사진을 보고 Peumothorax 와 Giant bullae 의 감별 및 동반 가능성을 고려해야 하겠습니다.

Misdiagnosis of pulmonary bullae 가 흔하기 때문에 진단에 있어서 기흉으로 생각하고 성급하게 결론을 내리는 것을 [Premature diagnostic closure 나 Commission bias (errors of omission과 반대되는 개념)] 조심해야 한다고 합니다.

기흉 가능성만 생각하고 Chest tube 만 넣었을 경우에 persistent air leak 및 증상 악화가 발생할 수 있고 bullectomy and pleurodesis 추가로 시행하는 것을 고려해야 합니다.

기흉이 더 acute 하고 Bullous emphysema 는 몇달에 걸쳐 dyspnea 가 발생하는 경향을 보이지만 기흉이 동반되면서 증상의 악화를 보이기 때문에 감별이 어렵습니다.

Tension pneumothorax 일 때 나타나는 생체증후가 (absence of shock, jugular venous pressure elevation or muffled heart sounds) 도움이 되기도 합니다.

 

결정적으로는 Chest CT 가 도움이 되며 동반된 secondary pneumothorax 를 확인할 때는 The
double wall sign 가 기흉이 동반되었는지 아는 clue 가 됩니다. 이 sign 이 없을 때는Bullae 를 시사하고 기흉은 시사하지 않으므로 불필요한 Chest tube 를 지양해야 합니다.

 

 

Emphysema is a pathologic process characterized by permanent enlargement of air spaces distal to the terminal bronchioles. Hyperinflation results from destruction of interalveolar septae and alveolar fusion into large air sacs. Leakage of air into the interstitium leads to the formation of blebs and bullae. Giant bullae, while uncommon, can lead to the compression of the adjacent normal lung tissue. When emphysema is associated with large bullae, the condition is referred to as bullous emphysema.

Bullous emphysema usually occurs as a complication of chronic obstructive pulmonary disease; however, primary bullous emphysema can occur. This phenomenon was originally reported in 1937 by Burke,1 who referred to it as "vanishing lung syndrome." Burke described a series of young men who developed progressive dyspnea associated with extensive and predominantly asymmetric upper lobe emphysema, eventually leading to respiratory failure.

Differentiating between bullous emphysema and a pneumothorax can be challenging. Patients with bullous emphysema complain of progressive dyspnea owing to a gradual increase in bullae size. Of note, bullae may occasionally regress spontaneously. Pneumothorax classically involves a history of sudden deterioration in respiratory function associated with chest pain, but some patients may present atypically. Moreover, bullae rupture in patients with bullous emphysema can lead to the development of acute respiratory distress. In unclear cases, a CT scan of the patient's chest will establish the diagnosis.2Emergency department ultrasonography may also be helpful in differentiating between these 2 diagnoses. In bullous emphysema, a bedside scan may reveal sliding of the lung tissue against the pleura during inspiration associated with "comet tail" artifacts, whereas in a pneumothorax such movement is absent.3

Patients with bullous emphysema may require a bullectomy. Indications for surgery include increasing bullae size, pneumothorax, pulmonary insufficiency and bullous infection.4 Total pneumonectomy may be indicated in patients with severe unilateral disease.