Surgical Management of Bullous Lung Disease

Alan Seikka
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DEFINITION
• A subpleural collection of air (<2cm) contained within the layers of the visceral pleura
• Alveolus ruptures  air subsequently leaks out, dissects through interstitial tissues to
Ble surface of lung (contained by thin fibrous tissues of visceral pleura)
• Usual cause of a primary spontaneous pneumothorax
b

• An air-filled space (≥1-2 cm in distended diameter), within lung parenchyma

• Forms as a result of destructive process of emphysema
Bull • A thin outer fibrous wall consisting of visceral pleura and an inner wall of variable
a thickness, consisting of the remnants of disintegrating emphysematous lung

Gia • One or more bullae that occupies more than one third of the hemithorax
nt
bull
ae
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ETIOLOGY

LoCicero III, J (ed.). Shields’ General Thoracic Surgery 8th edition. Philadelphia: Wolters Kluwer, 2019.
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PATHOPHYSIOLOGY

Lung retracts
from the
Air flows bullae
preferentiually
to the bullae
Space enlarges
 compliance
increases The bullae has no compressive effect, but rather
redirects airflow from normal lung to itself  lung
Local restriction and hypoventilation
destruction
of pulmonary Bullae had little or no elastic properties and
tissue behaved like a paper bag, increasing in volume
without large increases in pressure until filled to
capacity, then greatly increasing in pressure with
little change in volume
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Classification

Bullae are classified by DeVries and Wolfe as follows:

Group I: singular bulla with normal underlying lung

parenchyma

Group II: multiple bullae with normal underlying lung

parenchyma

Group III: multiple bullae with generalized emphysema

Group IV: multiple bullae with other diffuse lung diseases

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Diagnosis
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Clinical Examination

• Cough

• Chest pain

• Progressive dyspnea  correlation to size of bullae

• Diminished breath sound and increased resonance on percussion.

• Secondary infection  fever and purulent expectoration

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Radiology
• Chest radiographs
• Define the progression of giant bullae

• CT scan examination
• The size, location, and number of the bullae can be well visualized
• Bullae appear as avascular areas with curvilinear boundaries
• Double-wall sign  Distinguish pneumothorax from bullae
• Chest CT has replaced pulmonary angiography and bronchography in evaluating
for underlying emphysema
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INDICATION FOR SURGERY

 The most accepted criteria for giant bullectomy is as follows:

 Isolated bullae occupying 30% or more of a hemithorax
 Evidence of relatively nonventilated (compressed) and
nonemphysematous underlying lung parenchyma
 Dyspneic patient
 Asymptomatic patient: preventive surgery is justified if the bulla
occupies more than 50% of a hemithorax, adjacent lung is collapsed,
or the bulla has enlarged over a period of years
 Symptomatic patient: giant bulla and otherwise preserved underlying
lung stands to benefit from surgical treatment of the bulla
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OTHER INDICATIONS FOR SURGERY

• Hemoptysis / Pulmonary hemorrhage

• Chest pain
• Substernal & squeezing, radiating to the arms, and exercise related
• Air trapping in a bulla, with distention of the visceral or mediastinal
parietal pleura
• Pneumothorax
• Giant bullae vs a large pneumothorax on radiography
• Treatment consists of re-expanding the lung, closing the fistula, and
preventing recurrence
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PREOPERATIVE ASSESMENT

 Determination of the overall medical status of the patient

 Age, presence of comorbid diseases, past surgical and medical
history, smoking history

 Cardiac status
 Determine fitness for a thoracic procedure
 Presence of right-sided heart failure or cor pulmonale

 Pulmonary function testing

 Relation between size of bullae, underlying emphysema and FEV1

 Imaging studies
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OTHER CONSIDERATIONS
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 Smoking  cessation prior to surgery

 Lung cancer
 10x risk
 Radiographic features:
 An opacity in or adjacent to the bulla
 A focal or diffuse thickening of the wall of the bulla with an irregular inner surface
 Secondary signs including sudden enlargement or shrinkage of the bulla, straightening of the thin
curvilinear shadow of the bulla, fluid retention within the bulla, and pneumothorax
 Infected bullae:
 Resemble single or multiple cavitating abscesses
 An infected bulla may be distinguished from a lung abscess:
 Knowledge of preexisting bullous disease in the involved lung
 Other bullae in the same or contralateral lung
 Very rapid appearance of the air-fluid levels and extensive apparent cavitation after only a few days of
illness
 Relatively slight involvement of surrounding lung
 Initial absence of any pleural reaction
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SURGICAL MANAGEMENT
• Goal  remove the bulla while preserving as much underlying lung and lung function
as possible.
• Methods:
• resecting the wall of the bulla, as in bullectomy, with either a thoracotomy or median
sternotomy or through a thoracoscope
• removing the air within the bulla, effectively collapsing it, as in endocavitary drainage
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SURGICAL TECHNIQUES

 Thoracoscopic bullae resection

 Open bullae resection

 Resection of thick-walled bullae

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THORACOSCOPIC BULLA RESECTION

• Suitable for singular bullae

• Located peripherally

• A thorough inspection is
necessary

• Resect bulla and base the

adjacent healthy lung
parenchyma  optimal closure
and avoid bleeding

• In cases of pedunculated giant

bullae  incise the bullae first
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• Wedge or anatomic
resection through
anterolateral thoracotomy
• Indication:
• Multiple bullae
• Multiple lobe
distribution
• Intralobular bullae or
close to hilum
• Deep intraparenchymal
bulla

OPEN BULLA RESECTION

 RESECTION OF THICK-WALLED BULLA

• Used for giant bullae that

can be resected
completely
• The wall of the bulla is
grasped with forceps, and
an incision is made
lengthwise
• The surplus wall of the
bulla then is stretched with
clamps and resected
• Bronchi related to the
bullae are sutured to avoid
recurrence
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OUTCOME
▸ The size of the bulla
▹ A large bulla occupying 50% or more of the lung volume is
associated with significant improvements in FEV1 postoperatively
▸ The state of the underlying lung apart from the bulla
▹ CT evidence of relatively normal underlying lung with adequate
perfusion—and which has been significantly compressed by the
expanding bulla—is a predictor of good functional outcome after
bullectomy
▸ Demonstration of asymmetric regional distribution of lung
function
▹ A demonstration of poor contribution to overall lung function by
the bullous part is linked to better improvement in functional
parameters after bullectomy
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CONCLUSION

 Indication of surgery in bullous lung disease include size

of bullae occupying half or more of the hemithorax and
the compression of the remaining parenchyma
 The goal of surgical management in bullous lung disease
is to resect the bullous areas, prevent parenchymal
leakage and reexpansion of the residual lung
 The outcome of surgery relies on the amount and size of
the bullae and also the underlying parenchymal disease
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REFERENCES

 Patterson, GA (ed.). Pearson's Thoracic and Esophageal Surgery

3rd edition. Philadelphia: Churchill Livingstone, 2008.

 LoCicero III, J (ed.). Shields’ General Thoracic Surgery 8th edition.

Philadelphia: Wolters Kluwer, 2019.

 Grippi, MA (ed.). Fishman’s Pulmonary Diseases and Disorders 5th

edition. US: McGraw-Hill, 2015.

 Greenberg JA, Singhal S, Kaiser LR. Giant bullous lung disease:

evaluation, selection, techniques, and outcomes. Chest Surg Clin N
Am. 2003;13(4):631-649. doi:10.1016/s1052-3359(03)00095-4
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Thank you