Intensive Care Medicine

, Volume 37, Issue 2, pp 224–232 | Cite as

Sonographic diagnosis of pneumothorax

  • Giovanni VolpicelliEmail author



Over the last decade, the use of ultrasound as a technique to look for pneumothorax has rapidly evolved. This review aims to analyze and synthesize current knowledge on lung ultrasound targeted at the diagnosis of pneumothorax. The technique and its usefulness in different scenarios are explained, and its merits over conventional radiology are highlighted.


A systematic literature search (1995–2010) was performed, involving PubMed, to describe the more recent scientific evidence on the topic. Moreover, this review is also a synopsis of experts’ opinion and personal clinical experience.

Results and conclusions

Ultrasound diagnosis of pneumothorax relies on the recognition of four sonographic artifact signs: the lung sliding, the B lines, the lung point, and the lung pulse. Combining these few signs, it is possible to accurately rule in or rule out pneumothorax at the bedside in several different clinical scenarios. Sensitivity of a lung ultrasound in the detection of pneumothorax is higher than that of conventional anterior–posterior chest radiography, and similar to that of computerized tomography. A major benefit of a lung ultrasound is that it can be used quickly to diagnose pneumothorax at the bedside in any critical situation, like cardiac arrest and hemodynamically unstable patients. Moreover, it can be used to detect radio-occult pneumothorax and to quantify the extension of the air layer. Advantages in terms of reduced complexity, feasibility at the bedside, and absence of exposure to ionizing radiation make lung ultrasound the method of choice in several common clinical situations.


Emergency ultrasound Lung ultrasound Pneumothorax Chest sonography 

Supplementary material

Online Resource 1 Lung ultrasound scan showing the double lung point. The pleural sliding intermittently appears on both sides. Between the two lung points, an area of lung without pleural sliding can be visualized. (AVI 4341 kb)


  1. 1.
    Lichtenstein DA (2007) Ultrasound in the management of thoracic disease. Crit Care Med 35:S250–S261CrossRefPubMedGoogle Scholar
  2. 2.
    Bouhemad B, Zhang M, Lu Q, Rouby JJ (2007) Clinical review: bedside lung ultrasound in critical care practice. Crit Care 11:205CrossRefPubMedGoogle Scholar
  3. 3.
    Reissig A, Gorg C, Mathis G (2009) Transthoracic sonography in the diagnosis of pulmonary diseases. Ultraschall Med 30:438–458CrossRefPubMedGoogle Scholar
  4. 4.
    Volpicelli G, Cardinale L, Garofalo G, Veltri A (2008) Usefulness of lung ultrasound in the bedside distinction between pulmonary edema and exacerbation of COPD. Emerg Radiol 15:145–151CrossRefPubMedGoogle Scholar
  5. 5.
    Volpicelli G, Silva F, Radeos M (2010) Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department. Eur J Emerg Med 17:63–72CrossRefPubMedGoogle Scholar
  6. 6.
    Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ (2004) Comparative diagnostic performances of auscultation, chest radiography and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 100:9–15CrossRefPubMedGoogle Scholar
  7. 7.
    Soldati G, Testa A, Pignataro G, Portale G, Biasucci DG, Leone A, Gentiloni Silveri N (2006) The ultrasonographic deep sulcus sign in traumatic pneumothorax. Ultrasound Med Biol 32:1157–1163CrossRefPubMedGoogle Scholar
  8. 8.
    Ball CG, Kirkpatrick AW, Laupland KB et al (2005) Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces. Am J Surg 189:541–546CrossRefPubMedGoogle Scholar
  9. 9.
    Tocino IM, Miller MH, Fairfax WR (1985) Distribution of pneumothorax in the supine and semi-recumbent critically ill adult. AJR Am J Roentgenol 144:901–905PubMedGoogle Scholar
  10. 10.
    Lichtenstein DA, Menu Y (1995) A bedside ultrasound sign ruling-out pneumothorax in the critically ill. Lung sliding. Chest 108:1345–1348CrossRefPubMedGoogle Scholar
  11. 11.
    Noble VE, Lamhaut L, Capp R, Bosson N, Liteplo A, Marx JS, Carli P (2009) Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers. BMC Med Educ 9:3CrossRefPubMedGoogle Scholar
  12. 12.
    Monti JD, Younggren B, Blankenship R (2009) Ultrasound detection of pneumothorax with minimally trained sonographers: a preliminary study. J Spec Oper Med 9:43–46PubMedGoogle Scholar
  13. 13.
    Cunningham J, Kirpatrick AW, Nicolaou S, Liu D, Hamilton DR, Lawless B, Lee M, Brown DR, Simons RK (2002) Enhanced recognition of lung sliding with power color Doppler imaging in the diagnosis of pneumothorax. J Trauma 52:769–771CrossRefPubMedGoogle Scholar
  14. 14.
    Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, Hameed SM, Brown R, Simons R, Dulchavsky SA, Hamiilton DR, Nicolaou S (2004) Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST). J Trauma 57:288–295CrossRefPubMedGoogle Scholar
  15. 15.
    Lichtenstein DA, Lascols N, Prin S, Mezière G (2003) The lung pulse: an early ultrasound sign of complete atelectasis. Intensive Care Med 29:2187–2192CrossRefPubMedGoogle Scholar
  16. 16.
    Lichtenstein DA, Mezière G, Biderman P, Gepner A (2000) The lung point: an ultrasound sign specific to pneumothorax. Intensive Care Med 26:1434–1440CrossRefPubMedGoogle Scholar
  17. 17.
    Lichtenstein DA, Mezière GA (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 134:117–125CrossRefPubMedGoogle Scholar
  18. 18.
    Lichtenstein DA, Mezière G, Lascols N, Biderman P, Courret JP, Gepner A, Goldstein I, Tenoudji-Cohen M (2005) Ultrasound diagnosis of occult pneumothorax. Crit Care Med 33:1231–1238CrossRefPubMedGoogle Scholar
  19. 19.
    Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, Fava C, Frascisco M (2006) Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med 24:689–696CrossRefPubMedGoogle Scholar
  20. 20.
    Reissig A, Kroegel C (2003) Transthoracic sonography of diffuse parenchymal lung disease. The role of comet tail artifacts. J Ultrasound Med 22:173–180PubMedGoogle Scholar
  21. 21.
    Soldati G, Copetti R, Sher S (2009) Sonographic interstitial syndrome. The sound of lung water. J Ultrasound Med 28:163–174PubMedGoogle Scholar
  22. 22.
    Agricola E, Bove T, Oppizzi M, Marino G, Zangrillo A, Margonato A, Picano E (2005) Ultrasound comet-tail images: a marker of pulmonary edema. A comparative study with wedge pressure and extravascular lung water. Chest 127:1690–1695CrossRefPubMedGoogle Scholar
  23. 23.
    Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJR, Liteplo A (2009) Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. Chest 135:1433–1439CrossRefPubMedGoogle Scholar
  24. 24.
    Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF (2008) Bedside ultrasound for the monitoring of acute decompensated heart failure. Am J Emerg Med 26:585–591CrossRefPubMedGoogle Scholar
  25. 25.
    Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF (2008) Detection of sonographic B-lines in patients with normal lung or radiographic alveolar consolidation. Med Sci Monit 14:CR122–CR128PubMedGoogle Scholar
  26. 26.
    Lichtenstein D, Meziere G, Biderman P, Gepner A (1999) The comet-tail artifact, an ultrasound sign ruling out pneumothorax. Intensive Care Med 25:383–388CrossRefPubMedGoogle Scholar
  27. 27.
    Chun R, Kirkpatrick AW, Sirois M, Sargasyn AE, Melton S, Hamilton DR, Dulchavsky S (2004) Where’s the tube? Evaluation of hand-held ultrasound in confirming endotracheal tube placement. Prehosp Disast Med 19:366–369Google Scholar
  28. 28.
    Blaivas M, Lyon M, Duggal S (2005) A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 12:844–849CrossRefPubMedGoogle Scholar
  29. 29.
    Zhang M, Liu ZH, Yang JX, Gan JX, Xu SW, You XD, Giang GY (2006) Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma. Crit Care 10:R112CrossRefPubMedGoogle Scholar
  30. 30.
    Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Gentiloni Silveri N (2008) Occult traumatic pneumothorax. Diagnostic accuracy of ultrasonography in the emergency department. Chest 133:204–211CrossRefPubMedGoogle Scholar
  31. 31.
    Volpicelli G (2010) Usefulness of emergency ultrasound in non traumatic cardiac arrest. Am J Emerg Med. doi:  10.1016/j.ajem.2009.03.018
  32. 32.
    Niendorff DF, Rassias AJ, Palac R, Beach ML, Costa S, Greenberg M (2005) Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers. Resuscitation 67:81–87CrossRefPubMedGoogle Scholar
  33. 33.
    Breitkreutz R, Walcher F, Seeger FH (2007) Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm. Crit Care Med 35(5 Suppl):S150–S161CrossRefPubMedGoogle Scholar
  34. 34.
    Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J (2008) CAUSE: cardiac arrest ultra-sound exam—a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 76:198–206CrossRefPubMedGoogle Scholar
  35. 35.
    Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ (2005) Value of high-resolution ultrasound in detecting a pneumothorax. Eur Radiol 15:930–935CrossRefPubMedGoogle Scholar
  36. 36.
    Garofalo G, Busso M, Perotto F, De Pascale A, Fava C (2006) Ultrasound diagnosis of pneumothorax. Radiol Med 111:516–525CrossRefPubMedGoogle Scholar
  37. 37.
    Reissig A, Kroegel C (2005) Accuracy of transthoracic sonography in excluding post-interventional pneumothorax and hydropneumothorax. Comparison to chest radiography. Eur J Radiol 53:463–470PubMedGoogle Scholar
  38. 38.
    Rowan KR, Kirkpatick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S (2002) Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT: initial experience. Radiology 225:210–214CrossRefPubMedGoogle Scholar
  39. 39.
    Sartori S, Tombesi P, Trevisani L, Nielsen I, Tassinari D, Abbasciano V (2007) Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography. AJR Am J Roentgenol 188:37–41CrossRefPubMedGoogle Scholar
  40. 40.
    Gobien RP, Reines HD, Schabel SI (1982) Localized tension pneumothorax: unrecognized form of barotrauma in ARDS. Radiology 142:15–19PubMedGoogle Scholar
  41. 41.
    Hill SL, Edmisten T, Holtzman G, Wright A (1999) The occult pneumothorax: an increasing diagnostic entity in trauma. Am Surg 65:254–258PubMedGoogle Scholar
  42. 42.
    Ball CG, Kirkpatrick AW, Feliciano DV (2009) The occult pneumothorax: what have we learned? Can J Surg 52:E173–E179PubMedGoogle Scholar
  43. 43.
    Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA (2001) Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 119:590–602CrossRefPubMedGoogle Scholar
  44. 44.
    Henry M, Arnold T, Harvey J (2003) BTS guidelines for the management of spontaneous pneumothorax. Thorax 58(Suppl II):ii39–ii52PubMedGoogle Scholar
  45. 45.
    De Leyn P, Lismonde M, Ninana V, Noppen M, Slabbynck H, Van Meerhaeghe A, Van Schil P, Vermassen F (2005) Guidelines Belgian Society of Pulmonology. Guidelines on the management of spontaneous pneumothorax. Acta Chir Belg 105:265–267PubMedGoogle Scholar
  46. 46.
    Baumann MH, Noppen M (2004) Pneumothorax. Respirology 9:157–164CrossRefPubMedGoogle Scholar
  47. 47.
    Engdahl O, Toft T, Boe J (1993) Chest radiograph: a poor method for determining the size of a pneumothorax. Chest 103:26–29CrossRefPubMedGoogle Scholar
  48. 48.
    Dulchavsky SA, Schwarz KL, Kirkpatrick AW, Billica RD, Williams DR, Diebel NL, Campbell MR, Sargysan AE, Hamilton DR (2001) Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 50:201–205CrossRefPubMedGoogle Scholar
  49. 49.
    Kirkpatrick AW, Nicolau S, Rowan K, Liu D, Cunningham J, Sargsyan AE, Hamilton D, Dulchavsky SA (2005) Thoracic sonography for pneumothorax: the clinical evaluation of an operational space medicine spin-off. Acta Astronaut 56:831–838CrossRefPubMedGoogle Scholar
  50. 50.
    Volpicelli G (2008) Towards an appropriate use of ultrasound in resuscitation. Resuscitation 79:341–342CrossRefPubMedGoogle Scholar
  51. 51.
    Volpicelli G, Audino B (2010) The double lung point: an unusual sonographic sign of juvenile spontaneous pneumothorax. Am J Emerg Med. doi:  10.1016/j.ajem.2010.03.020
  52. 52.
    Soldati G, Sher S, Copetti R (2010) If you see the contusion, there is no pneumothorax. Am J Emerg Med 28:106–107CrossRefPubMedGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2010

Authors and Affiliations

  1. 1.Department of Emergency MedicineSan Luigi Gonzaga University HospitalTurinItaly
  2. 2.S.C.D.O. Medicina d’UrgenzaOspedale Universitario San Luigi Gonzaga, OrbassanoTurinItaly

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