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-specic 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] Dierentiation can be dicult with conventional
chest radiography. Treatment is dierent, and misdiagnosis can be
catastrophic. While CT remains the gold standard for distinguishing
the two, it may be logistically dicult for unstable patients. Point-of-
care chest ultrasound can help with the dierentiation.[2] It is fast, safe
and inexpensive, with a reported sensitivity and specicity 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, etal. Use of ultrasonography for dierentiation 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, etal. 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.
