Bullectomy for giant bullae in COPD
- Fernando J Martinez, MD, MS
Fernando J Martinez, MD, MS
- Gladys and Roland Harriman Professor of Medicine
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College
A bulla is defined as an air space in the lung measuring more than one centimeter in diameter in the distended state; the term giant bulla is used for bullae that occupy at least 30 percent of a hemithorax [1-3]. A single giant bulla may be surrounded by normal lung tissue or may be accompanied by a number of smaller adjacent bullae. Bullectomy involves the surgical removal of one or more giant bullae to improve symptoms and respiratory function in patients with bullous emphysema [4,5].
The indications and contraindications for bullectomy, as well as the perioperative management and operative technique of bullectomy will be reviewed here. The evaluation and medical management of giant bullae in patients with chronic obstructive pulmonary disease (COPD) and the roles of lung volume reduction surgery and lung transplantation in the management of advanced COPD are discussed separately. (See "Evaluation and medical management of giant bullae in COPD" and "Lung volume reduction surgery in COPD" and "Lung transplantation: General guidelines for recipient selection".)
Giant bullae adversely affect respiratory physiology in several ways. They occupy a large volume of the chest cavity and compress adjacent, more normal lung tissue. The compressed areas have reduced aeration and reduced elastic recoil. In addition, giant bullae can exert pressure on the diaphragm, leading to a flatter and less efficient shape. During exercise, bullae that communicate with the tracheobronchial tree increase in size due to dynamic hyperinflation and further impair respiratory function. (See "Dynamic hyperinflation in patients with COPD", section on 'Pathophysiology'.)
The proposed mechanisms by which excising a giant bulla and relieving lung compression improve lung function include [5-7]:
- Reducing the size mismatching between the hyperinflated lungs and the chest cavity, which restores the outward circumferential pull on the bronchioles (ie, increases elastic recoil).
- With improved elastic recoil, airway resistance is decreased and expiratory airflow improved, thus reducing air trapping.
- Removing the space occupying effect of the bulla and reducing air trapping help to restore the diaphragm to a more domed shape, which is more efficient.
- Reinflation of compressed areas decreases the physiologic dead space that was caused by compression of normal lung by the inflated bulla and improves matching of ventilation and perfusion.
- Reducing airway resistance, air trapping, and physiologic dead space decreases the work of breathing.
- Thurlbeck WM. Pathophysiology of chronic obstructive pulmonary disease. Clin Chest Med 1990; 11:389.
- Palla A, Desideri M, Rossi G, et al. Elective surgery for giant bullous emphysema: a 5-year clinical and functional follow-up. Chest 2005; 128:2043.
- Neviere R, Catto M, Bautin N, et al. Longitudinal changes in hyperinflation parameters and exercise capacity after giant bullous emphysema surgery. J Thorac Cardiovasc Surg 2006; 132:1203.
- Laros CD, Gelissen HJ, Bergstein PG, et al. Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 1986; 91:63.
- Snider GL. Reduction pneumoplasty for giant bullous emphysema. Implications for surgical treatment of nonbullous emphysema. Chest 1996; 109:540.
- Kinnear WJ, Tattersfield AE. Emphysematous bullae. BMJ 1990; 300:208.
- Shah SS, Goldstraw P. Surgical treatment of bullous emphysema: experience with the Brompton technique. Ann Thorac Surg 1994; 58:1452.
- Gaensler EA, Jederlinic PJ, FitzGerald MX. Patient work-up for bullectomy. J Thorac Imaging 1986; 1:75.
- Schipper PH, Meyers BF, Battafarano RJ, et al. Outcomes after resection of giant emphysematous bullae. Ann Thorac Surg 2004; 78:976.
- Meyers BF, Patterson GA. Chronic obstructive pulmonary disease. 10: Bullectomy, lung volume reduction surgery, and transplantation for patients with chronic obstructive pulmonary disease. Thorax 2003; 58:634.
- Nickoladze GD. Functional results of surgery for bullous emphysema. Chest 1992; 101:119.
- Ohta M, Nakahara K, Yasumitsu T, et al. Prediction of postoperative performance status in patients with giant bulla. Chest 1992; 101:668.
- Nakahara K, Nakaoka K, Ohno K, et al. Functional indications for bullectomy of giant bulla. Ann Thorac Surg 1983; 35:480.
- FitzGerald MX, Keelan PJ, Cugell DW, Gaensler EA. Long-term results of surgery for bullous emphysema. J Thorac Cardiovasc Surg 1974; 68:566.
- Gunstensen J, McCormack RJ. The surgical management of bullous emphysema. J Thorac Cardiovasc Surg 1973; 65:920.
- Martinez FJ, Chang A. Surgical therapy for chronic obstructive pulmonary disease. Semin Respir Crit Care Med 2005; 26:167.
- Brister NW, Barnette RE, Kim V, Keresztury M. Anesthetic considerations in candidates for lung volume reduction surgery. Proc Am Thorac Soc 2008; 5:432.
- Boasquevisque CH, Yildirim E, Waddel TK, Keshavjee S. Surgical techniques: lung transplant and lung volume reduction. Proc Am Thorac Soc 2009; 6:66.
- Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection, techniques, and outcomes. Chest Surg Clin N Am 2003; 13:631.
- Tsuchida M, Nakayama K, Shinonaga M, et al. Video-assisted thoracic surgery for thorascopic resection of giant bulla. Surg Today 1996; 26:349.
- Lewis RJ, Caccavale RJ, Sisler GE. VATS-Argon Beam Coagulator treatment of diffuse end-stage bilateral bullous disease of the lung. Ann Thorac Surg 1993; 55:1394.
- Wakabayashi A, Brenner M, Kayaleh RA, et al. Thoracoscopic carbon dioxide laser treatment of bullous emphysema. Lancet 1991; 337:881.
- Brenner M, Kayaleh RA, Milne EN, et al. Thoracoscopic laser ablation of pulmonary bullae. Radiographic selection and treatment response. J Thorac Cardiovasc Surg 1994; 107:883.
- Wakabayashi A. Thoracoscopic technique for management of giant bullous lung disease. Ann Thorac Surg 1993; 56:708.
- Barker SJ, Clarke C, Trivedi N, et al. Anesthesia for thoracoscopic laser ablation of bullous emphysema. Anesthesiology 1993; 78:44.
- Noppen M, Tellings JC, Dekeukeleire T, et al. Successful treatment of a giant emphysematous bulla by bronchoscopic placement of endobronchial valves. Chest 2006; 130:1563.
- Santini M, Fiorello A, Di Crescenzo VG, et al. Use of unidirectional endobronchial valves for the treatment of giant emphysematous bulla. J Thorac Cardiovasc Surg 2010; 139:224.
- Bhattacharyya P, Sarkar D, Nag S, et al. Transbronchial decompression of emphysematous bullae: a new therapeutic approach. Eur Respir J 2007; 29:1003.
- Cho S, Huh DM, Kim BH, et al. Staple line covering procedure after thoracoscopic bullectomy for the management of primary spontaneous pneumothorax. Thorac Cardiovasc Surg 2008; 56:217.
- Moser C, Opitz I, Zhai W, et al. Autologous fibrin sealant reduces the incidence of prolonged air leak and duration of chest tube drainage after lung volume reduction surgery: a prospective randomized blinded study. J Thorac Cardiovasc Surg 2008; 136:843.
- Brunelli A, Al Refai M, Muti M, et al. Pleural tent after upper lobectomy: a prospective randomized study. Ann Thorac Surg 2000; 69:1722.
- Venuta F, De Giacomo T, Rendina EA, et al. Thoracoscopic pleural tent. Ann Thorac Surg 1998; 66:1833.
- Chandra D, Soubra SH, Musher DM. A 57-year-old man with a fluid-containing lung cavity: infection of an emphysematous bulla with methicillin-resistant Staphylococcus aureus. Chest 2006; 130:1942.
- Goldstraw P, Petrou M. The surgical treatment of emphysema. The Brompton approach. Chest Surg Clin N Am 1995; 5:777.
- Froeschle P, Krishnadas R, Berrisford R. Video-assisted approach combined with the open Brompton technique for intracavitary drainage of giant bullae. Thorac Cardiovasc Surg 2012; 60:164.
- Boushy SF, Kohen R, Billig DM, Heiman MJ. Bullous emphysema: clinical, roentgenologic and physiologic study of 49 patients. Dis Chest 1968; 54:327.
- Celli BR, MacNee W, ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004; 23:932.
- Wesley JR, Macleod WM, Mullard KS. Evaluation and surgery of bullous emphysema. J Thorac Cardiovasc Surg 1972; 63:945.
- POTENTIAL BENEFITS
- PREOPERATIVE EVALUATION
- ANESTHETIC MANAGEMENT
- OPERATIVE APPROACH
- OPERATIVE TECHNIQUE
- Extent of resection
- Resection technique
- Reducing postoperative air leakage
- Final examination and closure
- Rarely used techniques
- POSTOPERATIVE CARE
- SUMMARY AND RECOMMENDATIONS