Clinical Case 028: Pink puffer with extra puff

This case come from Dr Adrian Goudie, Fremantle Hospital (where I haunted the wards as an intern).  Adrian is an Emergency Physician who is part of the excellent Ultrasound Village team – these guys run great basic training courses in ED and procedural US.  Check out their website as it has some golden learning resources and images as well as flyers for their upcoming courses.  I did their ECHO basics course a few weeks ago and learned a heap of stuff I probably should have been taught in Med School!  Fro me this one day of learning demystified cardiac anatomy and ECHO imaging in a commonsense, practical way – two thumbs up from me!

So here is Adrian’s case:

Elderly lady with severe CAL who was in extremis, marked dyspnoea.  Acute decompensation ? cause.  Here is her initial CXR:

Can you see any cause for her acute deterioration?

Quick – make a call before she crashes!

Localised / loculated pneumothorax in the left lower field – not where we usually look for them!

Adrian says: “everyone was keen [to put in the ICC] until they realized how low it would have to go and suddenly I was alone in the department. I certainly don’t enjoy putting these in – in addition to the usual kit I also made sure I had “spare underpants x 1” available!  Anyway – went in well and she improved immediately.
Nice work Adrian.


  1. Good case!
    I would be very nervous that this may be a giant bullae and not a pneumothorax, without any previous imaging to compare or a CT. When push came to shove I am sure it took some cajones to put the tube in and see if she improved!

    • Dr J. -- You are correct, it was a nervous moment (although I wasn’t actually left alone in the department (I admit to poetic licence there) -- the usual queue of trainees elbowing each other to try and ‘get’ the procedure suddenly became a group of silent observers).
      The usual rule about bullae v PTx regarding convex v concave surface works OK at the apex, but not if there’s an adhesion, so that didn’t help. CT wasn’t an option as she was unable to lie flat and would have had no hope of holding her breath for even a brief period (less of an issue now with faster multislice CT but still a significant limitation). She looked like she wasn’t going to last much longer, and given her age and known severe COPD, intubation was not considered appropriate. In the end, I decided it was highly likely to be a PTx based on the lack of large bullae elsewhere in the lungs and the chest drain scar that corresponded to where the adhesion appeared on CXR (not mentioned before so an unfair advantage to me in the discussion). No absolutes, we went with the probabilities in a situation where doing nothing was rapidly heading to a certain and negative outcome, and were fortunate enough to be correct. Her response was dramatic, reinforcing how little reserve she had.
      This was in the days (10+ yrs ago) when we were just starting to use ultrasound in ED with not enough experience to base decisions on it -- I’ve commented below on whether it might help in these situations.

      • Minh Le Cong says:

        Nice one Adrian
        Could you have needle aspirated first to confirm and maybe drain if she was in extremis?

        • Dear Minh,
          If I had aspirated it and the lung reinflated, it would have confirmed a PTx not bulla (and maybe eased her symptoms temporarily, although she would be highly likely to require an ICC due to underlying lung disease). I was pretty convinced it was a loculated PTx, my worries came from the idea of placing the ICC low enough to avoid the adhesions (and avoid creating a bronchopulmonary fistula or causing bleeding) and high enough not to enter the abdominal cavity. These days, I would use ultrasound to try and localize these landmarks more precisely (and in real time) at the start of the procedure.

  2. Tim Leeuwenburg says:

    Can one use USS to differentiate PTX from bullae? Especially pertientn for those of us without easy access to CT (most of rural Australia!)

  3. Casey Parker says:

    Hi Tim. In response to your question -- “can you use USS to differentiate pneumothorax from bullae?” Dr Goudie (see todays case) tells me that if you see good lung sliding on the USS then it is not likley a pneumothorax, however the absence of lung sliding is less specific -- could be a pneumo or a bullae. So if you have an area of lung on the CXR which could be either -- then do the USS and if it slides -- it is probably a bleb / bulla, not apneumothorax -- so don’t needle it!
    I will email your query to the US gurus and see what they say.

  4. Casey Parker says:

    Hi Broomedocs, {comment from Dr J Rippey -- US guru}

    I don’t think it would be wise to say we could reliably differentiate bullae from a pneumothoracies. In a single view they would look identical.
    The only difference that I can think of, that would confirm pneumothorax, would be that they tend to lie at the most apical portion of the thoracic cage and unless loculated are mobile.
    If on the erect CXR you were questioning an apical bullae vs apical PTX, with the patient in the erect position, look at the lung in inferolaterally. It should look normal with sliding etc. Now lie the patient on their side, slightly head down, with this point uppermost. If there is now loss of those normal ventilating lung characteristics, and it looks like pneumothorax it probably is!

    If not it would not exclude the possibility of loculated pneumothorax.

    James Rippey

  5. Casey Parker says:

    Dear Casey,
    I would say that the most important thing to remember is the sign to rule out PTx are different to the sign to rule in PTx.
    1) Lung sliding rules out PTx (at the point where you are holding the probe) -- so if there is no question of a loculated PTx then lung sliding at the most superior point (e.g. adjacent to the lower sternum if the patient is lying flat) excludes a PTx
    2) Lung point sign rules in PTx -- seeing the edge of lung sliding move in and out confirms PTx. The point where this occurs can be used to judge the size of the PTx (assuming no loculations)
    3) Noting that there are many causes of loss of lung sliding including adhesions, hypoventilation (e.g. single lung ventilation -- intended or unintended), pneumonia, ARDS (although the latter two cause a white pattern with rockets or consolidation rather than the black with regular horizontal reverberation artifact lines, so they look different).

    With patients with severe COPD, the hyperinflation means that the lungs don’t move as much, hence seeing sliding is difficult. This is particularly so at the apices, which I find even in normal people can be difficult to be sure if there is a small amount of sliding or if you’re just looking at a bit of ‘twinkling’ that you sometimes see along a surface with ultrasound. Usually the issue is resolved by, as James describes, moving the patient. I lie them flat and look along the sternal edge (I don’t lie them on their side or head down). Obviously this is very difficult in severe COPD patients who need to sit up. Having said which, I have on a few occasions looked at patients with bullae to try and get an example of bullae causing loss of sliding, and have on all occasions seen sliding. In theory, a large bulla sliding back and forth might be able to simulate a lung point sign, but I’ve never seen it and suspect it would be unlikely as these patients don’t have enough lung movement to cause the amount of movement seen with a lung point sign.

    Unfortunately, although it may (?usually) help, US is unlikely to be the panacea in all cases (then again, I’ve seen cases where even after CT, no one could be absolutely sure). Finally, I’ve never seen a description of ultrasound in chronic pneumothoraxes (who shouldn’t be getting a chest drain) so no idea if you can differentiate (I suspect not, and would have to rely on old XRays / records if available).

    In Summary --
    if I had a patient with a ?bulla ?pneumothorax, I would try ultrasound and if I saw sliding, confidently exclude a PTx (all the cases with bullae I’ve seen so far)
    If I saw a lung point, then I would diagnose a PTx (although possibly with a little hesitation if the lung point wasn’t sliding back and forward much and it were a very large bulla -- never seen this yet)
    If I saw no sliding (or so little I wasn’t sure), then I would search around to see if I could see a lung point, and if possible reposition the patient. If I couldn’t see a lung point then I would think it unlikely to be a PTx but wouldn’t be able to be absolutely sure.

    Hope this helps
    PS. One of the world experts in lung US (Prof G Mathis) has just agreed to attend next year’s Ultrasound Conference (in Sydney), so I’m hoping to find out the answers to some of the above issues.
    PPS. I’ve been nominated (= roped / hijacked / blackmailed into) to put together a clinician’s section for this conference (hence the inclusion of a lung expert) and would be keen to hear suggestions from the rural community as to what they would think would be worthwhile (ie. “what would make you excited enough to fly to Sydney and attend?”)

  6. In a single view they would look identical.The only difference that I can think of, that would confirm pneumothorax, would be that they tend to lie at the most apical portion of the thoracic cage and unless loculated are mobile.

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