Pneumothorax vs Large Bulla

When you see unilateral lucency, the first thing to rule out is Pneumothorax.

When you see unilateral lucency, the first thing to rule out is Pneumothorax. Pneumothorax is the presence of air in the pleural space.

Bulla is formed in an emphysematous lungs, when there is destruction of the interstitium of the lung. Sometimes it may be very difficult to differentiate bulla from pneumothorax. The differentiating features of bulla and pneumothorax are as follows-

Pneumothorax

Bulla

You can see the visceral pleura sign

Visceral pleura will not be visible

No vessels with be visible through the lesion

Vessels will be visible through the lesion

Centre of lesion lies outside lung

Centre of lesion lies inside lung

Adjacent lungs will be compressed

Adjacent lung will be expanded

The image shows a right upper and middle zone bulla. Note that , when we draw a circle outlining the lesion, the circle of the center falls within the lung. The visceral pleural line is not visible. The adjacent lungs are compressed. Though scanty, we can see the bronchovascular markings through the lesion ( yellow arrow) .

Evaluate this image and then ask yourself if the right sided lucency is pneumothorax or bulla.  Now evaluate your findings with the Xray provided below.

This is a pneumothorax. Note the visceral pleural line( yellow arrow) . Make a circle outlining the medial wall of the lucency, and center of lesion lies outside the lungs( yellow circle). There is compression of the adjacent lung.

 

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