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Usefulness of the Double-Wall Sign in Detecting Pneumothorax in Patients with Giant Bullous Emphysema

Gayle M. Waitches1, Eric J. Stern and Theodore J. Dubinsky

1 All authors: Department of Radiology, Harborview Medical Center, University of Washington, Box 359728, 325 Ninth Ave., Seattle, WA 98104.



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  		Fig. 1. —76-year-old man with giant bullous emphysema. Chest CT scan shows small drainage catheter entering anterior right chest wall. Catheter coursed through several upper lobe bullae creating iatrogenic bronchopleural fistula that required right upper lobectomy. Note small adjacent pneumothorax and double-wall sign of air on both sides of bulla walls, parallel to chest wall (arrow).

 


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  		Fig. 2A. —35-year-old man with giant bullous emphysema and left pneumothorax. Chest CT scan through lower thorax shows large lucency in lower lobe. It is difficult to determine whether this represents huge bulla or pneumothorax.

 


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  		Fig. 2B. —35-year-old man with giant bullous emphysema and left pneumothorax. Chest CT scan more superior than A shows that this air is in large bulla and that there is also double-wall sign of large pneumothorax (arrow). This information is invaluable in indicating and directing appropriate site for chest tube placement.

 


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  		Fig. 2C. —35-year-old man with giant bullous emphysema and left pneumothorax. Chest CT scan through mid thorax shows pneumothorax surrounding very large bulla, not evident in A. This emphasizes importance of visualization of air external to bulla (double-wall sign) and of not confusing air within adjacent large bulla as seen in Figure 5A,5B. Bulla wall is seen parallel to parietal pleura.

 


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  		Fig. 3. —49-year-old man with giant bullous emphysema and spontaneous right pneumothorax. Chest CT scan shows large asymmetric upper lobe bullae. Chest tube is located peripherally in right pleural space. Note presence of air in pleural space surrounding anterior bulla on right (arrow) and parallel configuration of bulla wall with chest wall. This is double-wall sign of pneumothorax. This case illustrates benefit of identifying this sign to distinguish intraparenchymal air, as seen in huge bullae on left, from small pneumothorax surrounding these large bullae on right.

 


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  		Fig. 4. —33-year-old-man with giant bullous emphysema and left pneumothorax. Chest CT scan shows asymmetric upper lobe bullae. Double-wall sign on left confirms presence of extrapleural air. Note comparison with right side where air is contained only within walls of bullae. Recognition of this sign in patients with giant bullae, shortness of breath, and suspicion of pneumothorax is invaluable in accurately directing appropriate chest tube placement.

 


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  		Fig. 5A. —60-year-old man with giant bullous emphysema and no pneumothorax. Chest CT scan shows large upper lobe bullae without evidence of pneumothorax. Double-wall sign is absent.

 


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  		Fig. 5B. —60-year-old man with giant bullous emphysema and no pneumothorax. Chest CT scan through upper thorax shows apparent double-wall sign (arrow) in absence of pneumothorax. However, CT scans at other levels (not shown) revealed apparent sign to be opposing walls of two adjacent bullae. Note absence of air external to these bullae and nonparallel configuration of bulla wall with chest wall.

 

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