A 30-year-old farmer with 20 pack-years of smoking history presented to the emergency department with shortness of breath, reduced effort tolerance, and pleuritic chest pain for three months. There were no other associated symptoms. There was no exposure to pulmonary tuberculosis or other infections.
On examination, he was cachectic with a body mass index (BMI) of 19. His pulse rate was 88 bpm, respiratory rate was 20 breaths per minute, and pulse oxymetry was 88% under room air. He was normotensive and afebrile. There was no peripheral or central cyanosis and no finger clubbing. On respiratory examination, the trachea was central, and there were hyper-resonant notes on percussion of both lung fields. There were reduced breath sounds and vocal resonance over the middle and upper zones bilaterally. The rest of the physical examinations were unremarkable.
His blood investigations revealed normal white cell count, C-reactive protein, and erythrocyte sedimentation rate. His arterial blood gas showed type 1 respiratory failure. Investigations for secondary causes of bullous disease were negative for hepatitis B, hepatitis C and human immunodeficiency virus (HIV). Serologic testing for connective tissue disease, including the anti-nuclear antibody (ANA) and extractable nuclear antibodies (ENA), were also negative. The serum Alpha-1 antitrypsin level was within the normal range (1.66g/L; N: 0.9-2.0 g/L).
On the initial chest radiograph, there was an absence of lung markings of both middle and upper zones (Fig. 1). A diagnosis of bilateral pneumothorax was made, and two 17-gauge chest drains were inserted. Despite the bilateral chest drain insertion, the patient remained breathless, and there was no clinical improvement. The repeat chest radiograph did not show lung re-expansion. An urgent HRCT thorax revealed bilateral giant bullae of the upper and lower lobes, compressing the lung parenchyma inferiorly. The chest tubes were abutting the pleura's parietal wall without puncturing the bulla (Fig. 2).
We referred this case to the cardiothoracic team, and the patient subsequently underwent bilateral video-assisted thoracoscopic surgery (VATS) and bullectomy with bilateral pleurodesis (Fig. 3). Post-operatively, the patient showed a significant clinical improvement with partial lung re-expansion. He was discharged home with bilateral portable one-way valve chest drainage (Pneumostat). He also underwent intensive outpatient chest physiotherapy. Upon clinic follow-up, the patient showed significant recovery, and the serial chest radiographs revealed marked improvement of lung expansion. The chest drain was removed after two weeks.
CT Thorax in axial view shows the tip of the right chest tube (arrow) is at the anterior wall of the right giant bullae. It is located in between the parietal and visceral wall of the pleura without puncturing the bullae.