Departments of 1Surgery, 2Medicine and 3Anaesthesia, Sultan Qaboos University Hospital, Muscat, Oman
*Corresponding Author’s e-mail: drjayakrish@hotmail.com 

اسرتواح الصدر املستمر
الناسور اجلنيب السنخي بسبب ثقب يف الفقاعة

عادل حمد الكندي، جاياكري�شنان باالكري�شنان، �شيف حممد املبيح�شي، نا�رش عبد اهلل الكمياين

Persistent Pneumothorax
Alveolar pleural fistula due to a hole in a bulla

Adil H. Al Kindi,1 *Jayakrishnan B.,2 Saif M. Al Mubaihsi,2 Nasser A. Al Kemyani3

A 22-year-old male patient, previously treated for pulmonary tuberculosis, presented to Sultan Qaboos University Hospital, Muscat, 
Oman in 2017 with sudden onset shortness of breath. 
Chest X-ray showed a pneumothorax on the left side 
[Figure 1A]. A 20F chest tube was placed and connected 
to a closed pleural drainage chamber with low suction. 
The lung failed to expand fully even after ten days. 
A computed tomography scan showed a large multi-
loculated pneumothorax with large bulla in the left 
apical region. Thoracoscopy revealed multiple emphy- 
sematous bullae in the left lung. Air was found to be 
leaking from a clean hole on one side of a large bulla in 
the left apex [Figure 1B]. This alveolar-pleural fistula-
like behaviour probably accounted for the continuing 
air leak and the persistence of the pneumothorax. The 
left lung apex including the bullae was resected using 
an endo-GIA™ stapler (Medtronic plc, Minneapolis, 
Minnesota, USA). The staple line was covered with 

dissected parietal pleura. Mechanical pleurodesis was 
performed on the rest of the pleura. The lung sub- 
sequently inflated fully and remained expanded on 
follow-up one month later.

Comment

The major cause of persistent pneumothorax is an 
ongoing air leak, which is indicated by prolonged air 
bubbling into the chest drainage system. Air leaks are 
classified as: grade 1, during forced expiration (cough) 
only; grade 2, expiratory only; grade 3, inspiratory 
only; or grade 4, continuous.1 A common cause of 
persistent air leak is an alveolar-pleural fistula, a 
communication between the pulmonary parenchyma, 
distal to a segmental bronchus and the pleural space. 
This is different from a bronchopleural fistula which, by 
definition, is a communication between a main stem, 
lobar or segmental bronchus and the pleural space. 

Sultan Qaboos University Med J, May 2019, Vol. 19, Iss. 2, pp. e164–165, Epub. 8 Sep 19
Submitted 19 Dec 18
Revision Req. 9 Jan 19; Revision Recd. 14 Jan 19
Accepted 24 Jan 19

 
Figure 1: A: Chest X-ray of a 22-year-old male patient showing pneumothorax on the left side and collapsed lung margins 
(arrows). B: Thoracoscopic photograph showing a clean hole (arrow) in a bulla on the upper lobe of the left lung.

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.

https://doi.org/10.18295/squmj.2019.19.02.015

interesting medical image 

https://creativecommons.org/licenses/by-nd/4.0/


Adil H. Al Kindi, B. Jayakrishnan, Saif M. Al Mubaihsi and Nasser A. Al Kemyani

Interesting Medical Image | e165

Common causes include a ruptured bulla, cavitary 
neoplasm, fibrotic sarcoidosis, radiation fibrosis, inter- 
stitial lung diseases, necrotising pneumonia and post-
thoracic surgical intervention.2 This is often difficult to 
identify and is seldom seen as clearly as in the current 
patient. 

References
1. Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management 

of persistent air leaks. Chest 2017; 152:417−23. https://doi.
org/10.1016/j.chest.2017.02.020.

2. Chaturvedi A, Lee S, Klionsky N, Chaturvedi A. Demystifying 
the persistent pneumothorax: Role of imaging. Insights Imaging 
2016; 7:411−29. https://doi.org/10.1007/s13244-016-0486-5.

https://doi.org/10.1016/j.chest.2017.02.020
https://doi.org/10.1016/j.chest.2017.02.020
https://doi.org/10.1007/s13244-016-0486-5