BULLOUS EMPHYSEMA X


typically unfiltered cannabis are also important; including a four-fold increase in tar and a resulting five-fold increase in carboxyhaemoglobin16


. (See Table 1.) 1.


70% INCREASE IN LUNG VOLUME FOR EACH INHALATION


2. LONGER BREATH HOLD 3. INCREASED PSYCHOACTIVE EFFECT 4. ENHANCED RISK OF BAROTRAUMA


 Table 1: Summary of smoking technique differences for cannabis compared to cigarette smoking.


DISCUSSION At present, there are no specific national guidelines for the diagnosis and management of bullous emphysema. The result of this could lead to lack of awareness and to disjointed management. It could be that despite potentially a life threatening scenario, a patient like this one falls between more established trauma or cardiac pathways. However, the National Institute for Health and Care Excellence (NICE) has produced guidance for the management and diagnosis of COPD17


. Presenting


symptoms combined with spirometry, form the main approach in making the diagnosis. Chest radiography is recommended to exclude other abnormalities, with CT of the chest reserved for patients with symptoms considered disproportionate to the spirometry and to follow-up abnormalities found in chest radiography17


.


This case perhaps, suggests the need for unified specific national guidelines for both chronic bullous emphysema and its acute exacerbation. The primary symptoms for bullous emphysema are


typically shortness of breath, either at rest or on exertion. The first line radiological approach for such a patient or in which bullous emphysema might be suspected, would be chest radiography17


might identify bullae, the role of CT in the management of bullous emphysema is increasingly important6,10,18


. Whilst chest radiography .


In a patient with a normal chest radiograph, but for whom symptoms warrant CT scanning, the use of high resolution computed tomography (HRCT) in identifying diffuse non-bullous emphysema is important5,10 The use of ultrasound in identifying complications


.


of bullous emphysema such as pneumothoraces, has been suggested by Sandionigi and colleagues18


. The


value of ultrasound in the management of traumatic pneumothoraces has been discussed by Rowan et al20


describe its use in a one patient .


However, identifying a pneumothorax in chronic lung disease using ultrasound is very much in its infancy, Sandionigi et al18


Radiographers in a commenting or formal reporting role are ideally positioned to make a difference in cases similar to this one


8


case study. While the quality of evidence for the use of ultrasound is low; speed, cost, portability and lack of ionising radiation are all attractive and therefore promising for the future. Lack of access to a CT scanner did result in some delay in this case, although without significant consequences. This does raise the question of whether ultrasound might have a role in the pre-hospital setting. When combined with an appropriate set of clinical features, ultrasound might be useful in identifying and guiding management in a tension pneumothorax scenario. Review of the literature suggests very little evidence of any other imaging modalities in the management of bullous emphysema. Given the concerning symptoms in this case, the chest radiograph appearances were considered to represent a large or tension pneumothorax. In a case study very similar to this one, Waseem and colleagues21


described a


coexistent large bulla and pneumothorax demonstrated on CT. Although similar to this case, the CT was carried out after the chest radiograph appearance was considered to represent a pneumothorax and after intervention. This leads to the suggestion that the intervention may have caused rather than relieved the pneumothorax. There have been case reports of secondary spontaneous pneumothoraces in patients with bullous emphysema, for varying causes.15,22,23


. In all cases, reliance on the


chest radiograph alone to distinguish large bullae from a JUNE 2017


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