176 AJTCCM VOL. 29 NO. 4 2023
PICK OF THE PICS
Figure 1 is a chest radiograph of a 52-year-old ex-smoker with known
moderate chronic obstructive pulmonary disease who presented to
the emergency department with 2 days of worsening dyspnea and
non-specic right chest pain. He was hemodynamically stable and
tachypneic with low oxygen saturations (87%). ere were reduced
breath sounds and increased resonance over the right hemithorax.
e clinical signs and radiology were thought consistent with the right
pneumothorax, and an intercostal drain was inserted. A persistent air
leak developed, which prompted a chest computed tomography (CT)
to be performed (Fig.2).
Giant bullae can mimic tension pneumothoraxes both clinically
and radiologically.[1] Dierentiation can be dicult with conventional
chest radiography. Treatment is dierent, and misdiagnosis can be
catastrophic. While CT remains the gold standard for distinguishing
the two, it may be logistically dicult for unstable patients. Point-of-
care chest ultrasound can help with the dierentiation.[2] It is fast, safe
and inexpensive, with a reported sensitivity and specicity of 100% for
large pneumothoraxes.[3] e presence of lung sliding or a lung pulse
at the pleural interface excludes a pneumothorax.
1. Aramini B, Ruggiero C, Stefani A, Morandi U. Giant bulla or pneumothorax:
How to distinguish. Int J Surg Case Rep 2019;62:21-23. https://doi.org/10.1016/j.
ijscr.2019.08.003.
2. Karacabey S, Sanri E, Metin B, etal. Use of ultrasonography for dierentiation between
bullae and pneumothorax. Emerg Radiol 2019; 26(1):15-19. https://doi.org/10.1007/
s10140-018-1640-9.
3. Hosseini-Nik H, Bayanati H, Souza CA, etal. Limited chest ultrasound to replace CXR
in diagnosis of pneumothorax Post image-guided transthoracic interventions. Can
Assoc Radiolog J 2022;73(2):403-409. https://doi.org/10.1177/08465371211034016.
Submitted 31 January 2023. Accepted 10 September 2023. Published 27 November 2023.
Should a drain be inserted?
M J Mpe, Cert Pulm (SA)
Sefako-Makgatho Health Sciences University, Pretoria, South Africa
Corresponding author: M J Mpe (john.mpe@smu.ac.za)
Fig.1. Chest radiograph
Fig.2. Computed tomography with intercostal drain.