LAUSR

A 52-year-old female non-smoker presented to emergency department with progressive dyspnoea in recent days. A chest radiograph showed marked right-sided hyperlucency. Several linear structures over right lung along with trachea and mediastinum were deviated to the left side (figure 1). The diagnosis of tension pneumothorax wasmade, and an 8 French pigtail was inserted. However, the collapsed lung did not expand. A chest CTshowed one giant bulla leading to right lung collapse without pneumothorax (figure 2). She received surgery because of persistent dyspnoea. The lung expanded well after videoassisted thoracic surgery (VATS) bullectomy. Giant bulla is defined as bullae that occupy more than 30% of a hemithorax, which typically develop because of cigarette smoking. Occasionally, giant bulla may be mistaken for a pneumothorax by a chest radiograph. In general, the pleural line associated with a large bulla is usually concave to the lateral chest wall, whereas the pleural line associated with a pneumothorax is convex. For dyspnoeic patients with exercise intolerance, bullectomy involves the surgical removal of one or more giant bullae by thoracotomy or VATS may be beneficial. The keys to the correct diagnosis in this case is the chest radiograph revealing right sidemarkedly hyperlucency with several linear structures over right lung. Besides, left lung volume reduction with smaller intercostal space hint the chronic disease course. For preventing further complications, such as pneumothorax, haemothorax and further respiratory distress, it is very important to make an early and quick diagnosis between giant bulla and pneumothorax before contemplating intervention. Right lung volume reduction preferably through a small incision should be the preferred treatment in this patient.