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Pulmonary bleb

Dr Owen Kang and A.Prof Frank Gaillard et al.

Pulmonary blebs are small subpleural thin walled air containing spaces, not larger than 1-2 cm
in diameter. Their walls are less than 1 mm thick. If they rupture, they allow air to escape into
pleural space resulting in a spontaneous pneumothorax.

On this page:
Article:

Epidemiology
Clinical presentation
Pathology
Radiographic features
Differential diagnosis
References

Images:

Cases and Figures

Epidemiology

Blebs are a very common finding in otherwise normal individuals. They are often found in young
patients. They are more common in thin patients and in cigarette smokers 1.

Clinical presentation

In the vast majority of cases, blebs remain asymptomatic. Occasionally they are thought to
rupture resulting a pneumothorax.

Pathology

Blebs are thought to occur as a result of subpleural alveolar rupture, due to overload of the elastic
fibres.

Pulmonary bullae are, like blebs, cystic air spaces that have an imperceptible wall (less than 1
mm). The difference between blebs and bullae is generally considered to be their size, with the
cross-over being around 2 cm in diameter. Blebs may, over time, coalesce to form bullae 1.

Radiographic features
Pulmonary blebs are not visible on chest x-rays, but can seen on the lung windows of CTs. In
patients who have had a pneumothorax secondary to a ruptured bleb, it is often difficult, if not
impossible to locate since it has decompressed is surrounded by pneumothorax and has deflated
adjacent lung.

CT

Blebs appear as small (<1-2 cm) subpleural air spaces, located most frequently at the lung apices.
They have thin, almost imperceptible walls.

Differential diagnosis

Key differential considerations include:

bulla: thin wall (<1 mm), usually considered larger than blebs (>2 cm)
pulmonary cyst: wall thickness 1-3 mm
pneumatocoele: deeper within the lung
Pulmonary bullae
A.Prof Frank Gaillard et al.

Pulmonary bullae are focal regions of emphysema with no discenible wall which measure more
than 1 cm in diameter 1-2. Some use the term pulmonary bleb for a 1-2 cm lesion, whereas others
use the terms bleb and bulla interchangeably. They are often subpleural in location and may
result in spontaneous pneumathoraces.

In some cases, bullae can be very large and result in compression of adjacent lung tissue.

Location specific sub types

subpleural bullae
Pulmonary cavity
Dr Yuranga Weerakkody and A.Prof Frank Gaillard et al.

Pulmonary cavities are gas-filled areas of the lung in the center of a nodule, mass or area of
consolidation. They are usually evident on plain radiography and CT. They are typically thick
walled and their walls must be greater than 2-5 mm. They may be filled with air as well as fluid
and may also demonstrate air-fluid levels.

On this page:
Article:

Terminology
Pathology
See also
References

Images:

Cases and Figures

Terminology

According to the Fleischner society pulmonary cavities are defined "gas-filled space, seen as a
lucency or low-attenuation area, within pulmonary consolidation, a mass, or a nodule" 7.

Pathology

The cause of pulmonary cavities is broad. They may develop as a chronic complication of a
pulmonary cyst, or secondary to cystic degeneration of a pulmonary mass. They may enlarge or
involute over time.

Causes

Pulmonary cavities may be the result of malignancy, infection, inflammation or be congenital:

cavitating malignancy
o primary bronchogenic carcinoma (especially squamous cell carcinoma)
o cavitating pulmonary metastases
squamous cell carcinoma
adenocarcinoma, e.g. gastrointestinal tract, breast
sarcoma
infection
o pulmonary tuberculosis 3
o pulmonary bacterial abscess/cavitating pneumonia
o post-pneumonic pneumatocoele: a thin walled pneumatocoele is not really a
cavity but when infected can be thick walled
o septic pulmonary emboli
o other rare infections
pulmonary coccidioidomycosis
pulmonary actinomycosis / thoracic actinomycosis
pulmonary nocardiosis
melioidosis
pulmonary cryptococcosis 8
non-infective granuloma
o granulomatosis with polyangitis
o rheumatoid nodules
vascular
o pulmonary infarct
trauma
o pneumatocoeles (a thin walled pneumatocoele is not really a cavity)
congenital (not true "cavity")
o congenital cystic adenomatoid malformation (CCAM)
o pulmonary sequestration
o bronchogenic cyst

A helpful mnemonic is CAVITY.

See also

pulmonary mass
pulmonary cyst
pulmonary cavity
o pulmonary cavity (mnemonic)
pulmonary nodule
Foto Thorax PA
d = CTR< 50%, tampak bercak eksudat di lobus medial&inferior hemithorax kanan dengan
batas jelas di fissura minor
k = pneumonia lobaris kanan

Stafilococcus = pembentukan kavitas-kavitas


d = tampak bercak kesuraman di basal paru kanan disertai cavitas-cavitas berdinding
tipis, dengan/tanpa air fluid level
k = pneumonia stafilokokus kanan

cavitas = dinding tipis, bisa disertai air fluid level


caverne = dinding tebal, proses spesifik aktif
residual cyst = dinding tipis, proses spesifik inaktif
eksudat = serbukan sel radang yg dibentuk oleh kuman nonspesifik di basal/medial paru
infiltrat = serbukan sel radang yang dibentuk oleh kuman spesifik di apex/lobus superior
transudat = cairan hasil transudasi/keluarnya cairan dari intra ke ekstra tanpa sel