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A 48-year-old woman with medical history significant for 20 pack-years of smoking presented with decreased exercise tolerance for the last year. On examination, her respiratory rate was 18 and oxygen saturation was 96% on room air with absent breath sounds within the left lung field. Alpha-1 antitrypsin levels were normal. Chest radiograph revealed giant emphysematous bulla with concern for concurrent pneumothorax (figure 1). CT scan of the chest revealed a massive bulla without a ‘double wall sign’ making superimposed pneumothorax unlikely (figure 2). Chest tube insertion was deferred and patient underwent bullectomy. Prior to surgery, her exercise tolerance …
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