SESSION TYPE: Airway Cases I
PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM
INTRODUCTION: Bullous disease is a common feature of emphysema. Rarely, some patients undergo spontaneous resolution of bullae. We present a case of a patient who experienced significant physiological improvement after spontaneous auto-bullectomy.
CASE PRESENTATION: A 31-year-old male with 30 pack-years of smoking presented in 1980 with severe upper lobe bullous emphysema. Over the following 3-5 years he developed worsening exercise capacity requiring continuous home oxygen. His course was complicated by recurrent pneumothoraces and respiratory failure requiring tracheostomy. The patient continued to have very poor functional status and persistent giant bullae with limited expansion of adjacent lung parenchyma. Over the next 10 years he had a progressive decline in lung function. In 2000 the patient was hospitalized with bullitis. Imaging demonstrated unexplained right upper lobe atelectasis with mediastinal shift and a fluid-filled left apical bulla. He was treated with antibiotics, which led to resolution of the air-fluid level. Over the next 2 years, he experienced some improvement in exercise capacity. By 2003, imaging demonstrated near-complete resolution of the giant left bulla. Spirometry just 7 months later was markedly improved. The patient was lost to follow-up in 2004 but returned in 2012. He had significant and sustained improvement in his exercise capacity with mild residual symptoms. He no longer required supplemental oxygen.
DISCUSSION: Pulmonary bullae are air collections that are usually >2 cm in diameter. Giant bullae are typically defined as those that occupy >50% of the involved hemithorax. Potential complications include dyspnea, pneumothorax, and superinfection (bullitis). The treatment of choice for severe bullae is bullectomy (lung volume reduction surgery). Auto-bullectomy refers to spontaneous regression of bullae. The mechanism by which this occurs is not clear, but most processes suggest inflammation causing bronchiolar obstruction with consequent air resorption and bulla shrinkage. Our patient suffered many complications of giant bullae including pneumothoraces, respiratory failure, and bullitis. Surgical resection is employed to allow expansion of normal lung, improve gas exchange, and optimize diaphragm function. This patient achieved similar results without surgical intervention.
CONCLUSIONS: In summary, our patient suffered a profound decline in lung function with numerous complications before a spontaneous improvement in symptoms and physiology. This case demonstrates that auto-bullectomy in severe bullous emphysema can achieve results equivalent to lung volume reduction surgery.
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2) Orton DF, et al. Spontaneous reduction in size of bullae. J Thorac Imaging. 1999;14(2):118-21.
3) Scarlata S, et al. Spontaneous resolution of a giant pulmonary bulla in an older woman: role of functional assessment. Respiration. 2011;81(1):59-62.
DISCLOSURE: The following authors have nothing to disclose: Mir Alikhan, Eric Honig
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