Synopsis
Detect pneumothorax across erect and supine imaging, recognise clinical tension physiology and connect radiographic size, symptoms and underlying lung disease to urgent management.
- An erect film shows a visceral pleural line with no vascular markings peripheral to it; inspect both apices and trace the line rather than relying on general hyperlucency.
- Supine pneumothorax may collect anteriorly and basally, producing an abnormally deep costophrenic sulcus instead of the classic apical line.
- Tension is defined by physiological compromise, not mediastinal shift alone: decompress an unstable patient immediately and do not delay for imaging confirmation.
Key red flags
Shock, severe respiratory distress, rapidly falling oxygenation, unilateral absent breath sounds or peri-arrest deterioration after trauma or positive-pressure ventilation raises tension pneumothorax.
Do not wait for chest radiography or CT when suspected tension physiology is causing haemodynamic instability or severe respiratory compromise.
A pneumothorax in a patient with significant underlying lung disease, pregnancy, bilateral disease or limited physiological reserve may be dangerous despite modest measured size.
Persistent air leak, failure of lung re-expansion or recurrent pneumothorax requires specialist review for bronchopleural fistula or recurrence prevention.
Positive-pressure ventilation can enlarge a pneumothorax rapidly; deterioration after intubation or line insertion demands immediate reassessment.
Severe respiratory compromise or haemodynamic instability with compatible unilateral findings requires immediate decompression before imaging.
Lack of re-expansion, ongoing bubbling, worsening surgical emphysema or tube migration requires urgent system, imaging and specialist review.
Investigation priorities
Confirm and estimate pneumothorax and look for underlying disease or an alternative diagnosis in a stable patient.
Management branches
An adult after chest trauma becomes shocked and severely hypoxic with unilateral absent breath sounds.
- Call the trauma and resuscitation team, deliver oxygen, assess airway and ventilation, and recognise suspected tension pneumothorax from the physiology and examination.
- Perform immediate chest decompression using the locally approved emergency technique without transferring the unstable patient for radiography.
A haemodynamically stable adult has a spontaneous pneumothorax confirmed on chest radiography.