A pneumothorax can sometimes be difficult to detect on a standard chest X-ray and further imaging with CT may be necessary
Expiratory chest X-rays are not considered to be of additional benefit in the routine assessment of pneumothorax (see British Thoracic Society for up to date guidelines) - occasionally CT may be required if there is diagnostic uncertainty which shows even the smallest pneumothorax
Note that air density (black) is the same inside and outside the chest