\oi.. 96, No.

SUBPULMONARY PNEUMOTHORAX*
By GERALD J. KURLANDER, Ml)., and CHARLES H. HELMEN, M.D.
INDIANAPOLIS, INDIANA

I A RECEVF publication, Fleiscilner’ strated the presence of a crescentic gas collec-

Ilas explained in some detail the mecha- tioll in tile base of tile left pleural cavity with
nisols for tIle variation in locations of free sonie extension of gas laterally about the dis-

pleural fluid. The same nlechanisrns appl\ eased lower lobe.

to t1IltI5tUtl locations of pneumothorax- CASE 11 (35-39-26). A.H., a 24 hour old feillale
specificall su bpulmonar pneurnothorax. infant, weigiled 6 pounds, 6 ounces at birtil.
\Ve have observed several instances of sub- Ille mother ilad a llorlllai pregnancy and a nor-

pulmonary distril)ution of free pleural gas. nial vmiginal delivery. At the tulle of birth the
ElliS brief communication is presented to condition of tile patient appeared good but at 20
ilours of age tile respiratory rate was noted to l)e
etllpilaSize the roentgen features of sul)-
rapid and tile infant refused feedings of glucose
pulmonar\ pneumothorax and to add fur-
water. Frontal and lateral chest roentgenograms
tiler roentgen confirmation to the theor of
( Fig. 2, /1 and B) at tllis tulle demonstrated a
pleu ral pressu re dnam ics as suggested by subpulmionary gas lucency on tile left witll loss
American Journal of Roentgenology 1966.96:1019-1021.

i’lei schner. of voluille of tile left lower lobe. Ihe subpui-

I1.LUSI’RAIIVE CASES
monary gas was seen beneath the left lower lobe
ill tile lateral projection. In addition, mediastinai
CASE I (12-04-38). D.G., a 25 year old white gas was seen in tile anterior mediastinuill on tile
female, was admitted with tile diagnosis of lateral projection. Roentgenograms of the chest
bronchopneulllonia. A frontal chest roentgeno- 7 days later were considered to be normal.
gram indicated bilateral basilar l)roncilopneu-
IllOiliZt (Fig. ‘M. An attempt to aspirate fluid CASE III (37-09-19). P.B. was a 31 ilour old
from tile left pleural cavity was unsuccessful. A ternl 1lale infant. At approxinately 27 ilours of
Iron til chest roen tgenogranl il ade jill mediately age tile patient was noted to be siigiltly cyanotic
following tile thOrtce1ltesis (Fig. i B) demon- and tacilypneic. The patient was tllen referred

11G. 1. Case i. (1) Frontal cilest roentgenogram shows bilateral basilar bronchopneumonia. (B) Frontal cilest
rOell tgenogram i1lmediately after tiloracentesis silows the crescen tic gas lucency of subpulmonary pneumo-
thorax. Intrapleural gas can be seen extending laterally d)out the diseased lower lobe.

* 1’rormm the Department of RaWology, Indiana University Medical Center, Indianapolis, Indiana.

1019
 1020 Gerald j. Kurlander and Charles H. Helmen A mR I I. I
American Journal of Roentgenology 1966.96:1019-1021.

11G. 2. Case II. (A) lrontal chest roentgenogram shows the crescentic gas lucencv (arrows’) of subpulmonary

pneumothorax. (B) Lateral chest roentgenogram shows free intrapleural gas (arrows) beneath tile mncom-

Pletel eXI)anded left lower lobe. The retrosternal lucencv is indicative of pneumomediastinum.

to tile Illdiana 1 niversity l\Iedical Cell ter. pneu Illotilorax . Blood , exu d a te, Ill Ii cosal
Physical exalllinatioll at tile tulle of adillission edenia, or aII intrabroncilial Illaterial lllav
sllowed an overactive apical impulse wilicll was obstruct the smaller bronchi of a lobe to
palpated adjacent to the right nipple. A frontal produce some degree of lobar collapse. Fx-
cilest roentgenogran (Fig. 3) demonstrated
cept when tile lobe is completely consoli-
dextrocardia, crescen tic shaped subpulnlon ary
dated, lobar collapse greatly enilances tile
pneumothorax on tile left associated witil in-
retractile tendency of tile lobe. A pneunlo-
filtration and loss of volume of the left lower
lobe. In addition, tilere was evidence of pneu-
tiloraX under these circumstances will tend

llloillediastinunl. The cardiac silhouette was to collect around tilis lobe VCll if ti’e pa-
located in tile right ilemithorax. During tile next tient is ill the upright positioll and tile lobe
2 weeks tile cyanosis disappeared alld the respi-
ratorv rate returned to nornal. Tille cardiac
diagnosis based on pllysical examination, chest
roen tgenograms, and electrocardiogranl was
dextrocardia, ventricular septal defect, and
possible pulmonary stenosis.

1) I S C U S S I 0 N
r
The normal lung remains expanded be-
cause it is subjected to atmospheric pressure F

via a patent tracheobronchial tree and be-

cause the intrapleural pressure is slightly
less than atmospheric pressure. In the pres-
ence of pneumothorax, a healthy lung will
retract in a nearly symmetric fashion
around its periphery, tending to preserve
the normal configuration. If a lobe of the
11G. 3. Case III. Frontal chest roentgenogram shows
lung is diseased, this symmetric collapse dextroca rd ia, pneu rnomedi as ti flUIll , a nd su bpu I-
pattern may not occur in the presence of monarv pneumothorax (arrows).
 VOL. 96, No. Subpulmonary Pneumothorax 1021

involved is a lower lobe. Here the atelecta- in the lower thorax which corresponds to
tic tendency of the diseased lower lobe re- gas in the fascial planes of the mediastinum
sists “re-expansion more than the rest of and diaphragmatic pleura in the region of
the lung.” In the patients described above, the lower esophagus. There should be no
all had evidence of disease of the left lower confusion between this lucencv and sub-
lobe and all had the crescentic gas lucency pulmonary pneumothorax. The former gas
i ndi cati ye of su bpulmonary pneumotho- collection is always accompanied by mcdi-
rax.2 The upper margin of this lucency con- astinal emphysema and is usually present
responds to the lower lobe with its visceral in very small amounts, occasionally de-
pleural covering and the lower margin con- tectable on routine chest roentgenognams.
responds to the diaphragm with its panietal Rarely, if ever, does the gas in the fascial
pleural coverillg. planes of the diaphnagmatic pleura extend
Sti bpulmonar’ pneumothonax when pres- to the lateral margin of the diaphragm.
ent on roentgenograms made in the up-
right position may be confused with free SUMMARY

i n traperi toneal gas. Si nce pneumonia, par- Subpulmonary pneumothorax is a rather

ticularlv of the lower lobe, can simulate frequent localization of free intrapleural
acute abdominal disease, the correct inter-
American Journal of Roentgenology 1966.96:1019-1021.

gas when there is disease in the lower lobe

pretation of the gas lucency is of the utmost of the lung. Its mechanism and roentgen
importance. Often some free gas may be features are briefly outlined.
seen about the lateral margin of the lower
lobe to establish the diagnosis of pneumo- Gerald J. Kurlander, M.D.
I)epartment of Radiology
thorax. If a crescentic gas lucency is seen
Indiana University Medical Center
in the presence of lower lobe disease, sub- I 100 West Michigan Street
pulmonary pneumothorax should be the Indianapolis, Indiana
first consideration rather than free intra-
peritoneal gas. A right on left lateral debubi- RE FERENCES

ttis roentgenogram of the lower chest and I. FLEISCHNER, F. G. Atypical arrangement of free
upper abdomen using a horizontally directed pleural effusion. Rad. C’/in. North America,
roentgen-ray beam silould provide defini- 1963, I, 347-362.
tive differentiation in questionable cases.
2. FLEISCHNER, F. G. Personal communication,
1965.
An early roentgen sign of spontaneous 3. PANARO, V. A., and LESLIE, E. S. Spontaneous
rupture of the esophagus is the “V” sign of rupture ofesophagus. Radio/ogy, 1965, 84, 252-
Naclerio.3 This is a V-shaped radiolucency 258.