- Email: [email protected]
Is Collapse of the Lung With Increased Lucency on a Chest X-Ray Always a Pneumothorax?
Is Collapse of the Lung With Increased Lucency on a Chest X-Ray Always a Pneumothorax? Satyajeet Misra, MD, DNB, PDCC,* Thomas Koshy, MD, PDCC,* Madathipat Unnikrishnan, MS, MCh,† and Shivananda Siddappa, MS†
A
39-YEAR-OLD MAN presented with a history of breathlessness of increasing severity for the last 3 months. He gave a history of 2 attacks of sudden-onset breathlessness in the last 6 months, the last one being 4 months ago. Both the attacks were diagnosed as pneumothorax and treated with intercostal tube drainage (ICD) without much relief. There was no history of trauma, tuberculosis, or bronchial asthma. He was a known smoker for the last 20 years, smoking 1 pack every day. On examination, the patient was dyspneic but able to speak complete sentences. His respiratory rate was around 25/min and saturation on room air measured 95%. His heart rate was 110 beats/min and regular, and blood pressure was 140/78 mmHg. The trachea was noted to be central on palpation. On auscultation, air entry was decreased over the right lung. Jugular venous pressure was not elevated. Pulmonary function tests revealed moderate dysfunction (forced expired volume in 1
Fig 1.
second/forced vital capacity 60% of predicted). A posteroanterior chest x-ray (CXR) showed collapse of the right lung with visible lung borders and absent vascular markings (Fig 1). What is the diagnosis?
From the Departments of *Anaesthesiology and †Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Kerala, India. Address reprint requests to Satyajeet Misra, MD, DNB, PDCC, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, Kerala, India. E-mail: [email protected] © 2009 Elsevier Inc. All rights reserved. 1053-0770/09/2306-0028$36.00/0 doi:10.1053/j.jvca.2008.08.008 Key words: pneumothorax, giant bulla, lung
Posteroanterior chest x-ray showing complete collapse of the right lung with visible lung border (dashed arrow).
Journal of Cardiothoracic and Vascular Anesthesia, Vol 23, No 6 (December), 2009: pp 911-913
911
912
MISRA ET AL
Fig 2. Computed tomography scan (axial cut) of the chest showing bilateral bullous lung disease with a giant bulla in the right upper lobe.
DIAGNOSIS: GIANT BULLA OF THE RIGHT LUNG
The CXR shows increased lucency on the right side with collapse of the right lung. Although the first impression is massive pneumothorax, its classical features like increased thoracic volume, increased rib separation, ipsilateral heart border flattening, contralateral mediastinal deviation, ipsilateral hemidiaphragmatic depression, and tracheal shifting are absent. Furthermore, the patient’s history (absence of acute breathlessness, unresponsiveness to ICD insertion on 2 previous occasions, and stable cardiovascular status with normal jugular venous pressure) favors the previously mentioned diagnosis. A computed tomography scan of the chest shows multiple emphysematous bullae involving both lungs with a giant bulla in the right upper lobe (Fig 2). There is no evidence of pneumothorax. The patient was posted for bullectomy and pleurodesis under general anesthesia. Intraoperatively, the upper lobe of the right lung was found to be bullous (Fig 3A) with multiple thin-walled daughter bullae (Fig 3B). The largest bulla measured 9.2 ⫻ 6.2 cm (Fig 4). First described by Burke in 1937, giant bullous emphysema, also called the “vanishing-lung syndrome,” is an idiopathic clinical syndrome of progressive dyspnea caused by extensive asymmetric bullous emphysema limited mainly to the upper
Fig 4. Intraoperative photograph of the largest bulla. (Color version of figure is available online.)
lobe of the lungs.1 The disease is predominantly encountered in young or middle-aged cigarette-smoking men and sometimes in nonsmokers who present with shortness of breath. Often, emphysematous bullae coalesce into a giant bulla and may mimic tension pneumothorax on CXR.2
Fig 3. Intraoperative photograph of the right upper lobe showing (A) bullous disease of the lung and (B) multiple thinwalled daughter bullae. (1) Giant bulla. (2) Right middle lobe. (Color version of figure is available online.)
COLLAPSE OF THE LUNG
913
It is important to distinguish between tension pneumothorax and giant bullous disease of the lung because treatment of the 2 conditions is entirely different. Tension pneumothorax is usually treated urgently by ICD insertion, whereas bullous disease of the lung generally requires bullectomy with or without a limited pulmonary resection. ICD insertion in the treatment of giant bulla not only does not relieve symptoms, but it also has the risk of leading to a prolonged air leak from a potential bronchopleural fistula, which may result in lobectomy.3 Both bullous emphysema of the lung and tension pneumothorax present with dyspnea. However, in a case of bullous emphysema, the dyspnea is present over a period of time with a gradual increase in severity, unless complicated by pneumothorax, hemorrhage, or infection. Patients are stable, and there is no cardiac decompensation.4 The criteria for giant bullous emphysema on CXR include
the presence of giant bullae in 1 or more lobes, occupying at least one third to one half of the ipsilateral hemithorax with compression of surrounding normal lung parenchyma.5 But in contrast to pneumothorax, the pleural border of a giant bulla is thinner and tends to curve away from the lateral chest wall. In addition, bullae are mostly confined to the apical lobes and do not shift with change in patient position as compared with pneumothorax in which air tends to be located in nondependent areas of the hemithorax.6 Therefore, lateral decubitus CXR films with the affected side up may clearly differentiate a pneumothorax from a bulla. Bullous disease and pneumothorax often coexist, and CXR may prove to be inconclusive. In such cases, videoassisted thoracoscopy,3 bedside ultrasound,7 or chest CT scan8 are helpful in differentiating bullous disease from pneumothorax and are indicated to aid diagnosis and assist management.
REFERENCES 1. Burke R: Vanishing lungs: A case report of bullous emphysema. Radiology 28:367-371, 1937 2. DeMeester TR, Lafontaine E: The pleura, in Sabiston DA, Spencer FC (eds): Surgery of the Chest. Philadelphia, PA, Saunders, 1990, pp 444-497 3. Kupferschmid JP, Carr T, Fonger JD, et al: Chronic tension pneumothorax mimicking tension bullae. Use of video-assisted thoracoscopy for diagnosis. Chest 104:1913-1914, 1993 4. Waseem M, Jones J, Brutus S, et al: Giant bulla mimicking pneumothorax. J Emerg Med 29:155-158, 2005
5. Roberts L, Putman CE, Chen JTT, et al: Vanishing lung syndrome: Upper lobe bullous pneumopathy. Radiol Interam Radiol 12: 249-255, 1987 6. Kong A: The deep sulcus sign. Radiology 228:415-416, 2003 7. Simon BC, Paolinetti L: Two cases where bedside ultrasound was able to distinguish pulmonary bleb from pneumothorax. J Emerg Med 29:201-205, 2005 8. Bourgouin P, Cousineau G, Lemire P, et al: Computed tomography used to exclude pneumothorax in bullous lung disease. J Can Assoc Radiol 36:341-342, 1985
A
39-YEAR-OLD MAN presented with a history of breathlessness of increasing severity for the last 3 months. He gave a history of 2 attacks of sudden-onset breathlessness in the last 6 months, the last one being 4 months ago. Both the attacks were diagnosed as pneumothorax and treated with intercostal tube drainage (ICD) without much relief. There was no history of trauma, tuberculosis, or bronchial asthma. He was a known smoker for the last 20 years, smoking 1 pack every day. On examination, the patient was dyspneic but able to speak complete sentences. His respiratory rate was around 25/min and saturation on room air measured 95%. His heart rate was 110 beats/min and regular, and blood pressure was 140/78 mmHg. The trachea was noted to be central on palpation. On auscultation, air entry was decreased over the right lung. Jugular venous pressure was not elevated. Pulmonary function tests revealed moderate dysfunction (forced expired volume in 1
Fig 1.
second/forced vital capacity 60% of predicted). A posteroanterior chest x-ray (CXR) showed collapse of the right lung with visible lung borders and absent vascular markings (Fig 1). What is the diagnosis?
From the Departments of *Anaesthesiology and †Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Kerala, India. Address reprint requests to Satyajeet Misra, MD, DNB, PDCC, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, Kerala, India. E-mail: [email protected] © 2009 Elsevier Inc. All rights reserved. 1053-0770/09/2306-0028$36.00/0 doi:10.1053/j.jvca.2008.08.008 Key words: pneumothorax, giant bulla, lung
Posteroanterior chest x-ray showing complete collapse of the right lung with visible lung border (dashed arrow).
Journal of Cardiothoracic and Vascular Anesthesia, Vol 23, No 6 (December), 2009: pp 911-913
911
912
MISRA ET AL
Fig 2. Computed tomography scan (axial cut) of the chest showing bilateral bullous lung disease with a giant bulla in the right upper lobe.
DIAGNOSIS: GIANT BULLA OF THE RIGHT LUNG
The CXR shows increased lucency on the right side with collapse of the right lung. Although the first impression is massive pneumothorax, its classical features like increased thoracic volume, increased rib separation, ipsilateral heart border flattening, contralateral mediastinal deviation, ipsilateral hemidiaphragmatic depression, and tracheal shifting are absent. Furthermore, the patient’s history (absence of acute breathlessness, unresponsiveness to ICD insertion on 2 previous occasions, and stable cardiovascular status with normal jugular venous pressure) favors the previously mentioned diagnosis. A computed tomography scan of the chest shows multiple emphysematous bullae involving both lungs with a giant bulla in the right upper lobe (Fig 2). There is no evidence of pneumothorax. The patient was posted for bullectomy and pleurodesis under general anesthesia. Intraoperatively, the upper lobe of the right lung was found to be bullous (Fig 3A) with multiple thin-walled daughter bullae (Fig 3B). The largest bulla measured 9.2 ⫻ 6.2 cm (Fig 4). First described by Burke in 1937, giant bullous emphysema, also called the “vanishing-lung syndrome,” is an idiopathic clinical syndrome of progressive dyspnea caused by extensive asymmetric bullous emphysema limited mainly to the upper
Fig 4. Intraoperative photograph of the largest bulla. (Color version of figure is available online.)
lobe of the lungs.1 The disease is predominantly encountered in young or middle-aged cigarette-smoking men and sometimes in nonsmokers who present with shortness of breath. Often, emphysematous bullae coalesce into a giant bulla and may mimic tension pneumothorax on CXR.2
Fig 3. Intraoperative photograph of the right upper lobe showing (A) bullous disease of the lung and (B) multiple thinwalled daughter bullae. (1) Giant bulla. (2) Right middle lobe. (Color version of figure is available online.)
COLLAPSE OF THE LUNG
913
It is important to distinguish between tension pneumothorax and giant bullous disease of the lung because treatment of the 2 conditions is entirely different. Tension pneumothorax is usually treated urgently by ICD insertion, whereas bullous disease of the lung generally requires bullectomy with or without a limited pulmonary resection. ICD insertion in the treatment of giant bulla not only does not relieve symptoms, but it also has the risk of leading to a prolonged air leak from a potential bronchopleural fistula, which may result in lobectomy.3 Both bullous emphysema of the lung and tension pneumothorax present with dyspnea. However, in a case of bullous emphysema, the dyspnea is present over a period of time with a gradual increase in severity, unless complicated by pneumothorax, hemorrhage, or infection. Patients are stable, and there is no cardiac decompensation.4 The criteria for giant bullous emphysema on CXR include
the presence of giant bullae in 1 or more lobes, occupying at least one third to one half of the ipsilateral hemithorax with compression of surrounding normal lung parenchyma.5 But in contrast to pneumothorax, the pleural border of a giant bulla is thinner and tends to curve away from the lateral chest wall. In addition, bullae are mostly confined to the apical lobes and do not shift with change in patient position as compared with pneumothorax in which air tends to be located in nondependent areas of the hemithorax.6 Therefore, lateral decubitus CXR films with the affected side up may clearly differentiate a pneumothorax from a bulla. Bullous disease and pneumothorax often coexist, and CXR may prove to be inconclusive. In such cases, videoassisted thoracoscopy,3 bedside ultrasound,7 or chest CT scan8 are helpful in differentiating bullous disease from pneumothorax and are indicated to aid diagnosis and assist management.
REFERENCES 1. Burke R: Vanishing lungs: A case report of bullous emphysema. Radiology 28:367-371, 1937 2. DeMeester TR, Lafontaine E: The pleura, in Sabiston DA, Spencer FC (eds): Surgery of the Chest. Philadelphia, PA, Saunders, 1990, pp 444-497 3. Kupferschmid JP, Carr T, Fonger JD, et al: Chronic tension pneumothorax mimicking tension bullae. Use of video-assisted thoracoscopy for diagnosis. Chest 104:1913-1914, 1993 4. Waseem M, Jones J, Brutus S, et al: Giant bulla mimicking pneumothorax. J Emerg Med 29:155-158, 2005
5. Roberts L, Putman CE, Chen JTT, et al: Vanishing lung syndrome: Upper lobe bullous pneumopathy. Radiol Interam Radiol 12: 249-255, 1987 6. Kong A: The deep sulcus sign. Radiology 228:415-416, 2003 7. Simon BC, Paolinetti L: Two cases where bedside ultrasound was able to distinguish pulmonary bleb from pneumothorax. J Emerg Med 29:201-205, 2005 8. Bourgouin P, Cousineau G, Lemire P, et al: Computed tomography used to exclude pneumothorax in bullous lung disease. J Can Assoc Radiol 36:341-342, 1985