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Cardiothoracic Surgery |

Giant Emphysematous Bulla

Christian Ghattas, MS; David Gemmel, PhD; Timothy Barreiro, DO
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Saint Elizabeth Health Center, Youngstown, OH


Chest. 2013;144(4_MeetingAbstracts):94A. doi:10.1378/chest.1702012
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Abstract

SESSION TITLE: Surgery Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Bulla is an air-filled space of 1cm or more in diameter within the lung parenchyma. Rarely, one or more bulla enlarge, occupying more than one third of the hemithorax creating a giant bulla (GB). Resulting hyperinflation of the chest increases breathing effort and causes dyspnea. We present a rare case of giant emphysematous bullae (GEB) that underwent bullectomy with improvement in quality of life.

CASE PRESENTATION: A 47 year old presented with shortness of breath. He was a 23 pack year smoker with no environmental exposures. Family history was negative for chronic lung disease. Examination revealed a tall thin gentleman with normal vital signs and oxygen saturation. Chest was symmetrical; breath sounds were diminished in the right upper thorax. The remainder of the exam was negative. CXR and high resolution CT scan demonstrated a 10 cm in diameter GB in the right apex as well as emphysematous changes. Alpha 1 anti-trypsin, IgE, and compliment levels were normal. Testing for lung function showed FEV1 65%, FVC 66%, and FEV1/FVC of 77%. Diffusion capacity was 67%.Ventilation perfusion scan revealed absence of perfusion and ventilation to the right upper hemi-thorax. He underwent right muscle sparing thoracotomy with apical bullectomy. The patient showed improvement of dyspnea.

DISCUSSION: Smoking, α1-anitrypsin deficiency, IV drug use, sarcoidosis, autoimmune and connective tissue diseases, and placental transmogrification of the lung are all associated with bullous disease. The most prevalent symptom is progressive dyspnea. Pathophysiology of GB is poorly understood. Some theories involve a positive pressure reservoir with a check valve, allowing only inspiratory air filling that compresses the surrounding lung. Another mechanism for GEB concludes that bullae develop within an area of lung weakness that is ventilated preferentially with no obstructive valvular mechanism. Treatment is bullectomy because it improves lung elastic recoil and exercise capacity. Favored surgical candidates are those with incapacitating dyspnea with isolated GB occupying more than 30% of the hemithorax with preserved underlying lung parenchyma. Asymptomatic patients should be observed closely. Poor outcomes are linked to advanced lung disease, and unrecognized systemic disease as the cause of the lung destruction. Although post-operative mortality is low, post-operative morbidity is common secondary to prolonged air leak >7 days (53%), atrial fibrillation (12%) and mechanical ventilation (9%).

CONCLUSIONS: GB is rare; progression is common. Ruling out systemic causes is vital to improved outcome and reducing surgical risks.

Reference #1: Schipper et al. Outcomes after resection of giant emphysematous bullae. Ann Thorac Surg. 2004 Sep;78(3):976-82.

DISCLOSURE: The following authors have nothing to disclose: Christian Ghattas, David Gemmel, Timothy Barreiro

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