Please do not put a chest drain in my chest! Vanishing lung syndrome

INTRODUCTION: Vanishing lung syndrome, also known as giant bullous emphysema is a condition usually reported in young male thin smokers. There are numerous case reports that have added to the body of evidence. There are also case reports of the giant bulla being misinterpreted for a pneumothorax. CASE REPORT: A 61 year old male with severe chronic obstructive lung disease presented to Accident and Emergency with progressive breathlessness. A chest radiograph showed a giant right sided bulla that was initially misinterpreted as a tension pneumothorax. Further review of his imaging and lung function pointed to him having vanishing lung syndrome. He was referred for a cardiothoracic opinion but was eventually managed conservatively. DISCUSSION: Vanishing lung syndrome is characterised by a slowly enlarging upper lobe bulla that compresses normal lung parenchyma and causes mediastinal shift, with the patients experiencing increasing dyspnoea and reduced exercise tolerance. Smoking cessation is the mainstay of treatment. If they are relatively asymptomatic, patients are managed conservatively. Otherwise a variety of lung volume reduction techniques can be considered. A large bulla can look the same as a pneumothorax but the former does not have a lung edge and has a more rounded appearance. A CT scan is very useful in differentiating between the two pathologies. Bullae are predominantly caused by smoking. Bullae will cause high total lung volumes and residual volumes, but low alveolar volumes. Bullae can be observed or treated by surgical techniques