Pneumatocele

Pneumatoceles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances. They may contain air-fluid levels and are usually the result of ventilator-induced lung injury in neonates or post-infectious. They should not be mistaken for a cavitating lung mass

Although pneumatoceles are seen in all age groups, they are most frequently encountered in infancy 1

The majority of pneumatoceles occur as a result of pneumonia (post-infectious pneumatocele). The causative agents include:

  • Staphylococcus aureus (most common)
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Escherichia coli
  • group A streptococci
  • Klebsiella pneumoniae
  • adenovirus
  • primary pulmonary tuberculosis

In addition to infection, pneumatoceles are also seen in a number of other settings, including:

  • trauma: usually blunt trauma
  • positive pressure ventilation, especially in preterm neonates 4
  • hydrocarbon ingestion

Three main theories have been put forward to explain the formation of pneumatoceles 1:

  1. pulmonary overinflation caused by transient bronchial/bronchiolar obstruction and a ball-valve effect.
  2. drainage of necrotic lung parenchyma with subsequent enlargement secondary to a ball-valve effect.
  3. focal collections of air within the pulmonary interstitium following inflammation and necrosis of the airway wall and fistula formation with the pleura.

Pneumatoceles are typically asymptomatic and, if secondary to pneumonia, remain visible after septic symptoms have resolved 1. Occasionally pneumatoceles become large enough to compress adjacent lung and the mediastinum enough to cause respiratory or cardiovascular symptoms. 

Secondary infection may occur resulting in features of chest sepsis. 

When mature, pneumatoceles appear as thin walled cystic spaces within the lung parenchyma, containing air. However, it is important to remember that as they usually occur in the setting of infection, their appearance may vary, depending on the stage at which they are imaged. 

They tend to appear within the first week of infection and have usually resolved by week six.

If they are imaged during formation, they may have surrounding consolidation and be difficult to distinguish from abscesses. Features that favour a pneumatocele over an abscess are 1:

  • smooth inner margins
  • little if any fluid content
  • the wall, if visible, is thin and regular
  • tend to persist despite an absence of symptoms

Post-infectious pneumatoceles tend to spontaneously resolve, providing that the infection is adequately treated with antibiotics.  Surgical intervention is only required if the pneumatocele causes symptoms due to mass effect or if it ruptures into the pleural space resulting in a pneumothorax.

Complications
  • a rupture of a pneumatocele may cause a pneumothorax 3
  • secondary infection of the pneumatocele 5

The differential is generally that of cavitating lung masses and other air-containing lung lesions. 

In an older patient, the differential diagnosis for a cavitating lung lesion include:

Share article

Article information

rID: 15516
System: Chest
Section: Gamuts
Synonyms or Alternate Spellings:
  • Pneumatocoeles
  • Pneumatocele
  • Pneumatoceles

Support Radiopaedia and see fewer ads

Cases and figures

  • Drag
    Case 1
    Drag here to reorder.
  • Drag
    Case 2
    Drag here to reorder.
  • Drag
    Case 3: traumatic pneumatocoeles
    Drag here to reorder.
  • Drag
    Case 4
    Drag here to reorder.
  • Drag
    Case 5
    Drag here to reorder.
  • Drag
    Case 6: gunshot injury
    Drag here to reorder.
  • Drag
    Two months after ...
    Case 7: post pneumonic
    Drag here to reorder.
  • Updating… Please wait.
    Loadinganimation

    Alert accept

    Error Unable to process the form. Check for errors and try again.

    Alert accept Thank you for updating your details.