Emphysematous bulla


Emphysematous bulla


  1. Abnormal permanent enlargement of distal air spaces with destruction of alveolar walls _ lung fibrosis. Overlaps with chronic bronchitis to form a disease spectrum known as chronic obstructive pulmonary disease.
  2. Due to an imbalance between lung proteases and anti-proteases.
  3. A bulla is an avascular low attenuation area that is larger than 1 cm and has a thin but perceptible wall.
  4. Associated with smoking but other chemicals and genetic disorders predispose to the condition (e.g. alpha-1 antitrypsin deficiency).
  5. Three types of emphysema
  • Panacinar, centrilobular and paraseptal.
  1. The different types of emphysema may coexist.

Clinical features

  1. May be asymptomatic, early in the disease.
  2. Exacerbations commonly precipitated by infection.
  3. Cough, wheeze and exertional dyspnoea.
  4. Tachypnoea, wheeze, lip pursing (a form of PEEP), use of accessory muscles (patients are referred to as pink puffers).
  5. Signs of hypercarbia include coarse tremor, bounding pulse, peripheral vasodilatation, drowsiness, confusion or an obtunded patient.

Radiological features

  1. CXR – focal area of well-defined lucency outlined with a thin wall. A fluid level may indicate infection within the bulla.
  2. Other CXR features include hyperexpanded lungs with associated flattening of both hemi-diaphragms, ‘barrel-shaped chest’, coarse irregular lung markings (thickened dilated bronchi – chronic bronchitisoverlaps) and enlargement of the central pulmonary arteries in keeping with pulmonary arterial hypertension.
  3. REMEMBER to look for lung malignancy/nodules; a common association.
  4. CT quantifies the extent, type and location of emphysema. It may also identify occult malignancy.

Differential diagnosis

  1. Post-infective pneumatoceles.
  2. Loculated pneumothorax.
  3. Oligaemia secondary to pulmonary emboli or hilar vascular compression.


  1. Emphysematous bullae form part of a spectrum of chronic obstructive pulmonary disease.
  2. Bullae in their own right usually need no active treatment. However, if severe disease, lung reduction surgery should be considered.

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