Bullous Lung Disease

A 34-year-old black man presented to the emergency department with right-sided pleuritic chest pain, productive cough, low grade fever, and dyspnea. He had a history of emphysema, deep vein thrombosis, protein C and S deficiency, and inferior vena cava filter. His physical exam was significant for fever, tachypnea, tachycardia, and decreased breath sounds over the right upper and middle lung fields.We obtained a chest radiograph (Figure 1).

Figure 1.

Frontal chest radiograph demonstrating a large right upper lung bulla with internal layering of fluid.

DIAGNOSIS

Giant emphysematous bulla is defined as air-filled spaces that occupy more than one-third of the hemithorax and develops in a lung destroyed by generalized emphysema.¹ Treatment typically involves surgery, although a variety of procedures have been proposed, including local excision of the bullae, plication, stapler resection, lobectomy, and videothoracoscopy.² Surgical therapy is indicated when patients have incapacitating dyspnea or for patients who have complications related to bullous disease, such as infection or pneumothorax.³ Most patients with bullae have a significant cigarette smoking history, although cocaine smoking, pulmonary sarcoidosis, alpha1-antitrypsin deficiency, 1-antichymotrypsin deficiency, Marfan’s syndrome, Ehlers-Danlos syndrome and inhaled fiberglass exposure have all been implicated.⁴ Additionally, marijuana smoking has resulted in extensive emphysematous bullous disease seen in many young patients.⁵

In our patient with an infected, fluid-filled bulla, surgical intervention was indicated and a pulmonary drain was placed into the bulla by computed tomography (CT) guidance. It should be realized that the initial chest radiograph could wrongly lead the emergency provider to place a chest tube, causing significant complications. A case published by Bourgouin et al⁶ reports 2 patients with bullous lung disease wrongly receiving chest tube placement. In patients with severe bullous lung disease CT (Figure 2) will differentiate emphysematous bullae from pneumothorax and save the patient an unnecessary and potentially dangerous procedure.⁷ Our patient was further evaluated with pulmonary function testing and eventually underwent video-assisted thorascopic surgery.

Figure 2.

Coronal chest computed tomography demonstrating extensive bullous disease of the lungs with a prominent bulla in the right upper lobe containing an air fluid level.