Pulm/ICU report: Pneumothorax and the deep sulcus sign

Thank you to the ICU team for presenting a chest xray with a pneumothorax c/b re-expansion pulmonary edema.
The deep sulcus sign
  • The most common finding of a pneumothorax on chest xray is the loss of lung vascular markings.
  • In a supine patient, the air can collect anteriorly and basally such that it does not show up in the classic way on a chest xray
  • instead, the costophrenic angle appears abnormally, disproportionately deep.
  • If you see an asymmetric, deep costophrenic angle on a chest xray, suspect a pneumothorax!
  • see an example below
The ddx of pneumothorax
  • primary pneumothorax – no underlying structural cause
  • structural lung abnomalities
    • COPD
    • cystic fibrosis
    • lung malignancy
    • pneumonia
      • PCP – causes 80% of pneumothoraces in patient with HIV. That’s why it’s called pneumocystis
      • necrotizing pneumonia
      • TB
    • asthma
    • barotrauma from mechanical ventilation
    • Anything else that changes the lung architecture including ILD
    • catamenial pneumothorax (pneumothorax caused by thoracic endometriosis.  Yikes.)
  • Oxygen for all! watch out for hypercapnea in people with severe COPD
  • Further management depends on size on chest xray
    • >2cm – chest tube, small bore more comfortable than large bore and just as efficacious
    • 1-2cm – needle aspiration vs small bore chest tube
    • <1cm – oxygen and observation
A useful resource:
Happy Monday everyone!

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