Core IM | Internal Medicine Podcast #186 Pneumothorax: 5 Pearls Segment
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Aug 25, 2025 Mihir Parikh, an interventional pulmonologist at BIDMC, dives into the complexities of diagnosing and managing pneumothorax. He breaks down the differences between X-ray, POCUS, and CT for diagnosis and discusses when chest tubes are truly necessary. Parikh also shares insights on effectively explaining pneumothorax to patients and the essential components of pleural drainage systems. Listeners will learn how to monitor air leaks and the best strategies for managing persistent issues, including innovative treatment options.
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Position Greatly Affects X-ray Sensitivity
- Upright chest x-rays are far more sensitive than supine films for pneumothorax detection.
- Supine films may miss pneumothoraces unless >150–200 mL of air is present.
Ultrasound Requires Clinical Context
- Lung ultrasound shows pleural sliding; loss of sliding suggests pneumothorax but is operator-dependent.
- Prior pleurodesis, poor respiratory motion, or large bullae can falsely abolish lung sliding.
CT Prevented Chest Tube Misplacement
- Dr. Darlene Nelson described CT to distinguish large bullae from true pneumothorax to avoid misplacing chest tubes.
- She reported cases where tubes were inadvertently placed into bullae seen as pneumothorax on x-ray.