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, Pleural Disease
Apr 21 2012

Mechanisms of Pneumothorax in the Critically Ill

Air can accumulate in the pleural space in three ways:

Diagnosis of Pneumothorax in the ICU

Pneumothorax can be difficult to recognize in a critically ill patient. Physical exam and clinical signs and symptoms are unreliable and nonspecific, but may raise clinical suspicion for pneumothorax:

Because clinical signs are unreliable, radiography is required to diagnose pneumothorax.

Chest Ultrasound to Diagnose Pneumothorax

Mounting evidence suggests that thoracic ultrasonography by an experienced operator can be as accurate as chest X-ray at diagnosing pneumothorax. However, a brief training period is required.

Mounting evidence

The "lung point" (absence of sliding lung next to sliding lung) has a 100% specificity for pneumothorax, but its sensitivity is lower. The lung point sign is dependent on at least part of the lung contacting the chest wall -- therefore, it's better to diagnose small pneumothoraces and becomes less sensitive as a pneumothorax increases in size.

The presence of B-lines along with sliding lung has a 100% negative predictive value for pneumothorax at the point examined -- multiple areas must be examined to rule out pneumothorax with confidence.

Video tutorial on the bedside ultrasound for pneumothorax (thanks to the Hennepin County Department of Emergency Medicine ):

Hennepin County Department of Emergency Medicine

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Chest CT and Chest X-ray to Diagnose Pneumothorax

Chest CT is the gold standard for diagnosing pneumothorax, as well as determining size. Size is of less importance than clinical severity (hypoxia, distress, pain, hemodynamics) and pneumothorax size should not dictate management on its own.

Authors argue that chest X-rays have become effectively obsolete and should not be relied upon to diagnose pneumothorax in the critically ill patient. Pitfalls include potential loculated pneumothoraces occurring in heterogeneous ARDS or patients with pleural adhesions, as well as difficulties interpreting supine films. Although they essentially argue ultrasound should replace chest-X-rays, it's clear that most intensivists do not have this expertise.


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In 1870 he was elected a member of the first school board for Birmingham; and for the next six years, and especially after 1873, when he became leader of a majority and chairman, he actively the Nonconformist opposition to denominationalism.
The democratic party was first by Jesolo and then by Malamocco.
But the Republicans, as is almost inevitable under a party system, the policy opposed by the other side, and declared themselves not only in favour of the maintenance of existing duties, but of the consistent and unqualified further application of protection.
The pre-Pauline date is by B.
During the Burgundian period it was the residence of Margaret of York, widow of Charles the Bold; and the pretender Perkin Warbeck, whom she , if not born there, was the reputed son of a Jew of Tournai.
It was not till after the cardinals of the two colleges had led to the convocation of the general council of Pisa that Pierre d'Ailly renounced the support of Benedict XIII., and, for want of a better policy, again allied himself with the cause which he had in his youth.
Basil of Caesarea, throwing over the cause of Eustathius, that of Meletius who, when after the death of Valens he returned in triumph to Antioch, was hailed as the leader of Eastern orthodoxy.
She found time in 1843 to edit the Letters of Mary, Queen of Scots, whose innocence she with enthusiasm.
It was in Bohemia that they the principle most openly, where they were striving for national separation and protection against the Czechs of the territories which they had inhabited since the Middle Ages.
1 Hussarek again gave the Reichsrat a chance; he recognized expressly the right of the peoples to free self-determination, adopted the standpoint of national autonomy, Polish independence, and announced the union of all the Southern Sla y s of Austria by constitutional means.
In Italy, a little later, Dante the divine right of the emperor (De Monarchia, 1311).
It the rights of private ownership against Socialism, and combated the anti-Rome movement which was taking place throughout the republic. In foreign affairs it supported the Government.
Some time in the 12th century the story was wrought into consecutive poems. The latest theory, with great skill by M.
But Bohemund was not secure in the possession of Antioch, even after its surrender and the defeat of Kerbogha; he had to make good his claims against Raymund of Toulouse, who the rights of Alexius.
He popular education and recommended the homestead policy to the national government, and from his sympathy with the working classes and his oft-avowed pride in his former calling he became known as the " mechanic governor."
He the complete laicization of the schools in Ontario, but unsuccessfully, the Roman Catholic church maintaining its right to separate schools.
Rutledge the Constitution in the South Carolina convention by which that instrument was adopted on behalf of the state.
- [ED.] III., the French king appeared the less dangerous, and the result was the Leo his cause with all his energies.
The exiled abbe Vincenzo Gioberti an Italian confederacy under the presidency of the pope; hand in hand with the unity of the nation should go the unity of the faith.
These articles, contained in the 5th Scheme, and zealously by the sectaries of the Jesuit order, reveal the immediate object for which the council of1869-1870was convened.
At this time Jefferson the natural right of expatriation, and gradual emancipation of the slaves.
One theory emphasized the necessity of grace; having been put together by St Thomas Aquinas, it was known as Thomism, and was especially by the Dominicans.
The Latin races, by Spain and supported by the papacy, fought the battle of the latter, and succeeded for a time in rolling back the tide of revolutionary conquest.
Webster declared that the Federal government through the Supreme Court was the ultimate expounder and interpreter of its own powers, while Calhoun the rights of the individual state under a written contract which reserved to each state its sovereignty.
Yet, by the maintenance of his peace policy, which had the full approval of the Emperor Francis Joseph, he came into serious conflict with the party led by the chief of the general staff, Conrad von Hdtzendorf, which a policy not afraid of energetic, warlike methods.
From the standpoint of the Pharisees who the hope of everlasting life and believed in the existence of angels, through whom God could communicate with men, they were infidels.
A pamphlet written in 1885 for an association called the Empire League by Mr Charles Leonard, who afterwards consistently the cause of civil equality and impartial justice in South Africa, maintained as follows: " (1) That the establishment of the English government here was beneficial to all classes; and (2) that the withdrawal of that government would be disastrous to every one having vested interests in the colony..
To Burlingame's appointment as minister to Austria (March 22, 1861) the Austrian authorities objected because in Congress he had advocated the recognition of Sardinia as a first-class power and had Hungarian independence.
The council was a power in politics only when manipulated by a great state, as Thebes, Macedon or Aetolia, and in such a case its decrees were most likely to give offence by their partisanship. Although the council sometimes the Hellenic cause, as could any association or individual, it never acquired a recognized authority over all Greece; and notwithstanding its frequent participation in political affairs, it remained essentially a religious convocation.
This having no effect, he issued the most outspoken of his works, De septem ecclesiae statibus, in which he reviewed the work of the reforming councils of his time, and, without touching the question of doctrine, a drastic reform of life and practice of the church on the lines laid down at Constance and Basel.
From the first he the cause of the Allies in the World War, and after America's entrance into the war he served as a naval chaplain.
On the 7th of June 1776 he seconded the famous resolution introduced by Richard Henry Lee that " these colonies are, and of a right ought to be, free and independent states," and no man these resolutions (adopted on the 2nd of July) so eloquently and effectively before the congress.
As editor of the Omaha World-Herald he then the cause of bimetallism in the press as vigorously as he had in Congress and on the platform, his articles being widely quoted and discussed.
The polyzoic view is ably by Braun (2) and (3).
Though a libertine and a free-thinker, he had the most bigoted and tyrannical high-church measures.
Unlike most men of the ruling classes in England, he warmly the cause of the North, and his pamphlets, especially one entitled Does the Bible sanction American Slavery?

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Witnesses were asked to comment on the use of science at the state level for managing fisheries and preventing overfishing. Mr. Chris Blankenship (Commissioner, Alabama Department of Conservation and Natural Resources), Mr. Chris Macaluso (Director; Center for Marine Fisheries, Theodore Roosevelt Conservation Partnership), and Mr. Mike Merrifield (Fish Section Chairman, Southeastern Fisheries Association) praised the management of state and recreational fisheries and articulated anglers’ trust for state level management. There was bipartisan support for encouraging federal-state research efforts.

Ranking Member Huffman called out the partisan nature of the reauthorization process and asked instead for bipartisan “mutually agreed upon priorities” and an end to “poison pill provisions” that would undermine environmental legislation such as the Marine Mammal Protection Act , the National Marine Sanctuaries Act , and the Endangered Species Act .

The current use of outdated stock assessments to set annual catch limits was broadly disliked by many panelists and Republicans and was acknowledged by NOAA and Democrats as a problem that could be fixed. Some struggled with the agency’s perspective of having the “best science available” and proposed that NOAA use alternative (more real-time) data sources from states or universities as a solution. How these data would be collected and which would be used has yet to be determined, but both parties agreed that state-federal cooperation would be advantageous.


“NOAA Fisheries stands ready to work with the Congress to craft a reauthorization bill that addresses current fishery management challenges and ensures the nation’s fisheries are able to meet the needs of both current and future generations.” – Mr. Chris Oliver (Assistant Administrator, NOAA Fisheries)

“We have been able to craft a fisheries management strategy that is flexible and based in sound science. The MSA is unique among natural resource laws in that best practices are crafted by fishermen and other stakeholders to deal with specific region challenges.” – Representative Nanette Barragán (CA-44)

“What we are dealing with is a one-size-fits-all, and it is not very adaptive, in my opinion.” – Representative Jody Hice (GA-10).

“The truth of the matter is there are plenty of fish out there…we just need to get our science right, and I think the bills that are being considered by this committee will get us there.” – Representative Bradley Byrne (AL-1)

Next Steps

Chairman Emeritus Young committed to progressing forward, declaring, “We’re going to try to get some things moving by October or November of this year.”

Find Out More

Watch the full hearing

Witness Testimonies:

Related coverage from the Consortium for Ocean Leadership

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