Obstructive Lung Diseases: Obstructive Lung Disease |

Where's the Lung? FREE TO VIEW

Yi Hern Tan, MMed; Jessica Quah, MMed
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Singhealth Residency, Singapore, Singapore

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A402. doi:10.1016/j.chest.2016.02.417
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SESSION TITLE: Obstructive Lung Disease

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: A 59 year old with chronic obstructive lung disease (COLD) presents with symptoms of acute infective exacerbation. The radiological findings and management are reviewed.

CASE PRESENTATION: A 59 year old Eurasian male with an 80 pack-year smoking history presented with coryzal symptoms for two days, with worsening dyspnea and productive sputum. He has ischaemic heart disease and is receiving anti-platelet therapy. He also has COLD for which he has not been compliant with outpatient reviews and medications. Initial assessment showed SpO2 93% on room air, and his arterial blood gas was pH 7.42 pO2 62 mmHg, pCO2 34 mmHg and HCO3 22 mmol/L. His chest radiograph demonstrated areas of lucency in bilateral upper lobes; this raised clinical suspicion of bilateral pneumothoraces. His CT thorax demonstrated extensive bullous disease with no pneumothorax. He received antibiotics, corticosteroids and nebulized bronchodilators but developed worsening respiratory distress. A trial of non-invasive ventilation was unsuccessful and he was intubated. The patient was extubated after 3 days of mechanical ventilation. Swabs performed on admission confirmed Influenza A infection. He progressed well in the ward, was initiated on Tiotropium and Symbicort inhalers and discharged.

DISCUSSION: Vanishing lung syndrome was described by Burke as an idiopathic syndrome of progressive dyspnea caused by extensive, predominantly upper lobe emphysema with typically asymmetrical involvement. It affects mainly young male smokers and is characterized by large bullae that occupy at least a third of a hemithorax. Bullous lung disease has been described in association with cigarette smoking, marijuana, sarcoidosis, alpha-1-anti-trypsin deficiency, Marfan syndrome and tuberculosis. High resolution CT is the most accurate means of diagnosing the condition and determining the extent of disease. CT features include extensive paraseptal emphysema coalescing into giant bullae, often compressing the normal lung parenchyma. Diagnostic evaluation includes pulmonary function testing and assessment of exercise tolerance. Treatment involves bronchodilators; video assisted thoracoscopic surgery for bullectomy is recommended for patients who have progressively enlarging bullae, worsening respiratory failure, and pneumothorax.

CONCLUSIONS: Vanishing lung syndrome is a distinct clinical entity with characteristic radiological features. CT thorax is a fast and reliable method of confirming the diagnosis and may help guide management.

Reference #1: Burke R. Vanishing lungs: a case report of bullous emphysema. Radiology 1937;28:367-71.

Reference #2: Sharma N Vanishing lung syndrome (giant bullous emphysema): CT findings in 7 patients and a literature review J Thorac Imaging. 2009 Aug;24(3):227-30. doi: 10.1097/RTI.0b013e31819b9f2a.

Reference #3: Kobe Van Bael Video-assisted Thoracoscopic Resection of a Giant Bulla in Vanishing Lung Syndrome: case report and a short literature review Journal of Cardiothoracic Surgery 2014, 9:4 doi:10.1186/1749-8090-9-4

DISCLOSURE: The following authors have nothing to disclose: Yi Hern Tan, Jessica Quah

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