Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Epidemiology
6. Pathophysiology
   1. Types Of Pneumothoraces
      1. Primary Spontaneous Pneumothorax
      2. Secondary Pneumothorax
      3. Neonatal Pneumothorax
      4. Traumatic Pneumothorax
      5. Open Pneumothorax
      6. Occult Pneumothorax
      7. Tension Pneumothorax
      8. Iatrogenic Pneumothorax
7. Differential Diagnosis
8. Prehospital Care
   1. Air Transport
   2. Ground Transport
   3. Positive-Pressure Ventilation
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
   3. Early Intervention
10. Diagnostic Studies
    1. Imaging Studies
       1. Chest Radiography
       2. Point-Of-Care Ultrasound
          • Findings In Normal Lungs
          • Findings Suggestive Of Pneumothorax
       3. Computed Tomography
    2. Size Quantification Of A Pneumothorax
       1. The Rhea Average Interpleural Distance Method
       2. The Light Index
       3. The Collins Method
       4. Comparison Of The Efficacy Of The Methods
       5. Comparison Of Diagnostic Studies For Quantifying Pneumothorax Size
       6. Management Based On Pneumothorax Size
11. Treatment
    1. Spontaneous Pneumothoraces
    2. Large Or Symptomatic Primary Spontaneous Pneumothoraces
    3. Surgical Method
    4. Modified Seldinger Technique
    5. Connection To A Drainage System
    6. Additional Surgical Interventions
    7. Complications Of Needle Thoracostomy, Placement Of Intercostal Catheters, And Tube Thoracostomy
12. Special Circumstances
    1. Secondary Pneumothoraces
    2. Open Pneumothoraces
    3. Occult Pneumothoraces
    4. Tension Pneumothoraces
       1. Interventions And Complications
13. Controversies And Cutting Edge
    1. Prehospital Use Of Ultrasound To Identify Pneumothoraces
    2. Outpatient Management With Chest Tubes
    3. Telemedicine Guidance Of Chest Tube Placement
14. Disposition
15. Summary
16. Risk Management Pitfalls In Pediatric Patients With A Pneumothorax
17. Time- And Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway For Management Of Pediatric Patients With Pneumothorax
20. Tables and Figures
    1. Table 1. Types And Characteristics Of Pneumothoraces
    2. Table 2. Diseases And Conditions That Increase The Risk Of Secondary Pneumothorax
    3. Table 3. Signs And Symptoms Of Pneumothorax
    4. Table 4. Imaging Modalities For Pneumothorax And Potential Findings
    5. Table 5. Definitions Of Large Pneumothoraces
    6. Table 6. Chest Tube Selection For The Surgical Method As Determined By Patient Weight
    7. Figure 1. Pneumothorax On Chest Radiography
    8. Figure 2. Deep Sulcus Sign On Chest Radiography
    9. Figure 3. Scapula And Skin Fold Mimicking Pneumothorax
    10. Figure 4. Normal Lung Findings On Thoracic Ultrasound
    11. Figure 5. Absence Of Lung Sliding Suggestive Of Pneumothorax
    12. Figure 6. The Surgical Method
    13. Figure 7. The Modified Seldinger Technique
    14. Figure 8. Evolving Tension Pneumothorax
21. References

Abstract

The clinical presentation of pneumothorax is highly variable. Spontaneous pneumothoraces may present with subtle symptoms when a small air leak is present, but can progress to hemodynamic instability in the setting of tension physiology. The etiologies are broad and the severity can vary greatly. A trauma patient with a pneumothorax may also have the added complexity of other potentially life-threatening injuries. While there is a wealth of evidence-based guidelines for the management of pneumothoraces in the adult literature, the approach to pediatric patients is largely extrapolated from that literature without a significant evidence base. In this issue, aspects of the history and physical examination, the use of various diagnostic imaging modalities, and the range of interventions available to the emergency clinician are discussed.

Case Presentationss

A 12-year-old boy is brought in by EMS with a single stab wound to the right lower-anterior chest. He is alert and oriented, but noted to be tachycardic, borderline hypotensive, and agitated. During your primary survey, you note that his airway is intact. Breath sounds on the left are normal, but there is no air movement on the right. There is a small laceration to the right anterior chest. Peripheral pulses are present but thready, and capillary refill is noted to be 4 to 5 seconds. You place the patient on supplemental oxygen and obtain IV access with 2 large-bore lines. The patient begins to decompensate and becomes anxious and combative. His blood pressure is now 62/30 mm Hg. What are the immediate life-threatening conditions you need to consider? What tools do you have at your disposal to make an appropriate diagnosis? As your heart races, you consider the possibility of a tension pneumothorax and life-threatening intrathoracic or intra-abdominal bleeding. Do you place a surgical thoracostomy tube? A pigtail catheter? Transfuse blood? What life-saving maneuvers should you perform immediately?

A 15-year-old boy then presents for evaluation of acute-onset chest pain and shortness of breath. The patient states that he felt sudden, sharp, right-sided chest pain in class an hour ago. The patient denies fever, upper respiratory symptoms, cough, nausea, vomiting, or diarrhea. There is no report of travel or trauma. The patient does report frequent marijuana and cigarette smoking. His vital signs are: heart rate, 94 beats/min; blood pressure, 112/70 mm Hg; respiratory rate, 18 breaths/min; and oxygen saturation, 97% on room air. Lung sounds are slightly diminished on the right. You send the patient for a chest x-ray and begin to consider management options. Are there other aspects of the history you should obtain? Should you order a chest CT to look for blebs or other malformations? Should you order screening labs or place a thoracostomy tube or a pigtail catheter? Should you admit this patient?

Introduction

A pneumothorax is the pathologic collection of air within the pleural space, which is a potential space between the visceral and pleural lining. A pneumothorax can be the result of a spontaneous perforation of the lung parenchyma, chest wall trauma, disruption of the bronchotracheal tree, or, rarely, it may be iatrogenic in nature. A pneumothorax represents many different disease entities that may vary greatly in severity. Pneumothoraces are classically divided into 2 distinct categories: spontaneous and secondary. Spontaneous pneumothoraces, are idiopathic, without obvious cause. Secondary pneumothoraces occur in the setting of trauma or an underlying condition, or they may be iatrogenically induced in patients after thoracic surgery, placement of a central venous catheter, or intubation.

Most data regarding the management of pneumothorax in the pediatric population are extrapolated from literature that evaluates primarily adult patients, with few papers and no randomized controlled trials evaluating pediatric patients or producing pediatric management guidelines.¹ There are no standardized guidelines promoting specific diagnostic modalities or therapeutic interventions for children with pneumothorax; however, early identification and appropriate management can reduce morbidity and mortality. In this issue of Pediatric Emergency Medicine Practice, the epidemiology, pathophysiology, diagnosis, and management of pneumothorax as relevant to practice in the emergency department (ED) are reviewed.

Critical Appraisal Of The Literature

A review of the relevant literature was performed using PubMed, Google Scholar, MEDLINE^®, and the Cochrane Database of Systematic Reviews, with search terms including: pneumothorax, pneumothoraces, pediatric pneumothorax, thoracic trauma, tube thoracostomy, pigtail catheter, simple aspiration, lung ultrasound, focused assessment with sonography in trauma (FAST), and pre-hospital care. A total of 163 articles published over the past 3 decades were reviewed. A search of the Cochrane Database of Systematic Reviews for the terms pediatric pneumothorax and pneumothoraces in children did not produce any results. Guidelines from the American College of Chest Physicians (ACCP) from 2001², British Thoracic Society (BTS) from 2003³, and Belgian Society of Pneumology (BSP) from 2005⁴ presented excellent, evidence-based approaches to pneumothorax in adults, but offered no specific guidance to management in the pediatric population. With these limitations in mind, relevant management recommendations from the adult literature can still be extrapolated to the pediatric population.

Risk Management Pitfalls In Pediatric Patients With A Pneumothorax

1. “I performed a needle decompression to save the life of a patient with a tension pneumothorax. I thought I was a hero, but he subsequently decompensated.”
   Remember that needle decompression is an important and life-saving maneuver in the management of a tension pneumothorax. However, it is the first step, and according to current recommendations, it must be followed by the placement of a chest tube to allow for the evacuation of a presumed ongoing air leak.
    
2. “I made the call to transport a patient with an untreated large pneumothorax by air transport for definitive care at the medical center. He decompensated en route.”
   Pneumothoraces can expand by up to 30% at high altitude, and failure to account for this can result in dramatic miscalculation of the risk of developing an enlarging pneumothorax or even a tension pneumothorax.
    
3. “The father has complained that his son was in a lot of pain during the tube thoracostomy for management of a PSP by the surgery resident.”
   This is a markedly painful procedure. In hemodynamically stable patients, appropriate analgesia and/or sedation with opioids should be considered. These can be delivered by parenteral or intranasal routes. Generous local infiltration with lidocaine is advised.
    
4. “Now I’m panicking. I’ve attempted to place a chest tube for the management of a traumatic pneumothorax. Frank blood is spilling out of the tube. On x-ray, the tube is below the diaphragm.”
   Injury to the spleen or liver leading to hemoperitoneum or organ penetration of either of these hollow-viscus structures is a feared complication of tube thoracostomy. If suspected, leave the tube in place, clamp it to minimize blood loss, and obtain 3-dimensional imaging (typically a noncontrast CT scan of the chest, abdomen, and pelvis), and urgently consult surgery. These patients will often require an emergent exploratory laparotomy.
    
5. “I was called to evaluate a PSP in a patient who had become acutely hypoxic. Breath sounds were absent, and I suspected a tension pneumothorax. Because of significant respiratory distress I elected to intubate the patient prior to addressing the pneumothorax. I placed the endotracheal tube on the first pass, and the patient acutely decompensated when placed on the ventilator.”
   Large pneumothoraces can have impressive symptomatic presentations and hypoxia. The immediate treatment of symptomatic large pneumothoraces is the placement of an intercostal catheter. Endotracheal intubation can cause the rapid accumulation of intrathoracic air, converting a simple pneumothorax to tension physiology, if it is performed before the placement of an intercostal catheter.
    
6. “I accepted a patient for transfer with a large right-sided pneumothorax who had a chest tube placed at a small community hospital. A basic-life-support ambulance was sent for transport, and the patient began to complain of chest pain en route. A repeat chest x-ray on admission showed reaccumulation of the pneumothorax.”
   During transfer of a patient with a pneumothorax, it is important to make sure the transporting crew has the ability and equipment necessary to maintain the chest tube and prevent reaccumulation of the pneumothorax. It is critical to maintain care of the tube en route to avoid kinking or disconnection.
    
7. “I placed a small-bore intercostal catheter for the management of a large pneumothorax. Repeat imaging shows no change in the size of the pneumothorax, and the catheter appears to be along the lateral aspect of the chest wall.”
   The placement of an intercostal catheter or surgical chest tube is associated with a complication 2% to 10% of the time. Failing to penetrate the thoracic cavity and inserting the tube into a subcutaneous space is both ineffective and painful, and requires a second procedure. Another common complication is tube dislodgement because of failure of the clinician to adequately secure the tube with sutures and a sterile occlusive dressing.
    
8. “I misread the x-ray and placed the chest tube on the wrong side.”
   There are a few case reports in the literature, predominantly out of the neonatal literature, of thoracostomy tubes that were placed on the wrong side. Discussion of these cases identified a failure to mark the affected side with a radiopaque (R = right or L = left) marker on chest x-ray, and a confirmatory mark on the patient.¹⁴²
    
9. “A patient intubated in my ED for severe status asthmaticus was noted to require increased ventilator pressures. A STAT portable supine chest radiograph was obtained, which, surprisingly, did not reveal a pneumothorax.”
   Recall that supine chest radiographs have both poor sensitivity and specificity for detecting pneumothoraces. Consider alternative imaging modalities such as thoracic ultrasound or CT scan of the chest if you have suspicion for a pneumothorax.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

1. * Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev. 2009;10(3):110-117. (Literature review)
2. * Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602. (Consensus guideline statement)
3. * Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax. 2003;58(Suppl 2):ii39-ii52. (Consensus guideline statement)
4. * De Leyn P, Lismonde M, Ninane V, et al. Guidelines Belgian Society of Pneumology. Guidelines on the management of spontaneous pneumothorax. Acta Chir Belg. 2005;105(3):265-267. (Consensus guideline statement)
5. Melton LJ 3rd, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Am Rev Respir Dis. 1979;120(6):1379-1382. (Retrospective review; 318 adult patients)
6. * Dotson K, Johnson LH. Pediatric spontaneous pneumothorax. Pediatr Emerg Care. 2012;28(7):715-720. (Literature review)
7. * Dotson K, Timm N, Gittelman M. Is spontaneous pneumothorax really a pediatric problem? A national perspective. Pediatr Emerg Care. 2012;28(4):340-344. (Retrospective review of the Healthcare Cost and Utilization Project Kids’ Inpatient Database between 1997 and 2006)
8. Shih CH, Yu HW, Tseng YC, et al. Clinical manifestations of primary spontaneous pneumothorax in pediatric patients: an analysis of 78 patients. Pediatr Neonatol. 2011;52(3):150-154. (Retrospective chart review; 78 patients)
9. Beg MH, Reyazuddin, Faridi MM, et al. Spontaneous pneumothorax in children--a review of 95 cases. Ann Trop Paediatr. 1988;8(1):18-21. (Retrospective chart review; 95 cases)
10. Poenaru D, Yazbeck S, Murphy S. Primary spontaneous pneumothorax in children. J Pediatr Surg. 1994;29(9):1183-1185. (Prospective cohort study; 30 neonates)
11. Cheng YL, Huang TW, Lin CK, et al. The impact of smoking in primary spontaneous pneumothorax. J Thorac Cardiovasc Surg. 2009;138(1):192-195. (Retrospective chart review; 115 patients)
12. Beshay M, Kaiser H, Niedhart D, et al. Emphysema and secondary pneumothorax in young adults smoking cannabis. Eur J Cardiothorac Surg. 2007;32(6):834-838. (Retrospective case series; 17 adolescents)
13. Soundappan SV, Holland AJ, Browne G. Sports-related pneumothorax in children. Pediatr Emerg Care. 2005;21(4):259-260. (Case report; 3 patients)
14. Apiliogullari B, Sunam GS, Ceran S, et al. Evaluation of neonatal pneumothorax. J Int Med Res. 2011;39(6):2436-2440. (Prospective cohort study; 30 patients)
15. Horbar JD, Badger GJ, Carpenter JH, et al. Trends in mortality and morbidity for very low birth weight infants, 1991-1999. Pediatrics. 2002;110(1 Pt 1):143-151. (Cross-sectional review of the Vermont Oxford Network Database; 118,448 patients)
16. Fernandes C. Pulmonary air leak in the newborn. UpToDate 2014; http://www.uptodate.com/contents/pulmonary-air-leak-in-the-newborn. Accessed February 15, 2017. (Review article)
17. Cooper A. Thoracic injuries. Semin Pediatr Surg. 1995;4(2):109-115. (Review article)
18. Coley E, Roach P, Macmillan AI, et al. Penetrating paediatric thoracic injury. J R Army Med Corps. 2011;157(3):243-245. (Case report; review of the literature)
19. Dilley A. Pediatric thoracic trauma. In: Wesson D, Cooper A, Scherer R, et al, eds. Pediatric Trauma: Pathophysiology, Diagnosis and Treatment. 1st ed. New York, NY: Taylor & Francis Group; 2006. (Textbook chapter)
20. Uva JL. Spontaneous pneumothoraces, pneumomediastinum, and pneumoperitoneum: consequences of smoking crack cocaine. Pediatr Emerg Care. 1997;13(1):24-26. (Case report; 1 patient)
21. Goodyear K, Laws D, Turner J. Bilateral spontaneous pneumothorax in a cannabis smoker. J R Soc Med. 2004;97(9):435-436. (Case report; 1 patient)
22. Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest. 1987;92(6):1009-1012. (Retrospective chart review; 138 adult patients)
23. Maeder M, Ullmer E. Pneumomediastinum and bilateral pneumothorax as a complication of cocaine smoking. Respiration. 2003;70(4):407. (Case report; 1 patient)
24. Partridge RA, Coley A, Bowie R, et al. Sports-related pneumothorax. Ann Emerg Med. 1997;30(4):539-541. (Case series; 3 patients)
25. Rothstein E, Edwards K. Health burden of pertussis in adolescents and adults. Pediatr Infect Dis J. 2005;24(5 Suppl):S44-S47. (Review article)
26. Toro JR, Pautler SE, Stewart L, et al. Lung cysts, spontaneous pneumothorax, and genetic associations in 89 families with Birt-Hogg-Dubé syndrome. Am J Respir Crit Care Med. 2007;175(10):1044-1053. (Prospective cohort study; 189 patients)
27. Kunogi M, Kurihara M, Ikegami TS, et al. Clinical and genetic spectrum of Birt–Hogg–Dubé syndrome patients in whom pneumothorax and/or multiple lung cysts are the presenting feature. J Med Genet. 2010;47(4):281-287. (Prospective cohort study; 36 patients)
28. Toro JR, Wei MH, Glenn GM, et al. BHD mutations, clinical and molecular genetic investigations of Birt-Hogg-Dube syndrome: a new series of 50 families and a review of published reports. J Med Genet. 2008;45(6):321-331. (Prospective cohort study; 50 families)
29. Serapinas D, Obrikyte V, Vaicius D, et al. Alpha-1 antitrypsin deficiency and spontaneous pneumothorax: possible causal relationship. Pneumologia. 2014;63(1):32-35. (Cohort study; 39 patients)
30. Geake JB, Ritchey DM, Burke J, et al. Sudden death in a young male with a recent pneumothorax: a case report. Eur Respir Rev. 2014;23(131):145-147. (Case report; 1 patient)
31. Cadranel JF, Rufat P, Degos F. Practices of liver biopsy in France: results of a prospective nationwide survey. For the Group of Epidemiology of the French Association for the Study of the Liver (AFEF). Hepatology. 2000;32(3):477-481. (Prospective study; biopsy procedures)
32. Roe D, Brown K. Catamenial pneumothorax heralding menarche in a 15-year-old adolescent. Pediatr Emerg Care. 1997;13(6):390-391. (Case report; 1 patient)
33. Ball CG, Kirkpatrick AW, Laupland KB, et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma. 2005;59(4):917-924. (Retrospective chart review; 338 patients)
34. Lee LK, Rogers AJ, Ehrlich PF, et al. Occult pneumothoraces in children with blunt torso trauma. Acad Emerg Med. 2014;21(4):440-448. (Prospective multicenter observational cohort; 8020 patients)
35. Martin M, Satterly S, Inaba K, et al. Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax? J Trauma Acute Care Surg. 2012;73(6):1412-1417. (Animal study)
36. Sharma A, Jindal P. Principles of diagnosis and management of traumatic pneumothorax. J Emerg Trauma Shock. 2008;1(1):34-41. (Literature review)
37. Paksu MS, Kilinc AA, Asilioglu N, et al. Iatrogenic tracheal rupture in a child: case study and review of literature. Pediatr Emerg Care. 2013;29(8):934-938. (Case report; 1 patient and review of the literature)
38. Karapinar B, Cura A. Complications of central venous catheterization in critically ill children. Pediatr Int. 2007;49(5):593-599. (Prospective observational study; 369 central venous line procedures)
39. Cahill AM, Baskin KM, Kaye RD, et al. CT-guided percutaneous lung biopsy in children. J Vasc Interv Radiol. 2004;15(9):955-960. (Retrospective chart review; 64 pediatric patients)
40. Naumann H, Pittaway A, Lynn AM, et al. CT-guided percutaneous lung biopsy under general anesthesia: a pediatric case series and literature review. Paediatr Anaesth. 2012;22(5):469-475. (Case series; 14 patients and review of the literature)
41. Bush CM, Jones JS, Cohle SD, et al. Pediatric injuries from cardiopulmonary resuscitation. Ann Emerg Med. 1996;28(1):40-44. (Retrospective chart review; 211 patient)
42. Blazer S, Naveh Y, Friedman A. Foreign body in the airway. A review of 200 cases. Am J Dis Child. 1980;134(1):68-71. (Retrospective chart review; 200 patients)
43. Vane DW, Pritchard J, Colville CW, et al. Bronchoscopy for aspirated foreign bodies in children. Experience in 131 cases. Arch Surg. 1988;123(7):885-888. (Retrospective chart review; 131 patients)
44. de Blic J, Marchac V, Scheinmann P. Complications of flexible bronchoscopy in children: prospective study of 1,328 procedures. Eur Respir J. 2002;20(5):1271-1276. (Prospective cohort study; 1328 procedures)
45. Lang T, Hummer HP, Behrens R. Balloon dilation is preferable to bougienage in children with esophageal atresia. Endoscopy. 2001;33(4):329-335. (Retrospective chart review; 34 patients)
46. Rivera R, Tibballs J. Complications of endotracheal intubation and mechanical ventilation in infants and children. Crit Care Med. 1992;20(2):193-199. (Prospective cohort study; 119 patients)
47. Ball CG, Wyrzykowski AD, Kirkpatrick AW, et al. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg. 2010;53(3):184-188. (Retrospective database review; 142 patients with pneumothorax)
48. Stevens RL, Rochester AA, Busko J, et al. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care. 2009;13(1):14-17. (Retrospective chart review; 110 patients)
49. Aylwin CJ, Brohi K, Davies GD, et al. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Engl. 2008;90(1):54-57. (Prospective cohort study; 52 patients, 91 chest tubes)
50. Barton ED, Epperson M, Hoyt DB, et al. Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews. J Emerg Med. 1995;13(2):155-163. (Retrospective chart review; 207 patients)
51. Davis DP, Pettit K, Rom CD, et al. The safety and efficacy of prehospital needle and tube thoracostomy by aeromedical personnel. Prehosp Emerg Care. 2005;9(2):191-197. (Retrospective chart review; 81 patients)
52. Warner KJ, Copass MK, Bulger EM. Paramedic use of needle thoracostomy in the prehospital environment. Prehosp Emerg Care. 2008;12(2):162-168. (Retrospective chart review; 39 patients)
53. Parsons CJ, Bobechko WP. Aeromedical transport: its hidden problems. Can Med Assoc J. 1982;126(3):237-243. (Review article)
54. Essebag V, Halabi AR, Churchill-Smith M, et al. Air medical transport of cardiac patients. Chest. 2003;124(5):1937-1945. (Review article)
55. Teichman PG, Donchin Y, Kot RJ. International aeromedical evacuation. N Engl J Med. 2007;356(3):262-270. (Review article)
56. Janahi IA. Spontaneous pneumothorax in children. UpToDate. 2014; http://www.uptodate.com/contents/spontaneous-pneumothorax-in-children?source=related_link. Accessed February 15, 2017. (Review article)
57. Wilcox DT, Glick PL, Karamanoukian HL, et al. Spontaneous pneumothorax: a single-institution, 12-year experience in patients under 16 years of age. J Pediatr Surg. 1995;30(10):1452-1454. (Case series; 17 patients)
58. Tocino IM, Miller MH, Fairfax WR. Distribution of pneumothorax in the supine and semirecumbent critically ill adult. AJR Am J Roentgenol. 1985;144(5):901-905. (Case series; 88 patients)
59. Stark P. Imaging of pneumothorax. UpToDate. 2015; http://www.uptodate.com/contents/imaging-of-pneumothorax. Accessed October 1, 2015. (Review article)
60. Kong A. The deep sulcus sign. Radiology. 2003;228(2):415-416. (Case report; 1 patient)
61. Sabbar S, Nilles EJ. Images in clinical medicine. Deep sulcus sign. N Engl J Med. 2012;366(6):552. (Case report; 1 patient)
62. Ding W, Shen Y, Yang J, et al. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest. 2011;140(4):859-866. (Meta-analysis; 20 studies, 7569 patients)
63. Carr JJ, Reed JC, Choplin RH, et al. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology. 1992;183(1):193-199. (Observational study; 5 radiologists)
64. Druda D, Kelly AM. What is the difference in size of spontaneous pneumothorax between inspiratory and expiratory x-rays? Emerg Med J. 2009;26(12):861-863. (Retrospective cohort study; 44 patients)
65. Seow A, Kazerooni EA, Pernicano PG, et al. Comparison of upright inspiratory and expiratory chest radiographs for detecting pneumothoraces. AJR Am J Roentgenol. 1996;166(2):313-316. (Retrospective chart review; 178 patients)
66. Fisher JK. Skin fold versus pneumothorax. AJR Am J Roentgenol. 1978;130(4):791-792. (Descriptive review)
67. Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad Emerg Med. 2003;10(1):91-94. (Review article)
68. Lichtenstein DA, Meziere G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33(6):1231-1238. (Retrospective study; 197 patients)
69. Soldati G, Testa A, Silva FR, et al. Chest ultrasonography in lung contusion. Chest. 2006;130(2):533-538. (Retrospective chart review; 109 patients/prospective cohort; 12 patient)
70. Savas R, Alper H. Fallen lung sign: radiographic findings. Diagn Interv Radiol. 2008;14(3):120-121. (Case report; 1 patient)
71. Ziter FM Jr, Westcott JL. Supine subpulmonary pneumothorax. AJR Am J Roentgenol. 1981;137(4):699-701. (Retrospective chart review; 32 patients)
72. * Lichtenstein D. Pneumothorax and introduction to ultrasound signs in the lung. In: General Ultrasound in the Critically Ill. Berlin, Germany: Springer-Verlag; 2005:105-111. (Textbook chapter)
73. * Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;37(2):224-232. (Literature review)
74. Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact: an ultrasound sign ruling out pneumothorax. Intensive Care Med. 1999;25(4):383-388. (Prospective cohort study; 41 patients)
75. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11-17. (Literature review)
76. Stone MB. Ultrasound diagnosis of traumatic pneumothorax. J Emerg Trauma Shock. 2008;1(1):19-20. (Single case report)
77. Lichtenstein D, Meziere G, Biderman P, et al. The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med. 2000;26(10):1434-1440. (Prospective observational study; 66 patients)
78. Volpicelli G, Boero E, Stefanone V, et al. Unusual new signs of pneumothorax at lung ultrasound. Crit Ultrasound J. 2013;5(1):10. (Review article)
79. Volpicelli G, Audino B. The double lung point: an unusual sonographic sign of juvenile spontaneous pneumothorax. Am J Emerg Med. 2011;29(3):355.e351-352. (Descriptive article)
80. Lichtenstein DA, Lascols N, Prin S, et al. The “lung pulse”: an early ultrasound sign of complete atelectasis. Intensive Care Med. 2003;29(12):2187-2192. (Prospective observation study; 60 cases)
81. Soldati G, Testa A, Pignataro G, et al. The ultrasonographic deep sulcus sign in traumatic pneumothorax. Ultrasound Med Biol. 2006;32(8):1157-1163. (Prospective blinded study; 186 patients)
82. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. (Consensus guidelines)
83. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest. 2012;141(3):703-708. (Systematic review and meta-analysis; 1048 patients)
84. 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(9):844-849. (Prospective, single-blinded study; 176 patients)
85. Warner BW, Bailey WW, Shipley RT. Value of computed tomography of the lung in the management of primary spontaneous pneumothorax. Am J Surg. 1991;162(1):39-42. (Prospective cohort study; 26 patients)
86. Ayed AK, Chandrasekaran C, Sukumar M. Aspiration versus tube drainage in primary spontaneous pneumothorax: a randomised study. Eur Respir J. 2006;27(3):477-482. (Prospective, nonblinded, randomized, controlled trial; 137 patients)
87. Tsou KC, Huang PM, Hsu HH, et al. Role of computed tomographic scanning prior to thoracoscopic surgery for primary spontaneous pneumothorax. J Formos Med Assoc. 2014;113(9):606-611. (Retrospective cohort study; 297 patients)
88. Rhea J, DeLuca S, Greene R. Determining the size of pneumothorax in the upright patient. Radiology. 1982;144(4):733-736. (Retrospective study)
89. Noppen M, Alexander P, Driesen P, et al. Quantification of the size of primary spontaneous pneumothorax: accuracy of the Light index. Respiration. 2001;68(4):396-399. (Prospective observational study; 18 patients)
90. Collins CD, Lopez A, Mathie A, et al. Quantification of pneumothorax size on chest radiographs using interpleural distances: regression analysis based on volume measurements from helical CT. AJR Am J Roentgenol. 1995;165(5):1127-1130. (Prospective observational study; 19 patients)
91. Hoi K, Turchin B, Kelly AM. How accurate is the Light index for estimating pneumothorax size? Australas Radiol. 2007;51(2):196-198. (Database review; 27 patients)
92. Kelly AM, Weldon D, Tsang AY, et al. Comparison between two methods for estimating pneumothorax size from chest x-rays. Respir Med. 2006;100(8):1356-1359. (Database review; 57 patients)
93. Salazar AJ, Aguirre DA, Ocampo J, et al. Evaluation of three pneumothorax size quantification methods on digitized chest x-ray films using medical-grade grayscale and consumer-grade color displays. J Digit Imaging. 2014;27(2):280-286. (Retrospective review; 76 patients)
94. Volpicelli G, Boero E, Sverzellati N, et al. Semi-quantification of pneumothorax volume by lung ultrasound. Intensive Care Med. 2014;40(10):1460-1467. (Prospective observational study; 124 patients)
95. Kelly AM, Druda D. Comparison of size classification of primary spontaneous pneumothorax by three international guidelines: a case for international consensus? Respir Med. 2008;102(12):1830-1832. (Retrospective cohort study; 44 patients)
96. Kelly AM. Treatment of primary spontaneous pneumothorax. Curr Opin Pulm Med. 2009;15(4):376-379. (Review article)
97. Kelly AM, Loy J, Tsang AYL, et al. Estimating the rate of re-expansion of spontaneous pneumothorax by a formula derived from computed tomography volumetry studies. Emerg Med J. 2006;23(10):780-782. (Retrospective chart review; 57 patients)
98. Chadha TS, Cohn MA. Noninvasive treatment of pneumothorax with oxygen inhalation. Respiration. 1983;44(2):147-152. (Prospective observation study; 8 patients)
99. Zierold D, Lee SL, Subramanian S, et al. Supplemental oxygen improves resolution of injury-induced pneumothorax. J Pediatr Surg. 2000;35(6):998-1001. (Animal study)
100. Northfield TC. Oxygen therapy for spontaneous pneumothorax. Br Med J. 1971;4(5779):86-88. (Prospective observational study; 22 patients)
101. Clark SD, Saker F, Schneeberger MT, et al. Administration of 100% oxygen does not hasten resolution of symptomatic spontaneous pneumothorax in neonates. J Perinatol. 2014;34(7):528-531. (Retrospective chart review; 83 patients)
102. Butler DA, Orlowski JP. Nitrogen washout therapy for pneumothorax. Cleve Clin Q. 1983;50(3):311-315. (Case series; 2 patient)
103. Shaireen H, Rabi Y, Metcalfe A, et al. Impact of oxygen concentration on time to resolution of spontaneous pneumothorax in term infants: a population based cohort study. BMC Pediatr. 2014;14:208. (Population-based cohort study; 92 patients)
104. Pasquier M, Hugli O, Carron P-N. Needle Aspiration of Primary Spontaneous Pneumothorax. N Engl J Med. 2013;368(19):e24. (Instructional video)
105. Chan SSW, Lam PKW. Simple aspiration as initial treatment for primary spontaneous pneumothorax: Results of 91 consecutive cases. J Emerg Med.28(2):133-138. (Retrospective review; 91 patients)
106. Harvey J, Prescott RJ. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs. British Thoracic Society Research Committee. BMJ. 1994;309(6965):1338-1339. (British Thoracic Society guidelines)
107. Andrivet P, Djedaini K, Teboul JL, et al. Spontaneous pneumothorax. Comparison of thoracic drainage vs immediate or delayed needle aspiration. Chest. 1995;108(2):335-339. (Prospective observational study; 97 patients)
108. Noppen M, Alexander P, Driesen P, et al. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Am J Respir Crit Care Med. 2002;165(9):1240-1244. (Multicenter, prospective, randomized study; 60 patients)
109. Wakai A, O’Sullivan RG, McCabe G. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev. 2007(1):CD004479. (Cochrane review; 1 randomized controlled trial)
110. Zehtabchi S, Rios CL. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Ann Emerg Med. 2008;51(1):91-100, 100.e101. (Systemic review of the literature; 3 randomized controlled trial)
111. Fysh ET, Smith NA, Lee YC. Optimal chest drain size: the rise of the small-bore pleural catheter. Semin Respir Crit Care Med. 2010;31(6):760-768. (Literature review)
112. Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest tubes for pneumothoraces in children treated in the emergency department. Pediatr Emerg Care. 2002;18(4):265-267. (Retrospective chart review; 27 patients)
113. Horsley A, Jones L, White J, et al. Efficacy and complications of small-bore, wire-guided chest drains. Chest. 2006;130(6):1857-1863. (Prospective cohort study; 44 patients)
114. Tsai WK, Chen W, Lee JC, et al. Pigtail catheters vs large-bore chest tubes for management of secondary spontaneous pneumothoraces in adults. Am J Emerg Med. 2006;24(7):795-800. (Retrospective chart review; 91 patients)
115. Dev SP, Nascimiento B Jr, Simone C, et al. Videos in clinical medicine. Chest-tube insertion. N Engl J Med. 2007;357(15):e15. (Instructional video)
116. Connors K, Terndrup T. Tube thoracostomy and needle decompression of the chest. In: King C, Henretig F, eds. Textbook of Pediatric Emergency Procedures. 1st ed. Philadelphia, PA: Williams & Wilkins; 1997:389-413. (Textbook chapter)
117. Lukanich J, Sugarbaker D. Chest wall and pleura. In: Townsend C, Beauchamp D, Evers B, et al., eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Practicsurgical Practice. 17th ed. Philadelphia, PA: Saunders; 2004:1728-1729. (Textbook chapter)
118. Qureshi FG, Sandulache VC, Richardson W, et al. Primary vs delayed surgery for spontaneous pneumothorax in children: which is better? J Pediatr Surg. 2005;40(1):166-169. (Retrospective chart review; 54 patients)
119. O’Lone E, Elphick HE, Robinson PJ. Spontaneous pneumothorax in children: when is invasive treatment indicated? Pediatr Pulmonol. 2008;43(1):41-46. (Retrospective review; 31 patients)
120. Butler KL, Best IM, Weaver WL, et al. Pulmonary artery injury and cardiac tamponade after needle decompression of a suspected tension pneumothorax. J Trauma. 2003;54(3):610-611. (Case report)
121. Rawlins R, Brown K, Carr C, et al. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J. 2003;20(4):383-384. (Case report; 1 patient)
122. Baldwin S, Terndrup T. Thoracostomy and related procedures. In: King C, Henretig F, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:355-390. (Textbook chapter)
123. Roberts JS, Bratton SL, Brogan TV. Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients. Chest. 1998;114(4):1116-1121. (Retrospective chart review; 91 patients)
124. Odita JC, Khan AS, Dincsoy M, et al. Neonatal phrenic nerve paralysis resulting from intercostal drainage of pneumothorax. Pediatr Radiol. 1992;22(5):379-381. (Case series; 4 patients)
125. Sherman SC. Reexpansion pulmonary edema: a case report and review of the current literature. J Emerg Med. 2003;24(1):23-27. (Case report; 1 patient, review of the literature)
126. Kira S. Reexpansion pulmonary edema: review of pediatric cases. Paediatr Anaesth. 2014;24(3):249-256. (Literature review; 22 cases)
127. Cantor R. Management of open chest wounds. In: King C, Henretig F, eds. Textbook of Pediatric Emergency Procedures. 1st ed. Philadelphia, PA: Williams & Wilkins; 1997:383-387. (Textbook chapter)
128. Wilson H, Ellsmere J, Tallon J, et al. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation? Injury. 2009;40(9):928-931. (Retrospective chart review; 1881 patients)
129. American College of Surgeons Committee on Trauma Advanced Trauma Life Support: Student Course Manual. Chicago, IL: American College of Surgeons; 2012. (ATLS textbook)
130. Inaba K, Branco BC, Eckstein M, et al. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011;71(5):1099-1103. (Cadaver study; 20 cadavers)
131. Zengerink I, Brink PR, Laupland KB, et al. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008;64(1):111-114. (Retrospective review; 774 patients)
132. Akoglu H, Akoglu EU, Evman S, et al. Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients. Injury. 2013;44(9):1177-1182. (Prospective observational study; 160 patients)
133. Yamagiwa T, Morita S, Yamamoto R, et al. Determination of the appropriate catheter length for needle thoracostomy by using computed tomography scans of trauma patients in Japan. Injury. 2012;43(1):42-45. (Retrospective review; 256 patients)
134. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012;147(9):813-818. (Retrospective chart review; 680 patients)
135. Roberts J, McManus J, Harrison B. Use of ultrasonography to avoid an unnecessary procedure in the prehospital combat environment: a case report. Prehosp Emerg Care. 2006;10(4):502-506. (Case report; 1 patient)
136. Nelson BP, Chason K. Use of ultrasound by emergency medical services: a review. Int J Emerg Med. 2008;1(4):253-259. (Review article)
137. Chin EJ, Chan CH, Mortazavi R, et al. A pilot study examining the viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol. J Emerg Med. 2013;44(1):142-149. (Prospective educational intervention; 20 participants)
138. * Voisin F, Sohier L, Rochas Y, et al. Ambulatory management of large spontaneous pneumothorax with pigtail catheters. Ann Emerg Med. 2014;64(3):222-228. (Retrospective analysis of prospectively gathered data; 132 patients)
139. * You JS, Park S, Chung SP, et al. Usefulness of a mobile phone with video telephony in identifying the correct landmark for performing needle thoracocentesis. Emerg Med J. 2009;26(3):177-179. (Prospective randomized mannequin study)
140. Gurley MB, Richli WR, Waugh KA. Outpatient management of pneumothorax after fine-needle aspiration: economic advantages for the hospital and patient. Radiology. 1998;209(3):717-722. (Retrospective chart review; 74 patients)
141. Campisi P, Voitk AJ. Outpatient treatment of spontaneous pneumothorax in a community hospital using a Heimlich flutter valve: a case series. J Emerg Med. 1997;15(1):115-119. (Case series; 14 patients)
142. Finnbogason T, Bremmer S, Ringertz H. Side markings of the neonatal chest x-ray: two legal cases of pneumothorax side mix up. Eur Radiol. 2002;12(4):938-941. (Case reports; 2 patients)