Chronic tension pneumothorax mimicking tension bullae. Use of video-assisted thoracoscopy for diagnosis

Differentiating Giant Bullous Emphysema From Tension Pneumothorax: A Case Report

Giant bullous emphysema (GBE) is a progressive disease that commonly presents with severe progressive dyspnea attributed to the progressive destruction of alveolar walls and the formation of large air pockets, resulting in impaired gas exchange. This presentation is most commonly seen in young, thin male smokers. GBE poses an interesting and unique clinical challenge due to its radiologic findings, which can be easily mistaken for tension pneumothorax. Despite the decreased acuity of GBE as compared to tension pneumothorax, inadequate treatment in a severe case can lead to spontaneous pneumothorax, infection, and/or respiratory failure. In this report, we highlight a case of severe GBE that presents similarly to tension pneumothorax in both symptomatology and radiologic findings. The case at hand is of a 50-year-old male patient with a history of chronic obstructive pulmonary disease (COPD) with complaints of dyspnea and subsequent findings of tachycardia, tachypnea, and hypoxemia with significantly decreased breath sounds in the right lung. Radiologic findings showed increased lucency of the right hemithorax and a mass effect with a mediastinal shift to the left. History and further imaging with CT led to an ultimate diagnosis of severe GBE and COPD exacerbations. The patient was treated with non-invasive medical management. With the challenges of overlapping presentations, landing on the correct diagnosis is imperative to accurately and adequately treat the patient since GBE and tension pneumothorax significantly differ in acuity and overall management, hence the need for a high level of suspicion based on the clinical picture and the use of high-resolution CT.

Tension Bullae With Peripheral Pneumothorax

The differentiation between tension bullae, chronic tension pneumothorax, and atypical pneumothorax is difficult just from history and physical examination alone. A chest X-ray may help determine the underlying etiology; however, further imaging with computed tomography in stable patients may be necessary for accurate assessment of size, number, and location before considering any interventions. In this article, we present a rare case report of tension bullae with peripheral pneumothorax and recommend against needle thoracostomy in stable patients with tension bullae in order to obtain further imaging that may result in a change in the standard management.

Tension pneumothorax managed without immediate needle decompression

Standard medical reference texts state that the immediate life-saving treatment for tension pneumothorax is needle decompression. This article reports a case of an 85-year-old man with tension pneumothorax who was managed without performing immediate needle decompression. Emergency physicians should be aware of the proper management of such cases. There seems to be a growing body of evidence in the literature to suggest that in spontaneously breathing patients with tension pneumothorax, the rate of deterioration of this condition is much less rapid compared to ventilated patients, and the risks of performing needle decompression need to be balanced against the benefits of this procedure. In the absence of hemodynamic instability or severe respiratory insufficiency, the proper approach to managing such cases may be to carefully monitor the patient, promptly obtain portable chest radiography, and immediately perform chest tube drainage once the diagnosis is confirmed.

Tension pneumothorax--time for a re-think. Emerg Med J. 2005;22:8-16. [PMID: 15611534 DOI: 10.1136/emj.2003.010421]

This review examines the present understanding of tension pneumothorax and produces recommendations for improving the diagnostic and treatment decision process.