Background: Patients with chronic obstructive pulmonary disease (COPD) are at risk for tension bullae, potentially leading to tension pneumothorax. Distinguishing tension bullae from tension pneumothorax in acutely dyspneic COPD patients is essential but challenging. A case was presented where chest tube placement in a tension bulla provided initial benefit but resulted in a bronchopleural fistula. Case Presentation: A middle-aged male with COPD presented to the Emergency Department with severe dyspnea. History, bedside ultrasound, and chest radiograph suggested tension bulla or tension pneumothorax. Computed tomography was done which confirmed tension bulla. Despite bullectomy being the preferred treatment, clinical deterioration necessitated urgent chest tube placement, leading to rapid improvement. However, 2 days later, a bronchopleural fistula developed, requiring thoracotomy. Conclusion: Emergency physicians must be aware of tension bullae as a rare cause of acute dyspnea in COPD. This case underscores the need for specific management protocols, potentially including smaller diameter catheters for stabilization before definitive surgical treatment.

Keywords: Tension bulla, pneumothorax, COPD, chest tube, bronchopleural fistula.