Suspected pneumothorax
Recommended: Upright Chest X-ray (in expiration if subtle) is the preferred imaging study for suspected pneumothorax. Tension pneumothorax is a clinical diagnosis — needle decompression first, do not image.
Recommended study
Upright Chest X-ray (in expiration if subtle)
Tension pneumothorax is a clinical diagnosis — needle decompression first, do not image.
If the default doesn't apply
Patient cannot stand
XR
Lateral decubitus CXR (suspected side up)
No contrast
Occult or complex pneumothorax suspected
CT
CT Chest without contrast
No contrast
Trauma context
US
Bedside thoracic ultrasound (E-FAST extended)
No contrast
Watch-outs
Tension pneumothorax (hypotension, JVD, tracheal deviation, absent breath sounds)
Needle decompression at the 2nd intercostal space, midclavicular line — DO NOT delay for imaging.
Supine portable CXR can miss anterior PTX
Look for the 'deep sulcus' sign and hyperlucent upper abdomen. Confirm with upright film or CT if stable.
Pearls
- Inspiratory CXR is usually sufficient — routine expiratory films add little.
- Thoracic ultrasound (loss of pleural sliding, lung point sign) is more sensitive than supine CXR for small PTX.
- Recurrent or large PTX warrants pulmonology / thoracic surgery referral for VATS or pleurodesis.