The Journal of Emergency Medicine, Vol. 29, No. 2, pp.

155–158, 2005
Copyright © 2005 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/05 $–see front matter

doi:10.1016/j.jemermed.2005.04.004

Clinical
Communications

GIANT BULLA MIMICKING PNEUMOTHORAX

Muhammad Waseem, MD, Jodi Jones, MD, Sargine Brutus, MD, John Munyak, MD,
Ramnath Kapoor, MD, and Joel Gernsheimer, MD
Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, New York
Reprint Address: Muhammad Waseem, MD, Department of Emergency Medicine, Lincoln Medical and Mental Health Center,
234 East 149th Street, Bronx, NY 10451

e Abstract—It is usually thought by emergency physicians
that the diagnosis of a pneumothorax is straightforward
and easy to make and to treat, but the diagnosis may
sometimes pose a challenge. The present report describes a
case of a giant pulmonary bulla in a 40-year-old man that
progressed to occupy almost the entire left hemithorax and
also subsequently ruptured to produce a large left pneumo-
thorax. The giant bulla was diagnosed only as a pneumo-
thorax, and initially managed with a chest tube only. The
differentiation between pneumothorax and a giant bulla
can be very difficult, and often leads to inaccurate diagnosis
and management. This case report demonstrates the clini-
cal presentation of giant bulla and its complications such as
pneumothorax and also highlights the difficulty in making
this diagnosis and appropriately treating it. In this article,
we emphasized how to differentiate between giant bulla and
pneumothorax utilizing history, physical examination, and
radiological studies including computed tomography (CT)
scan. © 2005 Elsevier Inc.
e Keywords— giant bulla; pneumothorax; pulmonary em-
physema; dyspnea; double wall sign
INTRODUCTION
It is usually thought by emergency physicians that the
diagnosis of a pneumothorax is straightforward and easy
to make and to treat, but the diagnosis may sometimes
pose a challenge. The present report describes a case of
a giant pulmonary bulla in a 40-year-old man that pro-
gressed to occupy almost the entire left hemithorax and
also subsequently ruptured to produce a large left pneu-
mothorax. The giant bulla was diagnosed only as a
pneumothorax, and initially managed with a chest tube
only. The differentiation between pneumothorax and a
giant bulla can be very difficult, and often leads to
inaccurate diagnosis and management.
CASE REPORT
A 40-year-old man presented with increasing shortness
of breath for 3 months. He complained of dyspnea and
had difficulty in climbing even one flight of stairs. He
denied frequent cough, sputum production, or wheezing.
There was no fever, chest pain or syncope. He had a
history of smoking for more than 25 years. He also had
a history of drug abuse (cocaine, marijuana and heroin)
but had stopped recently.
On examination, the patient was alert and oriented
without any respiratory distress. The vital signs were as
follows: blood pressure 114/62 mm Hg, pulse 104 beats/
min, respiratory rate 20 breaths/min, and temperature
36.7°C (98.1°F). Oxygen saturation was 97% on room
air. There were decreased breath sounds on the left side
without any dullness to percussion. Cardiac examination
was normal. His abdomen was soft and non-tender.
There was no cyanosis, clubbing or peripheral edema.
The rest of the examination was unremarkable.

RECEIVED: 14 November 2003; FINAL SUBMISSION RECEIVED: 2 March 2005;

ACCEPTED: 6 April 2005
155
156
Figure 1. Chest radiograph showing a left giant pulmonary
bulla.
A chest X-ray study was obtained (Figure 1) and was
interpreted by an attending radiologist as showing a large
left pneumothorax. After obtaining a surgical consulta-
tion, a left tube thoracostomy was performed. Despite the
insertion of a chest tube, the pneumothorax did not
resolve and the patient did not show clinical improve-
ment (Figure 2). Subsequently, a computed tomography
Figure 2. Chest radiograph obtained after chest tube place-
ment showing no improvement.
M. Waseem et al.
Figure 3. Chest computed tomography (CT) scan of the
chest showing a left giant pulmonary bulla with pneumotho-
rax.
(CT) scan of the chest was obtained (Figure 3), which
demonstrated that the patient had a giant bulla and a
pneumothorax. A thoracic surgery consultation was ob-
tained. At surgery both a left pneumothorax and giant
bullae were found. The patient underwent bullectomy
and pleurodesis. He showed marked clinical improve-
ment, and subsequently was discharged in stable condi-
tion.
DISCUSSION
A bulla is an air-filled space within the lung parenchyma
resulting from destruction of the integrity of the alveolar
tissue. Pulmonary bullae are pathologically dilatated air
spaces distal to the terminal bronchiole and are more
than 2 cm in diameter in the distended state (1). The
presence of emphysema associated with large bullae is
referred to as bullous emphysema. Bullous emphysema
either is congenital without general lung disease or a
complication of chronic obstructive pulmonary disease
with generalized lung disease. This entity is mainly seen
in young men and is characterized by the presence of
large progressive bullae that occupy a significant volume
of a hemithorax and are often asymmetrical. It is often
referred to as giant bullous emphysema, vanishing lung
syndrome, or primary bullous disease of the lung (2). It
was originally described by Burke in 1937 as an idio-
pathic, distinct clinical syndrome of severe progressive
dyspnea caused by extensive, predominantly asymmetric
upper lobe bullous emphysema that may eventually lead
to respiratory failure (3). Bullae can also develop during
infections. They involve predominantly the upper lobes
with sizes ranging from 1 to 20 cm2. By convention they
Giant Bulla vs. Pneumothorax
are called “giant bullae” when they occupy over one-half
of the volume of the hemithorax.
It can be very difficult for the emergency physician to
distinguish a pneumothorax from a giant bulla. Although
this very important differentiation with important thera-
peutic implications can be very difficult to make, it is
possible to do so using the history, the physical exami-
nation, plain radiographs, and if necessary, CT scan. The
history can be very helpful. Patients with giant bullae
usually present with a chief complaint of progressive
dyspnea over several months (4,5). Often there is a
history of associated lung disease such as emphysema or
sarcoidosis. Most patients with bullous emphysema are
cigarette smokers (6,7). In elderly non-smokers, basilar
bullous emphysema is often associated with alpha-1 an-
titrypsin deficiency (8). There usually is a family history
of emphysema at a relatively young age. There is an
increased frequency of associated lung carcinoma in
young men with large bullae (9 –11).
Pneumothorax usually presents with sudden shortness
of breath and chest pain. The presentation is usually
much more acute than that of giant bullae, and pain is a
more prominent symptom with pneumothorax. Sponta-
neous pneumothorax often may be seen in thin, young,
previously healthy men with a “marfanoid” appearance.
It also can occur in patients with an acute or chronic
pulmonary problem such as asthma or pneumonia. As
noted above, giant bullae tend to slowly increase in size
(although they occasionally may regress spontaneously)
and cause slow progression of shortness of breath (12–
14). However, sometimes a bulla can cause sudden de-
terioration due to rupture,e causing pneumothorax (15).
Although a relationship between idiopathic spontaneous
pneumothorax and visible parenchymal bullae and blebs
has been reported, a causal relationship between bullae
and spontaneous pneumothorax has been questioned.
In fact, giant bullae are considered to be hard to
rupture, because the rise in the internal pressure in a bulla
spreads in a horizontal direction and the bigger the bulla,
the less is the change of pressure inside the bulla (16).
Patients with bullae may also suddenly deteriorate from
infection or hemorrhage inside a bulla, therefore, patients
with bullae who become acutely worse must be evalu-
ated for spontaneous pneumothorax, pulmonary infec-
tion, and hemorrhage. They must be treated appropri-
ately and aggressively, keeping in mind that these
patients do not have much reserve pulmonary function to
begin with due to underlying pulmonary disease and
compression of any normal lung by the bullae.
The physical examination may also assist the emer-
gency physician in differentiating a pneumothorax from
a giant bulla. With a large pneumothorax, the clinician is
more likely to find absent or markedly diminished breath
sounds with hyper-resonance to percussion. It must be
157
noted that our patient with a giant bulla and a pneumo-
thorax had diminished breath sounds. Transmitted voice
sounds, whispered pectoriloquy, and tactile fremitus are
all diminished with a pneumothorax. If the pneumotho-
rax causes tension, then acute deterioration of the pa-
tient’s vital signs will be seen (hypotension, tachycardia
and dyspnea) with distended neck veins and, possibly,
tracheal deviation away from the side of the tension
pneumothorax. The emergency physician is expected to
make the diagnosis of tension pneumothorax clinically
without obtaining any radiograph, and to emergently
treat this life-threatening condition with needle decom-
pression and insertion of a thoracostomy tube.
As noted above the diagnosis of pneumothorax versus
giant bulla is usually suggested by the clinical history
and physical examination but usually must be confirmed
by chest radiographs. However, this may be difficult, as
it was in our case, and can be misinterpreted. If a pleural
line can be clearly seen with no lung parenchyma distal
to it, then this would establish the diagnosis of pneumo-
thorax. Expiratory films make it easier to see the pleural
line and lack of lung markings beyond it can facilitate the
diagnosis of pneumothorax. Sometimes the line demar-
cating a bulla can be confused with that of the visceral
pleura over a localized pneumothorax. However, the line
demarcating a bulla is usually more horizontal. If signs
of tension such as tracheal deviation or mediastinal shift
are seen, that would help confirm the diagnosis of tension
pneumothorax.
The diagnosis of giant bullous emphysema is made
radiologically. The criteria for this diagnosis include the
presence of giant bullae in one or both upper lobes (giant
bullae have a propensity for the upper lobes), occupying
at least one-third of the hemithorax and compressing
surrounding normal lung parenchyma (17). CT scans,
particularly high resolution scans (HCRT), are the most
accurate means of detecting emphysema and determining
its type and extent (18).
The CT scan can be very useful in distinguishing
pneumothorax from giant bullae, especially in patients
with giant bullous emphysema who may have developed
a secondary spontaneous pneumothorax. Signs that have
been used to detect pneumothorax in patients with giant
bullous emphysema, such as our patient, are compressed
or consolidated lung, non-anatomic hyperlucency, and
the double wall sign. Although these signs may be seen
on plain films, better delineation is seen on CT scan. The
double wall sign is a valuable sign to help distinguish a
pneumothorax from adjacent giant bullae (19). This sign
occurs when one sees air outlining both sides of the bulla
wall parallel to the chest wall. Absence of this sign
provides evidence against the diagnosis of pneumotho-
rax, which can prevent unnecessary chest tube place-
ment. In addition, if a patient has a pneumothorax and a
158
chest tube is placed, there should be immediate symp-
tomatic relief and evidence of lung re-expansion on the
chest radiograph (20).
Although patients with giant fluid-filled bullae have
been treated successfully by closed chest thoracostomy
tube drainage, symptomatic patients with progressive
dyspnea should undergo removal of the bullae. Indica-
tions for surgery with giant bullae are 1) increasing bulla
size, 2) pneumothorax, 3) pulmonary insufficiency, and
4) infection within the bulla (21–23). A significantly
large bulla, which requires surgical intervention, is one
that occupies one-third to one-half of the hemithorax and
is compressing non-bullous lung. Due to this very large
bulla, progressive dyspnea, and concomitant persistent
pneumothorax, our patient underwent a bullectomy with
pleurodesis. He improved and was discharged home in
stable condition.
CONCLUSION
We present a case of a patient with a giant pulmonary
bulla and a large pneumothorax that looked like a large
simple pneumothorax and was initially treated with a
chest tube. It demonstrates the difficulty and importance
of making the correct diagnosis. A chest CT scan should
be considered in patients when the diagnosis of bullae
versus pneumothorax based on clinical grounds and plain
films is uncertain (24).
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