparable to, or even greater than, ultrasound in comparison with the criterion standard,
routine radiography, with sensitivities in experimen- with a likelihood ratio of a positive test of 69.7 and a
tal studies ranging from 90% to 100% using CT as specificity of 99.1%. The sensitivity in our study was
the criterion standard.3,4,6 With the addition of power higher, but the two specificities were comparable.
Doppler, the detection of the pleural sliding as Despite the promise for high accuracy, a potential
Doppler shift, called the ‘‘power slide,’’ may further for false-positive results on a sliding lung sign search
increase the sensitivity.16 With Doppler, the US ma- does exist in certain clinical situations. Presence of
chine detects the movement of the two pleural layers bullous emphysema has been associated with loss of
past each other as blood flow in a vessel, and displays the sliding lung sign when no pneumothorax is pres-
it as a color map (Figure 2A). This may be especially ent. Other potential pitfalls are the presence of pleural
helpful when the human eye does not pick up the adhesions and, possibly, extensive subcutaneous em-
pleural sliding due to limited resolution or some type physema.7 Knudtson et al. described the absence of a
of interference. sliding lung sign in the presence of subcutaneous
Several previous studies have evaluated, with vary- emphysema not associated with a pneumothorax.1
ing success, whether the size of a pneumothorax could However, subcutaneous emphysema should be obvi-
be estimated when utilizing US. Using archived taped ous to the experienced sonologist, as image loss from
examinations, Sistrom et al. found minimal correlation air interference occurs essentially at skin level rather
between US findings and size of pneumothorax.11 In a than deep to the ribs. Finally, large lung contusions
porcine model, however, a partial lung sliding sign can lead to false-positive findings due to a change in
was seen with as little as 150 mL of air insufflated into the pleura. This was seen in one patient in our study
the pleural space. This consisted of visualization of with a large unilateral contusion. The patient was
lung sliding in a portion of the scanning window with believed to have an absence of the sliding lung sign on
adjacent absence of sliding noted in the same win- US. Chest radiography did not show a pneumothorax,
dow.11 As the insufflation volumes increased, there and neither did the CT. However, the CT revealed the
was progressive loss of lung sliding from the anterior contusion.
to the lateral to the posterior windows. These results In contrast to many prior studies utilizing the
suggested that US may allow for distinction between sliding lung sign, all of the subjects in this study
pneumothoraxes of varying sizes. were evaluated with the microconvex probe on a true
In a recent study, Kirkpatrick et al. evaluated a hand- portable US machine, SonoSite 180PLUS. Although a
carried ultrasound unit for detection of traumatic 7.5-MHz linear transducer allows better resolution of
848 Blaivas et al. d ULTRASOUND FOR DIAGNOSIS OF PNEUMOTHORAX
Figure 3. The progression of lung separation from the thoracic wall is shown with increasing volume of pneumothorax (PTX) in frames
A through C. Note that the medium (B) PTX tends to extend as far laterally as the large one, C. However, the absolute volume of the
large PTX in the chest appears significantly larger.
the pleural–pleural interface due to the close proximity smaller, but the surface area in which sliding lung
to the skin, the 3.5-MHz microconvex transducer is sign is absent increases less significantly.
typically used for the FAST examination. Therefore, The ability to grade the size of a pneumothorax
with the high sensitivity demonstrated in our study for could be of considerable utility in a number of
the detection of the sliding lung sign, a microconvex situations. If a large pneumothorax is noted, a chest
probe has the distinct advantage of being adequate for tube may need to be placed prior to transfer to a
performing both examinations. Further, the micro- radiography area or another facility. This may be
convex probe allows for easier imaging through the especially useful at disaster scenes with multiple
ribs due to its small-footprint size and pie-shaped casualties, or on the battlefield, where other imaging
image. Therefore, rib shadowing can be minimized by modalities may not be available. Further, if a chest
probe maneuvers such as rotation or angling more tube is not placed, periodic evaluation for increasing
easily than with a large-footprint linear probe. pneumothorax size without repeat doses of ionizing
We attempted to determine the size of the pneu- radiation is clinically useful. This scenario may occur
mothorax by evaluating for the sliding lung sign in in an observation setting such as patients admitted
multiple areas of the chest in supine trauma patients. with small pneumothoraxes after trauma, or in cases
The areas chosen should reflect an increasing volume of spontaneous pneumothorax that did not warrant a
of a pneumothorax inside a human hemithorax when chest tube on initial diagnosis.
the patient is supine. Unless limited by significant A surprising difficulty occurred with bilateral
adhesion or as part of a bleb, air first moves to the pneumothoraxes found in two cases involving very
most superior portion of the hemithorax when the thin female patients without a history of significant
patient is supine. As would be expected based on trauma or mechanism. In both cases, the study phy-
the porcine model, small pneumothoraxes were seen sician correctly detected lack of sliding lung sign, but
in the anterior portion of the chest only, whereas thought that it must have been due to technical error.
larger pneumothoraxes were easily seen in much CT later confirmed small bilateral pneumothoraxes in
more lateral and even posterior locations. Chest radi- both patients.
ography routinely failed to detect pneumothorax in
patients for whom US showed an absence of the
sliding lung sign only in the anterior position (i.e., a
LIMITATIONS
small pneumothorax), and this was also expected. This study has several limitations. It selected patients
One potential reason for increased difficulty in differ- who were more severely injured than patients who
entiating between medium and large pneumothor- may only receive a chest radiograph without under-
axes on US was likely due to the pattern of lung going abdominal CT. However, the criterion standard
collapse, as seen on CT (Figure 3A, B). As the volume of CT would not have been available to us for
of the pneumothorax increases, the lung is pushed comparison otherwise. Patients were enrolled on a
away from the chest wall, thus eliminating the sliding researcher-availability basis. However, this is unlikely
lung sign in an increasing arc from the anterior to to have led to any selection bias, because the re-
lateral portion of the chest. As the pneumothorax searchers worked all shifts and all days in the ED
volume increases from medium to large, the lung during the study’s course. The study researchers were
volume inside the thorax becomes progressively all hospital-credentialed in emergency US, and results
ACAD EMERG MED d September 2005, Vol. 12, No. 9 d www.aemj.org 849
may not translate to novice US users. The CTs were 5. Choi CM, Um SW, Yoo CG, et al. Incidence and risk factors
often performed more than 10 minutes after initial US, of delayed pneumothorax after transthoracic needle biopsy
of the lung. Chest. 2004; 126:1516–21.
thus giving time for the pneumothorax to enlarge in 6. Lewis FR, Blaisdell FW, Schlobohm RM. Incidence and
some cases. We did not use attending radiology read- outcome of posttraumatic respiratory failure. Arch Surg. 1977;
ings of chest radiographs, because they were not avail- 112:436–43.
able at the time of patient care, and the need for 7. Rowan K, Kirkpatrick A, Liu D, Forkheim K, Mayo J, Nicolaou
prompt clinical decisions was our primary concern. S. Traumatic pneumothorax detection with thoracic US:
correlation with chest radiography and CT—initial experience.
We believe this is a common practice not only in many Radiology. 2002; 225:210–4.
academic trauma centers, but also in other real-world 8. Neff MA, Monk JS, Peters K, Nikhilesh A. Detection of occult
settings, and more accurately reflects modern prac- pneumothoraces on abdominal computed tomographic scans
tice. Our subjects were all trauma patients, and thus in trauma patients. J Trauma. 2000; 49:281–5.
results may not be generalizable to medical patients. 9. Plummer D, Brunette D, Asinger R, Ruiz E. Emergency
department echocardiography improves outcome in
penetrating cardiac injury. Ann Emerg Med. 1992; 21:709–12.
10. Dulchavsky SA, Schwartz KL, Kirkpatrick AW, et al.
CONCLUSIONS Prospective evaluation of thoracic ultrasound in the detection
With CT as the criterion standard, US is more sensitive of pneumothorax. J Trauma. 2001; 50:201–5.
11. Sistrom CL, Reiheld CT, Spencer BG, Wallace KK. Detection
than plain AP chest radiography in the diagnosis of
and estimation of the volume of pneumothorax using real-time
traumatic pneumothorax. Furthermore, US allowed ultrasonography. AJR Am J Roentgenol. 1996; 166:317–21.
sonologists to differentiate between small, medium, 12. Sargsyan AE, Hamilton DR, Nicolaou S, et al. Ultrasound
and large pneumothoraxes with good agreement evaluation of the magnitude of pneumothorax: a new concept.
with CT. Am Surg. 2001; 76:232–6.
13. Seaberg DC, Yealh DM, Ilkhanipour K. Effect of nitrous
oxide analgesia on pneumothorax. Acad Emerg Med. 1995; 2:
References
287–92.
1. Knudtson JL, Dort JM, Helmer SD, Smith RS. Surgeon- 14. American College of Emergency Physicians. ACEP emergency
performed ultrasound for pneumothorax in the trauma suite. ultrasound guidelines—2001. Ann Emerg Med. 2001; 38:
J Trauma. 2004; 56:527–30. 470–81.
2. Rowan KR, Kirkpatick AW, Liu D, Forkheim KE, Mayo JR, 15. Ratanen NW. Diagnostic ultrasound: diseases of the thorax.
Nicolaou S. Traumatic pneumothorax detection with thoracic Vet Clin North Am. 1986; 2:49–66.
US: correlation with chest radiography and CT: initial 16. Cunningham J, Kirpatrick AW, Nicolaou S, et al. Enhanced
experience. Radiology. 2002; 225:210–4. recognition of lung sliding with power color Doppler imaging
3. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling in the diagnosis of pneumothorax. J Trauma. 2002; 52:769–71.
out pneumothorax in the critically ill. Chest. 1995; 108:1345–8. 17. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held
4. Goodman TR, Traill ZC, Phillips AJ, Berger J, Gleeson FV. thoracic sonography for detecting post-traumatic
Ultrasound detection of pneumothorax. Clin Radiol. 1999; 54: pneumothoraces: the extended focused assessment with
736–9. sonography for trauma (EFAST). J Trauma. 2004; 57:288–95.