BULLOUS EMPHYSEMA


pneumothorax has been discouraged in favour of CT15,23 or ultrasound22


.


published guidelines for the correct management of chest drain placement24


The National Patient Safety Agency (NPSA) has . Distinguishing bullae from a


pneumothorax is an important consideration prior to chest drain insertion, as insertion into a bulla can lead to significant respiratory complications or even death25,26


.


In this case, a needle decompression technique was used. The combined effects of the severity of the symptoms and the appearances of the chest radiograph led to a dilemma. The patient presented to an urgent care centre, which did not have access to a CT scanner. The clinical features and chest radiograph appearances suggested a tension pneumothorax so needle decompression was considered the best option. Needle decompression can be used, relatively safely, in a pre-hospital setting, as a potentially life-saving measure for a tension pneumothorax with accompanying haemodynamic instability6


data supporting their use in poly-trauma patients, as highlighted by Wernick and colleagues27


. However, there is an absence of high quality . Although often


a life-saving measure, the technique is associated with risks27,28


by Chen et al29 and Waseem et al21 . No evidence was found to support the use of


needle decompression for pneumothoraces specifically in bullous emphysema. This case shares many similarities with cases described , Findlay et al30


, where


a bulla was thought to represent a tension or large pneumothorax. In these examples, the value of CT and perhaps ultrasound is once again highlighted. Findlay and colleagues also point out the presence of faint lung marking within the pneumothorax as a sign of a bulla; this was also evident in this case study (Figure 3)30


.


Spontaneous pneumothorax in bullous emphysema has also been reported with some suggesting that this may be caused by deep inhalation and breathe holding smoking techniques specifically employed by cannabis smokers15,23,31


.


On reflection, whether this patient definitely exhibited the signs of a tension pneumothorax both clinically and radiologically, and whether needle decompression relieved a pneumothorax or was its cause, remain unanswered. Despite the urgency of the symptoms, this case also highlights the importance of thorough history gathering, including review of previous imaging. Radiographers in a commenting or formal reporting


role are ideally positioned to make a difference in cases similar to this one. Distinguishing the features of a large bulla from a large or tension pneumothorax early in an acute setting will have significant implications. While often subtle, the presence of faint lung markings is the key defining appearance (Figure 3).


CONCLUSION The implications for the increase in chronic lung pathology associated with cannabis smoking are a cause for concern. Acute exacerbation in bullous emphysema is common. Radiology plays a key role in distinguishing a large bulla from a pneumothorax, the implications of which are very important for ongoing management. A thorough history, careful examination of the chest radiograph appearances, early use of CT and increasingly ultrasound, play an important role in the management of acute presentation in bullous emphysema. Awareness of the differences between pneumothoraces and bullae at the point of decision making will have important implications for the management of an acute exacerbation.


JUNE 2017 HOW TO USE THIS ARTICLE FOR CPD


1. Read the article by Jeremy Weldon in Imaging and Therapy Practice.


2. Understand the disease processes of emphysema and bullous emphysema and their causes.


3. Consider how radiology supports the care of patients with emphysema and bullous emphysema and the value of the different modalities.


4. Be aware of the complications of emphysema.


5. Identify features that help distinguish bullae from pneumothoraces on chest radiography.


6. Be able to confidently engage and discuss these chest radiograph appearances with a clinician to help guide initial management.


7. Have an overview of how complications of bullous emphysema are managed.


8. Reflect on the learning you have gained from this plan using CPD Now.


9. Set a review date for this plan.


REFERENCES http://www.sor.org//learning/library- publications/itp


This article has been prepared following local guidance relating to the use of patient data and medical images.


To comment on this article, please write to editorial@itpmagazine.co.uk


ABOUT THE AUTHOR Jeremy Weldon is Consultant Radiographer and an expert Reporting Radiographer at Northwick Park Hospital, London.


QA Code: 2243CB2A


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