A 28-year-old man with a known history of asthma presents acutely with severe breathlessness. Chest X-ray reveals hyperinflation, a thin vertical line of visceral pleural edge parallel to the chest wall on the left with no lung markings peripheral to it, and shifting of the mediastinum to the right. What is the most accurate description of the radiological finding and its management implication?

• A Large left pneumothorax with tension physiology; requires immediate needle decompression ✓
• B Left-sided pleural effusion; requires diagnostic thoracocentesis
• C Left upper lobe collapse; requires bronchoscopy
• D Pneumomediastinum; managed conservatively with oxygen

Explanation

A large pneumothorax is identified by the visible visceral pleural line separated from the parietal pleura with absent lung markings peripherally. Mediastinal shift to the contralateral side in the clinical context of haemodynamic compromise indicates tension pneumothorax, which requires emergency needle decompression at the second intercostal space mid-clavicular line before formal chest drain insertion. Left upper lobe collapse would show leftward mediastinal shift. Pneumomediastinum shows air outlining mediastinal structures without a pleural line.

Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.