A 28 y.o. presents with shortness of breath. What should you do?

this is his cxr

Our patient had congenital lobar emphysema.   It is a cause of respiratory distress in the neonate, but can also be found in young adults.  The diagnosis is often made on cxr. Key findings include hyperlucency on the affected side with atelectasis of the normal lobes.  The mediastinum may be displaced away from the affected side and may herniate into the contralateral hemithorax.  Lung slide may be absent although there is no pneumothorax. The patient does not need a chest tube. This condition should be distinguished from Swyer- James,  which is acquired hyperlucency after an adenovirus infection where the lung does not grow normally.

In two other conditions a chest tube is not needed although it may look like it on first glance. One condition is a large bleb which can mimic a pneumo.  The danger of putting a chest tube into such a patient is that a persistent air leak can develop.

CXR with a large bleb below

Another condition that can mimic a pneumo/hemo  is a collapsed lung. The image below is  from a patient who presented one month ago to the ED.  There was a call from the triage doctor stating, “patient is coming to TCC 2 needing an urgent chest tube. “ The image is below and represents a completely obstructed L mainstem bronchus with L lung collapse.  A chest tube would not be indicated but rather a bronch.

Our patient underwent a resection of the emphysematous upper lobe and recovered without incident.It was easy to make the diagnosis on history in his case and it was confirmed on CT where lung markings could be seen on the empysematous side..

Stern EJ, Webb WR,  Weinacker A, Muller NL.  Idiopathic giant bullous emphysema (vanishing lung syndrome) imaging findings. In nine patients . AJR , 162(1994) 279-282.

Boushy SF, Kohen R, Billig DM, Heiman MJ.  Bullous emphysema: clinical, roentgenologic and physiologic study of 49 patients. Dis Chest, 1968. 54:327-334.

Gelabert, C, Nelson M.  Bleb Point: Mimicker of Pneumothorax in bullous lung disease. 201516(3).447-449.

lung markings seen on the emphysematous side