(Chest. 1999;116:1809-1811.)
© 1999
American College of Chest Physicians
Development of a Giant Bulla After Lung Volume Reduction Surgery*
Mobeen Iqbal, MD;
Leonard Rossoff, MD;
Kerry Mckeon, RN, RRT;
Michael Graver, MD, FCCP and
Steven M. Scharf, MD, PhD
*
From the Division of Pulmonary and Critical Care Medicine (Drs. Iqbal, Rossofl, McKeon, and Scharf) and the Division of Cardiothoracic Surgery (Dr. Graver), Long Island Jewish Medical Center, New Hyde Park, NY 11040.
Correspondence to: Leonard Rossoff, MD, Department of Pulmonary and Critical Care, Room C-20, Long Island Jewish Medical Center, New Hyde Park, NY 11040
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Abstract
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Lung volume reduction surgery (LVRS) is being evaluated in the
treatment of emphysema. The proposed mechanisms of improvement are
increased elastic recoil of the lung and improved mechanical efficiency
of the muscles of respiration. We report a unique patient with
emphysema who developed a giant bulla 3 years subsequent to LVRS. The
patient underwent extensive evaluation, including measurements of lung
mechanics. Bullectomy was performed, but it was unsuccessful. Although
the mechanisms behind the development of giant bullous disease remain
speculative, heterogeneous improvement in elastic recoil following LVRS
may be one of the responsible mechanisms.
Key Words: elastic recoil • giant bulla • lung volume reduction surgery
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Introduction
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Emphysema
is characterized by a reduced maximum expiratory flow due to a
combination of airway disease and loss of elastic recoil.1
The latter leads to an increase in static pulmonary
compliance,2
static and dynamic hyperinflation, intrinsic
positive end-expiratory pressure, and increased work of
breathing.3
Chronic hyperinflation also puts the muscles
of respiration at a great mechanical disadvantage.
Lung volume reduction surgery (LVRS) is currently undergoing evaluation
for the treatment of pulmonary emphysema. Recent studies have
documented improved quality of life and relief of dyspnea in at least
some patients.4
5
Proposed mechanisms of improvement after
LVRS are increased elastic recoil,6
7
decreased airway
resistance, and improved respiratory muscle function.8
9
10
There are few studies describing long-term follow-up in LVRS patients.
It is theoretically possible that interaction within the lung due to
inhomogeneous changes in elastic recoil and airway function could
result in bulla formation. The following is a case report of the
development of giant bullous disease following LVRS, and we postulate
that improved elastic recoil contributed to this complication.
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Case Presentation
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A 58-year-old white woman with severe emphysema was evaluated in
our LVRS clinic. Her CT scan (Fig 1
, left) showed centrilobular emphysema predominantly
involving the upper lobes. After initial workup and pulmonary
rehabilitation, she underwent bilateral LVRS through median sternotomy.
Three months postoperatively, she improved subjectively and
objectively, as shown by pulmonary function tests (Table 1
). In the third year after LVRS, she gradually became more dyspneic and
was referred back to the LVRS clinic. The CT scan (Fig 1
,
right) now showed development of a giant bulla in the right
upper lobe occupying more than one third of the right hemithorax.
Serial chest radiographs (not shown here) at 3 and 6 months
postoperatively showed no evidence of bullous disease. Radiographs at 1
year after LVRS revealed the development of a bulla in the right upper
lobe less than one third the size of the hemithorax. Subsequent films
after 3 years showed the growth of the bulla. Serial pulmonary function
tests are shown in Table 1
. Pressure-volume (PV) curves are shown in
Figure 2
, top, A. Maximal static recoil pressure improved 3 months
after surgery, although specific compliance remained unaltered. The
3-year curve showed decreased maximal recoil pressure compared with 3
months, but it was still greater than it was before the LVRS.
Static recoil-maximum flow curves (Fig 2 , right, B)
demonstrated improved flow rates 3 months after LVRS. However, by 3
years, there was decreased maximum expiratory flow at any given recoil
pressure. An echocardiogram showed an estimated peak pulmonary systolic
pressure of 40 mm Hg with normal left ventricular function. She
underwent giant bullectomy but died postoperatively following massive
intrathoracic bleeding and ARDS. The cause of bleeding could not be
determined.
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Figure 1.. Left: CT scan before LVRS showing
bilateral, predominantly upper lobe centrilobular emphysema.
Right: CT scan 3 years after LVRS with a giant bulla
occupying most of the right hemithorax
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Discussion
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The long-term prognosis and the effect of LVRS on the lung
mechanics have not yet been characterized. This case reports the
development of a giant bulla as a late complication of LVRS, a finding
not previously reported.
Different mechanisms of bulla formation have been suggested. One
postulate is a ball valve mechanism in a small airway subtending the
distended airspace.11
Air is progressively trapped in
alveoli distal to the obstruction and expands to form a bulla. However,
bronchi connecting with bullae are patent, thus rendering this
explanation implausible.12
13
Ting et al13
studied isolated bullae after
resection and found that bullae were very compliant with a sharp
elastic limit and that the inflation pressures for bullae are less than
they are for surrounding lungs. Morgan et al12
measured
pressures in bullae just before excision and found that the pressure
was never positive during inspiration and never more positive than
pleural pressure at end-expiration. Accordingly, bullae appear to be
formed by emphysematous destruction of pulmonary tissue and enlarge by
the retractive forces of surrounding lung parenchyma. Improved recoil
after LVRS could act to exaggerate this process.
The serial PV curves of the patient mentioned above are consistent with
the latter theory.12
Before bullectomy (3-year curve),
there was a right shift on the normalized PV curve. This could be
consistent with the presence of the large bulla. The lung would be
essentially divided into two compartments: a nondeflating bulla and a
normally deflating compartment. The serial static recoil and maximum
expiratory flow curves initially showed improved expiratory flows at
any specific elastic recoil after LVRS. This may have been due to
decreased airway resistance engendered by increased recoil tethering
open airways. The curve after the development of giant bulla is shifted
to the right with decreased flow rates. Progressive narrowing and/or
distortion of airways surrounding the expanding bulla may explain this.
The surgical removal of a giant bulla in generalized emphysema is an
accepted procedure. The success depends on the size of the bulla and
evidence of retraction of adjacent lung tissue.14
Long-term follow-up after a giant bullectomy reveals little recurrence
and decline in pulmonary function comparable to the general
population.15
16
In our case, we cannot be sure whether
bulla formation represented natural disease progression or a
consequence of LVRS. However, the temporal relation to the LVRS, as
well as above considerations, suggest that bulla formation was a
consequence of the surgery.
In conclusion, we speculate that heterogeneous improvement of elastic
lung recoil after LVRS contributed to the bulla formation. The
retraction of lung surrounding the bulla may have distorted or narrowed
the bronchi, thus leading to decreased flow rates at comparable recoil
pressures over the long term. This patient fared poorly after the
bullectomy, and it is not clear if this procedure can be recommended
for treatment of this possible complication of LVRS.
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Footnotes
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Abbreviations: LVRS = lung volume reduction
surgery; PV =pressure-volume; TLC = total lung capacity
Received for publication March 29, 1999.
Accepted for publication June 8, 1999.
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References
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-
American Thoracic Society standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. Am Rev Respir Dis 1987; 136:225–244
-
Boushy, SF, Aboumrad, H, North, LB, et al (1971) Lung recoil pressure, airway resistance, and forced flows related to morphologic emphysema. Am Rev Respir Dis 104,551-561[ISI][Medline]
-
Tschernko, EM, Wisser, W, Hofer, S, et al (1996) The influence of lung volume reduction on ventilatory mechanics in patients suffering from severe chronic obstructive lung disease. Anesth Analg 83,996-1001[Abstract]
-
Cooper, JD, Trulock, EP, Triantafillow, AN, et al (1995) Bilateral pneumonectomy (volume reduction) for chronic obstructive lung disease. J Thorac Cardiovasc Surg 109,106-119[Abstract/Free Full Text]
-
Gaissert, HA, Trulock, EP, Cooper, JD, et al (1996) Comparison of early functional results after volume reduction or lung transplantation for chronic obstructive pulmonary disease. J Thoracic Cardiovasc Surg 111,296-306[Abstract/Free Full Text]
-
Gelb, AF, McKenna, RJ, Jr, Brenner, M, et al (1996) Contribution of lung and chest wall mechanics following emphysema resection. Chest 110,11-17[Abstract/Free Full Text]
-
Scharf, SM, Rossoff, L, McKeon, K, et al (1998) Changes in pulmonary mechanics after lung volume reduction surgery. Lung 176,191-204[CrossRef][ISI][Medline]
-
Martinez, FJ, de Oca, MM, Whyte, RI, et al (1997) Lung volume reduction improves dyspnea, dynamic hyperinflation and respiratory muscle function. Am J Respir Crit Care Med 155,1984-1990[Abstract]
-
Teschler, H, Stamatis, G, el-Raouf Farhat, AA, et al (1996) Effect of surgical lung volume reduction on respiratory function in pulmonary emphysema. Eur Respir J 9,1779-1784[Abstract]
-
Keller, CA, Ruppel, G, Hibbete, A, et al (1997) Thoracoscopic lung volume reduction surgery reduces dyspnea and improves exercise capacity in patients with emphysema. Am J Respir Crit Care Med 156,60-67[Abstract/Free Full Text]
-
Cooke, FN, Blades, BB (1952) Cystic disease of lung. J Thorac Surg 23,546-569
-
Morgan, MDL, Edwards, CW, Morris, J, et al (1989) Origin and behavior of emphysematous bullae. Thorax 44,533-538[Abstract/Free Full Text]
-
Ting, EY, Klopstock, R, Lyons, HA (1963) Mechanical properties of pulmonary cysts and bullae. Am Rev Respir Dis 87,538-544[Medline]
-
Pride, NB, Barter, CE, Hugh-Jones, P (1973) The ventilation of bulla and the effect of their removal on thoracic gas volumes and tests of overall pulmonary function. Am Rev Respir Dis 107,83-98[Medline]
-
Laros, CD, Gelissen, HJ, Bergstein, PG, et al (1986) Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 91,63-70[Abstract]
-
Pearson, MG, Ogilvie, C (1983) Surgical treatment of emphysematous bullae: late outcome. Thorax 38,134-137[Abstract/Free Full Text]
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TOP
Abstract
Introduction
