71 - Barotrauma and Inhalation Injuries
Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.
Title: General Thoracic Surgery, 6th Edition
Copyright 2005 Lippincott Williams & Wilkins
> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section XIV - Congenital, Structural, and Inflammatory Diseases of the Lung > Chapter 84 - Bullous and Bleb Diseases of the Lung
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Chapter 84
Bullous and Bleb Diseases of the Lung
Jean Deslauriers
Jocelyn Gr goire
Pierre LeBlanc
Bullae were defined at the 1959 Ciba symposium as emphysematous spaces larger than 1 cm in diameter in the inflated lung, usually but not necessarily demarcated from surrounding lung by curved hairline shadows. Most bullae are secondary to emphysema, and pathologically they consist of enlarged air spaces covered by visceral pleura and connective tissue.
In general, bullous emphysema is considered a medical disease other than to manage specific complications such as pneumothorax or infection. Resection of bullae to reduce dyspnea and improve pulmonary function is still a controversial issue because indications for surgery are unclear and results are difficult to interpret objectively.
TERMINOLOGY AND CLASSIFICATION
Blebs
Miller (1926) defined pulmonary blebs (Fig. 84-1) as well-circumscribed intrapleural air spaces separated from the underlying parenchyma by a thin pleural covering. They result from subpleural alveolar rupture, which occurs when the elastic fibers in the alveoli have been stretched beyond the breaking point. The outer wall of a bleb is made of visceral pleura and the underlying lung is normal. Blebs are small and peripheral, and most are located at the lung apices. Not uncommonly, blebs will coalesce to form larger air spaces or even giant bullae.
Bullae
Bullae can be associated with any variety of emphysema. Their walls are made of destroyed lung, and inside they are crisscrossed by fibrous strands that are the remnants of interlobular septae. Small bronchial openings are usually located at the base of a bulla.
Reid (1967) distinguished three types of bullae. Type 1 bullae project from the pleural surface like a mushroom, have a narrow neck, and a sac that is empty except for a few strands of tissue. They represent a small amount of lung greatly overdistended. Type 2 bullae have a broad neck, are produced by relatively less overinflation of a shallow subpleural layer of lung, and the sac usually contains strands of tissue, most frequently near its base. Type 3 bullae have only moderate protrusion above the pleural surfaces and they represent the least overinflation of a much deeper region of the lung. In addition, these bullae have no well-defined neck, and they contain emphysematous lung evenly throughout the bulla.
Most surgeons prefer a more practical classification of bullous emphysema that is based on the presence or absence of significant anatomic emphysema in the nonbullous lung.
Group I: Bullae and Almost Normal Underlying Lung
Group I bullae (Fig. 84-2) account for approximately 20% of all bullae. They are well demarcated from surrounding lung, are usually located at the apex, and typically they have a narrow base of implantation. When the bulla becomes larger or even giant (fills one half or more of the hemithorax), it displaces adjacent lung but patients remain relatively symptom free with close to normal pulmonary function.
Group II: Bullae Associated with Diffuse Emphysema
Group II bullae are seen in over 80% of all patients with bullous lung disease. Initially, at least, these bullae are simply a local exaggeration of diffuse panacinar emphysema (Fig. 84-3). These bullae are often multiple and bilateral, and they vary considerably in extent and size. Patient's symptoms are dependent on the severity of underlying emphysema rather than on bulla size.
Vanishing lungs feature complete loss of parenchymal architecture, distended air spaces disseminated throughout both lung fields, and absence of well-demarcated bullae.
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Fig. 84-1. Pulmonary blebs. Operative photograph shows well-circumscribed subpleural blebs at the apex of the lung. |
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Another practical classification of bullous emphysema is the one proposed by DeVries and Wolfe (1980). Group I includes patients with a single bulla and a normal underlying lung while group II patients have multiple bullae but still a normal lung. Groups III and IV identify bullous disease in patients with generalized emphysema and in patients with other diffuse lung disease (group IV), respectively.
ORIGIN AND BEHAVIOR OF BULLOUS LUNG DISEASE
Controversial views on the origin and behavior of bullous lung disease are based on early observations made by Baldwin and colleagues (1950) and Cooke and Blades (1952), who believed that a ball valve mechanism, present in the bronchial communication between bulla and adjacent airways, was responsible for progressive enlargement of the bulla. It was postulated that because destroyed and inflamed bronchi existed at the base of the bulla, gas was allowed to enter the air space but not allowed to leave. The bulla became progressively larger over time because of increased intrabullous pressure that eventually caused compression and collapse of the unsupported adjacent emphysematous lung tissue. The physiologic alterations associated with a bulla were therefore those of a space-occupying lesion that compressed and interfered with adjacent normal and functional lung. FitzGerald and co-workers (1973) further believed that the resulting decrease in lung volume and loss of elastic recoil caused by emphysema would lead to relaxation of peribronchial tension, narrowing of small airway diameter, and, eventually, expiratory obstruction affecting the less diseased portions of the lung.
More recently, Morgan and colleagues (1986, 1989) have shown through dynamic computed tomographic (CT) scan observations, intrabullous gas and pressure measurements,
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and pathologic examination that bullae are unlikely to grow and behave in the manner previously thought. According to these researchers and to Klingman and associates (1991), the lung surrounding a bulla is less compliant than the bulla itself; therefore, the pressure required to inflate it exceeds the pressure necessary to inflate the bulla. In other words, when bulla and lung are exposed to the same negative intrapleural pressure, the bulla is preferentially and always completely full before the adjacent lung. Consequently, once a parenchymal weakness exceeds a certain size, it results in a space within the lung that fills preferentially. Progressively, the forces of elastic recoil produce more retraction of the adjacent lung away from the bulla, and this action tends to further enlarge the bulla.
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Fig. 84-2. Bulla associated with almost normal underlying parenchyma. A 52-year-old man was admitted for rapidly progressive dyspnea. A. Chest radiograph shows decreased vascular markings in the right upper lobe area. Lung function was almost normal with a forced expiratory volume in 1 second of 2.55 L (65% of predicted) and a vital capacity of 4.94 L (95% of predicted). B. Operative photograph shows a large bulla herniating through the thoracotomy wound with normal underlying parenchyma. C. After bullectomy, the expanded lung fills the hemithorax. |
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Fig. 84-3. Bulla associated with diffuse emphysema. This 47-year-old emphysematous man was admitted for worsening dyspnea. A. Chest radiograph shows bilateral basal bullae with flattening of the hemidiaphragms. Lung function was impaired, with a forced expiratory volume in 1 second of 0.3 L (8% of predicted) and a value for diffusing capacity of the lungs for carbon monoxide of 8.60 mL/min per mm Hg (49% of predicted). B. Operative photograph shows that the bulla is in fact a local exaggeration of diffuse panacinar emphysema. |
Based on this understanding, the purpose of surgery in bullous lung disease may be more to permit the lung to regain its architecture and elasticity than to remove a space-occupying lesion.
Surgical Management of Bullous Disease
Among all procedures that have ever been promoted for the surgical management of chronic obstructive lung disease, the only operation that has stood the test of time is bullectomy, in which distended air spaces are resected to allow the reexpansion of restricted but potentially functional adjacent lung tissue.
Rationale and Indications for Surgery
Nondyspneic Patients
Surgery for Complications of the Bulla
In patients without ventilatory symptoms (Table 84-1), surgical intervention is mostly indicated for complications such as pneumothorax, infection, or hemoptysis that are clearly attributable to the bulla.
Gaensler and co-workers (1986) noted that bullous emphysema predisposes to pneumothorax and that, in such circumstances, a pneumothorax can be troublesome because of further reduction of function in already compromised patients, prolonged air leaks often unresponsive to tube drainage, and higher risk for recurrence than in patients with primary spontaneous pneumothorax. In a series of 67 patients with secondary spontaneous pneumothoraces,
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Tanaka and colleagues (1993) showed that the most common underlying diseases were emphysema and tuberculosis and that the most frequent presenting symptom was dyspnea.
Table 84-1. Rationale and Indications for Surgery in Patients with Complications of Their Bullae | ||||||||||||
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Infection of bullae is unusual, and most bullae containing a fluid level (Fig. 84-4) are only the site of an inflammatory reaction secondary to peribullous infection. Surgery is not indicated for this problem alone, and Rubin and Buchberg (1968) showed that fluid resorption may be associated with significant shrinkage and resolution of the bulla (autobullectomy) (Fig. 84-5). In a series of 10 patients with fluid within a bulla reported by Mahler and colleagues (1979), the air fluid levels disappeared in 3 days to 36 weeks (mean 11 weeks), whereas the alveolar infiltrate generally cleared at a slower rate. Rothstein (1954) has also shown that the usual course of events in bullae infected by Mycobacterium tuberculosis was that of gradual shrinkage and eventual replacement of the previous radiologic shadows by nondescript and linear densities.
Truly infected bullae (Fig. 84-6) should be managed conservatively, even though medical treatment is often unsuccessful because of the poor communications between the infected bulla and the bronchial tree. Surgical indications for resection are essentially the same as for primary lung abscesses, and they include failure of response to a 6-week course of adequate medical management, suspicion of occult bronchial carcinoma, and specific complications, such as hemoptysis or free pleural space rupture. Dean and colleagues (1987) showed that percutaneous drainage of the infected bulla should be considered in these high-risk patients.
Hemoptysis from an eroded artery is even more uncommon than infection. Berry and Ochsner (1972) reported one of the few cases in which hemoptysis was thought to be secondary to rupture of thin-walled pulmonary vessels passing through the alveolar wall and fibrous septae of a bulla. Because hemoptysis is seldom associated with
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bullous emphysema, another lesion in a different lung zone that could account for the bleeding should always be ruled out before surgery.
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Fig. 84-4. Bulla containing an air fluid level. A. This 35-year-old man with previous bullectomy on the right side has an asymptomatic loculation in the left upper lobe. B. At operation, he was found to have a large bulla containing serous and noninfected fluid. |
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Fig. 84-5. Shrinkage of a bulla after peribullous infection. A. This 74-year-old man had a left basal bulla that shrank significantly. B. After a 3-month episode of pulmonary infection. |
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Fig. 84-6. True infection of the bulla. A. Initial chest radiograph of a 64-year-old man with bilateral apical bullae. B. This patient was readmitted 3 years later for high fever, chest pain, and hemoptysis. The radiograph shows multiple loculations within the left bulla. At surgery, he had a pyogenic infection of the bulla. |
Gaensler and associates (1983) and Witz and Roeslin (1980) described cases in which chest pain was the main symptom and sole indication for surgery. The pain was most often retrosternal and related to exercise, and in some cases it mimicked angina. This symptom was explained by overdistention of the bulla during hyperventilation with secondary mediastinal shift. All patients improved after surgical removal of their bullae.
Primary lung cancer closely associated with a large bulla was analyzed in 32 patients by Tsutsui and colleagues (1988) in an attempt to elucidate radiographic features of the tumor. They proposed three radiographic patterns of neoplasm development: nodular opacity within or adjacent to the bulla, partial or diffuse thickening of the bulla wall, and secondary signs of the bulla, such as changed diameter, fluid retention, and pneumothorax. Stoloff and associates (1971) investigated the population of Philadelphia between 1947 and 1967 and found that the frequency of lung cancer in men without emphysema was 0.19%, whereas in individuals with bullous emphysema, the frequency was 6.1%. Similarly Goldstein and co-workers (1967) found that in 411 patients with bullous emphysema 4.3% had lung cancer. Nickoladze (1993) proposed the following hypothesis to explain this phenomenon: (a) lung cancer occurs more frequently in lung scars that favor development of bullae, (b) dystrophic changes in lung parenchyma caused by bullous emphysema promote development of lung cancer, and (c) bullae are unventilated or poorly ventilated spaces in which carcinogens linger and predispose to the development of lung cancer. It is important to remember that it is often difficult to make a definite diagnosis of lung cancer within a bulla and that thoracotomy may be necessary to confirm the presumption of neoplasm.
Other unusual complications of bullous emphysema include cervical herniation of an apical bulla, such as in the case reported by Victor and colleagues (1987) and dysphagia as reported by Ueda and associates (1994).
Preventive Surgery
Preventive surgery is defined as the resection of asymptomatic bullae on the premise that most of them will ultimately lead to serious and irreversible complications. It is also assumed that with longer periods of compression, it is less likely that the function will return to normal even if the lung appears to reexpand well. This, in part, relates to the loss of surfactant in chronically functionless parenchyma and to the development of various degree of interstitial fibrosis.
The role of preventive surgery is, however, unclear because of the little known information about the natural history of untreated and asymptomatic bullae. Boushy and associates (1968) observed that apical bullae tend to enlarge, but this enlargement was not seen in every case and it could not be predicted. Furthermore, they were unable to document any relationship between change in bulla size and deterioration of pulmonary function. Ribet (1992) reported 23 patients in whom the bullae were first discovered on chest radiography before the appearance of any symptoms. In this group, only 4 of 23 patients were still symptomless when surgery was performed, with a delay between discovery of the bulla and surgery of 0 to 12 years (mean 39 months). Ribet (1992) concluded that giant bullae may be symptomless, but remain so in a minority of cases, and that symptomless bullae can suddenly become complicated and cause death despite emergency aspiration. As a general principle, a planned operation is always better and associated with less morbidity than an emergency operation.
Most researchers agree that preventive surgery is legitimate when the bulla occupies one half or more of the
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hemithorax, compresses normal lung, or has enlarged over a period of years. Spear and associates (1961) believed that any bulla occupying one third or more of the hemithorax would ultimately be associated with impaired drainage, infection, and permanent tissue damage to the adjacent compressed lung.
Dyspneic Patients
Based on physiologic observations, the removal of bullae in emphysema and dyspneic patients can be performed for the following reasons: removal of a space-occupying and possibly compressive lesion; reduction in expiratory airway resistance; and reduction of dead-space ventilation (Table 84-2).
As summarized by De Giacomo and colleagues (2002), the physiopathologic basis of respiratory improvement after bullectomy relates to the reduction of residual volume (RV) and thoracic hyperinflation, reexpansion of adjacent functional lung, and improvements in diaphragm contractility, chest wall mechanics, and intrathoracic hemodynamics.
Removal of a Space-Occupying Lesion
Compression of relatively healthy lung near the bullae may impair overall gas exchange, with low ventilation-perfusion ratios in the restricted lung zone. Expansion of previously restricted lung should therefore increase vital capacity (VC) and arterial oxygen saturation.
High intrathoracic pressures generated by the bullae also may result in major hemodynamic dysfunction. Expiratory compression of the pulmonary arterial system and systemic venous return may decrease cardiac output both at rest and, more importantly, during exercise. Lowering intrathoracic pressures by removing large bullae may correct some of these hemodynamic parameters and decrease the degree of dyspnea.
Bullous emphysema, particularly when localized in the lower lobes, may finally have a deleterious effect on the function of the diaphragm and of the chest wall muscles, including the intercostals. In one patient reported by Travaline and colleagues (1995), impairment in diaphragmatic function was dramatically corrected by bullectomy, which restored the diaphragm to a more normal configuration with significant improvement in its strength. Removal of a large bulla is also likely to improve chest wall mechanics.
Reduction in Expiratory Airway Resistance
Ting and colleagues (1963) showed that bullae have little, if any, elastic recoil. At low volume, small variations in pressure bring important volumetric changes. At a critical level, however, compliance becomes extraordinarily low and the bulla cannot be stretched any more. Bullae can be compared with paper bags that are extremely compliant until they are full, when they become tense.
When associated with emphysema, the low compliance of the bulla significantly decreases the elastic recoil of the intervening lung and causes relaxation of the peribronchial tension. Ultimately, it creates an extrinsic airway obstruction affecting the less diseased portions of parenchyma around the bulla.
Removal of bullae may improve the elastic recoil of the previously restricted lung tissue, thus reducing the tendency of airways to collapse on exhalation.
Reduction of Dead-Space Ventilation
If a bulla is well ventilated and under perfused, the objective of surgery is to reduce this physiologic dead space and thereby decrease the work of breathing. Isotopic perfusion-ventilation studies have shown, however, that most bullae are neither perfused nor ventilated. The bulla was acting as a site of significant dead-space ventilation in only 1 of 14 patients studied by Pride and co-workers (1973).
Selection of Patients for Surgery
Because of the emergence of modern techniques for lung imaging and functional evaluation, guidelines have been proposed to help select individuals most likely to benefit from surgical intervention (Table 84-3). Although no single preoperative test is considered an absolute predictor of
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improvement, the main determinants of a successful outcome after surgery are the size of the bulla, the condition of the rest of the lung, and the evidence of compression. The best results are obtained in patients with large bullae, and in whom compression of a significant volume of potentially functional surrounding lung parenchyma can be demonstrated.
Table 84-2. Rationale and Indications for Bullectomy in Dyspneic Patients with or Without Diffuse Emphysema | ||||||||||||
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Table 84-3. Selection of Patients for Surgery | |||||||||||||||||||||||||||||||||
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Because these are the premises for successful surgery, a complete evaluation should attempt to answer the following questions: (a) Is there a localized or enlarging bulla, or both? (b) Is the bulla nonfunctional and does it compress adjacent lung, mediastinum, diaphragm? (c) Can the compressed lung reexpand and what is its potential to function once reexpanded? (d) What is the extent and severity of emphysema in the remaining lung? (e) What is the cardiac performance? (f) Does the patient have significant associated comorbidities, weight loss, or both? (g) Can the patient withstand an operation?
Anatomy of Bullous Area
Bullae are recognized by increased radiolucencies (avascular areas) surrounded by arcuate hairline shadows (cyst wall). Their diagnosis, number, location, and volume can be estimated from standard radiographs, but CT scanning should be used to determine the true size of a given bulla. The observation that a bulla has enlarged over time is pertinent, especially if the enlargement is associated with concomitant deterioration in pulmonary reserve (Fig. 84-7).
CT scanning is a sensitive diagnostic tool because it clearly shows the full extent and anatomical severity of bullous
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disease, features often not discernible on simple posteroanterior and lateral radiographs (Fig. 84-8). CT scanning may also help in differentiating a pneumothorax from a large emphysematous bulla.
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Fig. 84-7. Enlargement of a bulla. Serial radiographs demonstrate enlargement of an isolated right upper lobe bulla over 8 years. A. Only minimal overdistention. B. A well-demarcated apical bulla. C. After bullectomy, the underlying parenchyma reexpanded adequately. |
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Fig. 84-8. A 53-year-old man had dyspnea. A. The standard posteroanterior radiograph shows almost normal parenchyma. B. The CT scan demonstrates well-demarcated bilateral basal bullae. Postoperatively, his forced expiratory volume in 1 second increased from 1.1 to 1.7 L and his vital capacity from 2.9 to 3.3 L. Courtesy of Dr. Marcel Dahan. |
With the help of CT scanning, Morgan and associates (1986) were able to differentiate between patients with generalized emphysema that was locally worse in the area of the suspected bulla and patients with well-defined bullae that were potentially operable. They also used CT scanning to measure the volume and ventilation of bullae, and these measurements confirmed that most true bullae do not contribute to ventilation.
Morgan and Strickland (1984) also showed that CT scans obtained during expiration (dynamic CT) can offer important advantages over traditional radiology. According to these researchers, the advantages of CT scanning are (a) clarification of features visible on plain radiographs, such as number, size, and position of bullae; (b) disclosure of features invisible on the plain radiographs, such as small bullae at the lung apices or in the costophrenic sinuses; (c) assessment of features often obscured by other diseases on standard radiographs, such as scoliosis; and (d) clarification and assessment of associated lung diseases.
As suggested 20 years ago by Carr and Pride (1984), CT scanning has now become the ultimate imaging technique to delineate the anatomy of bullous lung disease.
In general, the best results after bullectomy are obtained with bullae occupying one third to one half of one or both hemithoraces (giant bullae), and the results are worse when bullae are small, multiple, and bilateral. In an interesting study of 25 patients, Baldi and associates (2001) showed that, statistically, the radiographic bulla volume was the single most important factor determining the increase in forced expiratory volume in 1 second (FEV1) after bullectomy (r = 0.80, p > 0.0001).
Function of the Bulla
The distinction between communicating and noncommunicating bullae may be relevant to the understanding of the pathophysiology of a given bulla, but it is relatively unimportant in making a surgical decision. Pulmonary areas that are to be resected, however, must be areas of poor perfusion.
Most bullae are not ventilated or poorly ventilated, so the change in size in inspiration and exhalation is small. The amount of trapped air in the bulla, however, as estimated by the difference between functional residual capacity measured by the helium dilution method and by plethysmography, is large. This difference reflects the true volume occupied by the bulla. After resection of such bullae, an increase in VC and FEV1 is expected. Morgan and associates (1986) have shown by CT scan studies of the volume of bullae and of their VC that, with few exceptions, little change in the volume of true bullae occurs between full inspiration (mean 1,454 mL) and full exhalation (mean 1,333 mL).
Bullae that communicate freely have large volume variations between inspiratory and expiratory images, but small volume difference between plethysmographic and helium dilution measurements. Little change is expected in postoperative VC, but FEV1 improves if the space taken by the bulla is replaced by normal lung parenchyma.
Isotope scans can also be used to determine the function of a bulla with respect to perfusion. It is particularly helpful to demonstrate that the bulla to be resected is not perfused or is underperfused when compared with the adjacent lung, thus improving the chances of a good outcome after bullectomy (Fig. 84-9).
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Fig. 84-9. A. Posteroanterior view of a ventilation scan (xenon 133) shows poor ventilation in a right upper lobe bulla. B. The scan taken during the washout shows trapping in the bulla but excellent ventilation and clearance of 133Xe in all other lung zones. C. Postoperatively, all lung zones return to normal. This patient is an ideal candidate for bullectomy. |
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Compression Index
Once it is decided that a symptomatic space-occupying bulla is present, the next step is to demonstrate that it is compressive and prevents adequate expansion of adjacent parenchyma. This is a key consideration because overstretching of unrestricted lung may ultimately lead to some functional loss. Laros and colleagues (1986) noted that in patients with vanishing lung syndrome, for instance, the destroyed lobe had a buffer function in preventing overexpansion of the remaining lung.
Brochard and associates (1986) described a simple but effective compression index based on initial radiographic data. Patients were rated 0 to 6, according to the number of compression signs present: 1 = vascular crowding in the parenchyma adjacent to the hyperinflated lung; 2 = arcuate displacement of blood vessels in the periphery of the bulla; 3 = displacement of the hilum; 4 = mediastinal displacement during inspiration, exhalation, or both; 5 = anterior mediastinal herniation of the lung; and 6 = displacement of lung fissures. They were able to correlate subjective results of surgery with the severity of compression.
Most of these signs can readily be seen on standard radiography or contrast-enhanced CT scan of the chest. Although pulmonary artery angiography is no longer routinely used, it may occasionally be useful to document vascular crowding (Fig. 84-10) and assess capillary filling in the periphery of adjacent parenchyma. Thinning or disruption of pulmonary capillaries (Fig. 84-11) suggests the presence of widespread emphysema and poor response to surgery.
State of Compressed Lung
Although difficult to predict, the potential for reexpansion and function of the compressed lung can be assessed by angiography, CT scan, and by isotopic studies of regional lung function. Adequacy of perfusion in the compressed lung is a prerequisite of functional recovery and is best demonstrated by dense peripheral capillary filling and flow on angiography and contrast CT. Ventilation in the compressed lung is more difficult to appreciate but can be estimated from inspiration-exhalation radiography of the chest, dynamic CT scanning, and ventilation scans. Dynamic ventilation per volume calculated from xenon (133Xe) washout half-time was reported by Nakahara and colleagues (1983) to be a good indicator of regional ventilatory efficiency as well as a good predictor of postoperative functional improvement (see Fig. 84-9).
Severity of Emphysema
Because diffuse emphysema is much more likely to be associated with poor outcome after bullectomy, one major goal of preoperative evaluation is to assess its severity. The extent and severity of emphysema can usually be gauged by
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CT scanning (anatomic) and by measurements of lung volumes and gas exchange (functional).
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Fig. 84-10. Angiography. A. Chest radiograph of a 64-year-old man with previous left lower lobectomy and extensive bullous disease in the remaining upper lobe. B. The angiogram demonstrates a large bullous lesion with significant vascular compression. C. Postoperatively, the lung expands adequately. |
Pride and associates (1973) showed that tests of overall function reflect the condition of the nonbullous lung and that they can be used to predict the possibility of generalized emphysema. Airflow limitation is probably the most significant functional abnormality seen in emphysema, and it can be estimated accurately by forced expiratory maneuvers. Several studies have stressed the importance of FEV1 as a predictor of results after bullectomy. FitzGerald and colleagues (1974) noted that patients with severe reductions in FEV1 are less likely to be improved after operation. Nakahara and co-workers (1983) also observed that symptomatic and functional improvement after bullectomy was less in patients whose FEV1 was smaller than 35% of predicted value. With large bullae, a low FEV1 may indicate
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slow emptying of the bulla rather than diffuse emphysema, especially if the value of diffusing capacity of the lung for carbon monoxide (DLCO), is close to the predicted value. In general, however, patients with an FEV1 of around half or more of predicted values seem to gain most benefit from bullectomy, while those with an FEV1 lower than 40% of predicted usually have more severe chronic obstructive pulmonary disease and do poorly after surgery. In addition, postoperative morbidity is increased in the presence of generalized emphysema.
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Fig. 84-11. Chest radiograph (A) and angiogram (B) of a 57-year-old man with severe chronic obstructive lung disease and large basal bullae. This patient is not an ideal surgical candidate because of a low index of compression. Peripheral capillaries in the left upper lung zone are significantly thinned. |
Patients with emphysema have a reduced capacity for oxygen or carbon monoxide transfer, or both. Abnormal Dlco correlates well with the morphology of emphysema, but resting arterial partial pressure of oxygen (Po2) is often normal until the disease reaches its end stage. Arterial hypoxemia is best demonstrated during a graded exercise tolerance test (treadmill or stationary bicycle ergometer), and the degree of desaturation correlates well with the values of Dlco and the severity of emphysema. Hugh-Jones and Whimster (1978) noted that preserved Dlco, together with minimal changes in blood gases during exercise, tend to be associated with sustained good results after bullectomy.
Clinical Features and Medical Status
Dyspnea Index
Because the primary objective of operation is to relieve dyspnea, selection should be based on clinical considerations. For patients with diffuse emphysema, the dyspnea must be disabling enough to limit work or everyday activities, or both, despite adequate medical treatment. Incapacitating dyspnea associated with hypoxia and hypercapnia is not considered a contraindication to operation, but surgery for patients requiring mechanical ventilation is controversial.
Clinical evaluation must also rule out any other comorbidities, such as heart disease, that may contribute to the intensity of dyspnea.
Other Clinical Features
Gaensler and associates (1986) showed that virtually all patients with bullae have a history of smoking and that smoking cessation improves the chances for a good surgical result. Hughes and colleagues (1984) also showed that among 11 patients who had received surgical treatment for bullous emphysema, all lung function variables declined at a faster rate in those who continued to smoke than in ex-smokers, the difference in rate being significant (p > 0.05) for FEV1, and Dlco.
Patients with clinical signs of chronic bronchitis, bronchospasm, recurrent infections, or dramatic weight loss generally have a higher surgical risk and a lower chance for a sustained good result. Some studies have shown, however, that improved postoperative pulmonary function often results in a return to normal eating habits and significant weight gain.
Age alone is not an absolute contraindication for surgery, although emphysema is more severe and the expected operative mortality rate is higher in older people. Woo-Ming and associates (1963) noted that the mean age at operation of patients who had a good result was 45.4 years, whereas the mean age of patients who experienced a fair or poor result was 54.5 years.
Patients with significant comorbidities such as cancers or others should not have a bullectomy.
Cardiac Performance
Assessment of cardiac performance by heart catheterization may be indicated for patients with clinical signs of heart failure or cor pulmonale. With right-sided heart failure, the surgical risk is higher, but Harris (1976) and others have shown excellent functional results. Minor pulmonary hypertension is common in severe bullous emphysema, but because it is often related to a restricted vascular bed in the adjacent lung field, it is not considered to be a contraindication to surgery.
Occasionally, patients with large bullae present with the gas tamponade syndrome, as described by Even and associates (1980). This syndrome occurs when large bullae compress the heart and mediastinum, which are displaced toward the opposite side. This displacement creates a shift of the right atrium and angulation of both vena cavae, which ultimately produces a significant decrease in cardiac output during exhalation. Clinically, this syndrome is characterized by dyspnea with minimal exercise, coupled with a small heart on chest radiography, normal oxygen saturations in arterial blood, and spirometric values that are altered only moderately.
Operative Procedure
Choice of Operation
General agreement exists that the operative strategy should be to remove the bulla while preserving all vascularized and potentially functioning lung tissue (Table 84-4). This is best accomplished by limited resections, primarily local excision or plication of visible bullae, or both, or by
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intracavitary tube suction and drainage of the bulla. Segmental resections are rarely indicated because bullous disease is seldom confined to an anatomic segment, and lobectomy (or pneumonectomy) should only be done when the entire lobe (or lung) is destroyed. Indeed, Gaensler and colleagues (1983) cautioned against performing lobectomy, because functional lung is often found at the hilum even when the surgeon believes that the entire lobe is destroyed.
Table 84-4. Ground Rules for Successful Surgery | |
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Preoperative Preparation
Before proceeding with the operation, bronchoscopy should be performed to exclude a bronchial obstructive lesion. Patients with chronic obstructive lung disease must have optimal preparation before bullectomy. Because the operative procedure is mostly elective, time must be spent preoperatively to teach methods for coughing, deep breathing, incentive spirometry, and chest physiotherapy. Specific drug treatment also must be given to reverse airway obstruction and bronchospasm as well as to control any intercurrent pulmonary infection. In addition, every possible attempt should be made to stop smoking. If possible, corticosteroid therapy should be discontinued also, because this is almost invariably associated with poor healing, prolonged air leaks, and increased chances of postoperative infections. Prophylaxis against deep vein thrombosis with subcutaneous low-dose heparin (5,000 IU twice daily) may be started the day of surgery.
Anesthetic Considerations and Monitoring
The technique of anesthesia must take into account the abnormal physiology of the emphysematous lung and the possibility of specific complications such as a tension pneumothorax occurring intraoperatively. In addition, the anesthetist must try to provide a quiet operative field during resection of the bulla.
All patients should be monitored as they would be for any other major thoracic surgical procedure. A thoracic epidural catheter should be inserted prior to the beginning of the operation with the understanding that continuous administration of epidural narcotics perioperatively will decrease the need for intravenous medication or other anesthetic agents. The surgeon must be present in the operating room during induction because the pleural space may need quick decompression in the event of a pneumothorax, whether it is ipsilateral or contralateral. Tension pneumothoraces may rapidly become catastrophic events because they impair venous return as well as further compromise oxygenation.
Patients are ventilated and anesthesia is maintained with a double-lumen tube so that the lung being operated upon can be collapsed. Indeed Benumof (1987) showed that a double-lumen tube was far superior than a single-lumen tube, especially if complications were to occur. Once the operation is completed, assisted ventilation is discontinued as soon as the patient has regained consciousness and body temperature has returned to normal. Most patients are extubated in the operating room unless they are unable to maintain adequate gas exchange. Before extubation, the patient has flexible bronchoscopy to aspirate retained blood, mucus, or other debris.
Standard Operative Approaches and Techniques of Bullectomy
Most bullectomies are performed via the standard posterolateral approach through the fifth or sixth interspace. They can be performed also through an anterolateral incision with presumably less interference with chest wall mechanics and less incisional discomfort. Axillary incisions are usually reserved for bullae located in the upper third of the lung. Lima and associates (1981) reported four cases of severe bilateral bullous emphysema treated by bilateral resection through median sternotomy. Reduced disability and the ability to treat both lungs at once are possible benefits of using this approach. Other researchers, such as Iwa and associates (1981), as well as Vishnevsky and Nickoladze (1990), have also reported minimal morbidity and good clinical results with simultaneous bilateral operations using median sternotomy. In Vishnevsky and Nickoladze's series of 16 patients, no operative mortality occurred, and expansion of compressed lung was achieved in all cases. Long-term follow-up for 5 years showed that perfusion and ventilation of lung parenchyma improved.
Despite these good results, we prefer bilateral staged operations in which functional results of the first procedure can be evaluated before proceeding with contralateral thoracotomy. This approach avoids not only the potential risks of sternal infection and mediastinitis but also the technical difficulties of operation if dense and massive adhesions are present between the pleural surfaces or if the bullae are located over the posterior surfaces of the lung. Dartevelle and colleagues (1995) have also reported that the phrenic nerve, especially the left, is more likely to get injured during sternotomy than when bullectomy is performed through other approaches. FitzGerald and associates (1974) reported on 84 patients undergoing operations for bullous emphysema, and of these, only 11 subsequently required contralateral thoracotomy for resection of bullae in the other lung.
Pedunculated bullae are easily managed through suture ligation of the pedicle and excision of the bulla. For patients with diffuse disease, the basic technique of plication is simple (Fig. 84-12). The development of surgical staplers has made the procedure even easier, and a modification of the Naclerio and Langer method (1947), as reported by Nelems (1980), is now used.
The largest bulla is opened longitudinally and the cavity is explored from within. Strands of fibrous septae are excised (Fig. 84-13) and long Allis forceps are applied from inside so that they grasp the pleura at the reflection of relatively normal parenchyma with the cyst cavity. The visceral
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pleura (cyst wall) is then folded back over the remaining raw surface of lung and a linear stapler is applied along the base of the bulla. The stapler is applied as many times as necessary until the raw surfaces of the entire base of the cyst are closed off. This double layer of pleura acts as a buttress for the staples. This reduces and may even prevent air leakage from the staple margin. Biological glues are useful to improve air tightness, but they limit pulmonary reexpansion somewhat when applied over lung surfaces. Other techniques designed to improve air tightness and minimize leakage from the suture line include the use of mechanical suture line reinforced by a polydioxanone ribbon, as described by Juettner and associates (1989), by Teflon strips (DuPont, Wilmington, DE, U.S.A.), as reported by Connolly and Wilson (1989), or bovine pericardial strips (Peri-Strips, Bio-Vascular, Inc., St. Paul, MN, U.S.A.), as described by Cooper (1994). In Parmar and colleagues' series (1987), of eight bullectomies performed in seven patients, two strips of Teflon felt approximately 1 cm wide were applied on either side of the line of resection and a continuous horizontal mattress suture of No. 2 0 silk was passed through all layers. All drains could be removed within 8 days with a mean interval of 4.5 days, and no patient developed a pneumothorax or atelectasis. In some cases, autologous parietal pleura can be cut into thin slices and wrapped around the GIA stapler before firing it as described by Whitlark and Hsu (1994).
 |
Fig. 84-12. Operative technique. A. Longitudinal opening of the bulla. B. Folding of visceral pleura over the raw surface of the lung and stapling of the entire base of the cyst. C. Completed bullectomy. Courtesy of Dr. J. D. Cooper. |
 |
Fig. 84-13. Operative photograph shows trabeculations and fibrous septae that must be excised before stapling of the bulla. |
Some researchers have stressed the importance of associating a pleurectomy or a pleural tent to the bullectomy. Eschapasse and Berthomieu (1980) advocated parietal pleurectomy, not only to prevent pneumothoraces, but also to reinforce the periphery of the lung in the hope of preventing further bulla formation. Pleural space reduction by tailoring the pleura (pleural tent), as Miscall and Duffy (1953) described, is useful when the lung does not appear to be large enough to fill the entire space. This tent is made out of parietal pleura mobilized from the apex and sutured to the lower border of the incision. Pneumoperitoneum is indicated only occasionally for patients with subpulmonic residual spaces. Because of the considerable air leak that may follow bullectomy, two properly placed drainage tubes should be left in the pleural space.
Video-Assisted Bullectomy
The surgery of bullous disease by video-assisted thoracic surgery (VATS) approaches and techniques has gained considerable popularity over recent years and it has somewhat widened the indications for surgery, especially in high-risk patients. De Giacomo and colleagues (2002) believe that VATS bullectomy is safe, effective, and fully justified in patients with severe impairment of lung function.
Blebs and bullae can be stapled, ligated with the Endoloop (Ethicon UK Ltd., Edinburgh, U.K.), as suggested by Liu and associates (1999), or cauterized with electrocautery, argon beam electrocoagulator, or laser. Like Landreneau and colleagues (1992), we advocate VATS staple resection of bullous disease with the Endo-GIA 30 or 60
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staplers (Auto-Suture, United States Surgical Corporation, Norwalk, CT, U.S.A.).
General endotracheal double-lumen anesthesia is always used with the patient positioned for a full posterolateral thoracotomy. Three trocars are usually necessary to perform the procedure. The first trocar, the thoracoscopic trocar, is inserted approximately two finger breadths below the tip of the scapula, through the sixth or seventh intercostal space. A 12-mm port is then inserted halfway between the posterior border of the scapula and the spine. If a port cannot be inserted, which could happen in smaller or obese individuals, the skin and muscle incision should be wide enough to allow the free passage of an Endo-GIA stapler without a trocar. Once the bullae are seen and their bases are well demarcated, they are deflated and excised using multiple applications of the Endo-GIA staples, usually six to eight for large bullae. A subtotal parietal pleurectomy can then be performed with thoracoscopic scissors and cautery. During the pleurectomy, care must be taken to remain within the endothoracic fascia to preserve the intercostal pedicle and to stay away from the costovertebral angle to avoid the sympathetic chain.
Several reports have shown that VATS stapler bullectomy can be performed with minimal morbidity and with results similar to those obtained with open bullectomy. In De Giacomo's series (2002) of 25 patients, there was no operative mortality, and excellent functional results were obtained in patients with stages 1 and 2 bullous disease.
The use of the argon beam coagulator was evaluated by Rusch and associates (1990), and they showed that it is effective both in controlling blood loss and sealing air leaks after resection. The instrumentation is safe and it causes less tissue injury than does standard electrocautery. Lewis and colleagues (1993) reported on eight patients with end-stage bullous disease, unresponsive to medical therapy and not considered candidates for a thoracotomy, who underwent unilateral VATS ablation of bullae using the argon beam coagulator. Hospitalization averaged 13.6 days, all patients made a complete recovery, and each was subjectively improved.
Torre and Belloni (1989) reported the use of neodymium:yttrium-aluminum-garnet laser pleurodesis through thoracoscopy in 14 patients. The fiber of the laser was advanced through the operative channel of the thoracoscope, and the blebs were coagulated with low-power laser pulses. No side effects were recorded, and in 13 patients the treatment was successful without recurrences. Wakabayashi and associates (1990) reported the use of the CO2 laser in the treatment of patients with apical blebs and diffuse bullous emphysema. The procedure was conducted under general anesthesia with a double-lumen tube and the entire inner surfaces of the bullae were exposed to the laser. The air leaks were successfully sealed in all but one patient.
More recently, Shigamura and co-workers (2002) reported a case in which they successfully excised a bulla with an ultrasonic-driven scalpel (Ethicon Endo-Surgery, Johnson & Johnson Medical, Cincinnati, OH, U.S.A.) and successfully sealed the cut ends using the Ligasure vessel sealing system (Valley Lab. Inc., Boulder, CO, U.S.A.).
External Drainage of a Bulla
External drainage of a bulla, reported by Head and Avery (1949), is a simple, useful, and expeditious technique that can be used as a temporary or permanent measure for patients considered at poor risk for thoracotomy. The procedure can be performed using local anesthesia and does not preclude later bullectomy. Because tension pneumothorax is a potentially serious complication of the technique, MacArthur and Fountain (1977) recommended removing 2.5 cm of rib over the center of the bulla and inserting a purse-string suture between parietal wall and cyst wall.
Venn and associates (1988) reported 22 intracavitary intubations performed on 20 patients for the relief of symptoms of bullous lung disease. They used the technique initially introduced by Monaldi (1938, 1947) to drain pulmonary cavities after tuberculous infection. A limited thoracotomy (5 7 cm) is performed to resect a portion of the underlying rib, the site of incision being determined according to the anatomy of the bulla and the disposition of adjacent compressed lung tissue. Once the pleura is opened and the bulla is incised, the interior of the bulla is inspected and the septae are perforated to allow free communication with adjacent loculae or bullae. Iodized talc is then liberally insufflated into the bullous cavity. A large Foley catheter (32F) is inserted into the cavity through a separate stab incision, and the balloon is inflated with 30 to 40 mL of air to function as a self-retaining drain. Previously inserted purse-string sutures are then tied around the catheter and an intrapleural drain is inserted at the most dependent part of the pleural space. Postoperatively, the Foley catheter remains on underwater seal drainage and is removed at 8 days, irrespective of residual air leak. After removal of the drain, the bronchocutaneous fistula spontaneously closes within 24 to 48 hours. Shah and Goldstraw (1994) reported 58 patients who underwent this procedure over a 10-year period (1983 to 1992). The operative mortality rate was 6.9% (four patients), and 52 patients (89.6%) noted symptomatic improvement. In all patients, improvement in symptoms was accompanied by an objective improvement in lung function.
To reduce the amount of postoperative air leakage from the bulla, Oizumi and colleagues (1990) proposed adding bronchofiberoptic occlusion of the drainage bronchus with fibrin glue to external drainage of the bulla. The fibrin glue is injected both in the base of the bulla and into the feeding segmental bronchus. In another report, Hillerdal and associates (1995) presented five patients with poor lung function in whom fibrin glue was injected into the bullae through the thoracoscope. Results of surgery were excellent, with no serious intra- or postoperative complication.
In the series of 20 patients who had external drainage of their bulla reported by Venn and associates (1988), 3 patients
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died after surgery, and symptomatic improvement was reported in 16 of the remaining 17 patients; this improvement was maintained over a median follow-up of 1.6 years. Potential advantages of intracavitary drainage over standard bullectomy are that no lung tissue is removed, and both the limited incision and brief anesthesia are better tolerated by the patient.
Results
Mortality
The reported mortality varies, but in general, age at operation, patient selection, surgical approach and technique, presence or absence of cor pulmonale, and severity of diffuse emphysema are excellent predictive variables.
Witz and Roeslin (1980) reported a mortality rate of 1.5% for 151 patients with relatively normal underlying lung, but the mortality rate was 11% in patients with diffuse emphysema. Most deaths resulted from respiratory failure or pleuropulmonary infection. By contrast, only two deaths (2.3%) were clearly related to surgery in the series reported by FitzGerald and associates (1974). This significant difference relates to patient selection, which was more standardized in the series of FitzGerald and associates (1974) (one institution) than in the series of Witz and Roeslin (1980) (data collected from 27 institutions in five different European countries). In three series from the 1980s (Table 84-5), no operative fatalities occurred among 66 patients who underwent bullectomy or lobectomy for bullous disease. The operative mortality rate for bullous emphysema should range between 1% and 5%.
Morbidity
Adequate postoperative care must include monitoring in an intensive care unit, prompt recognition and treatment of potential problems, early ambulation, drug treatment when needed, and above all, aggressive chest physiotherapy. This care is possible only with appropriate pain control. New techniques, such as epidural narcotic perfusion and patient-controlled intravenous analgesia, have been significant developments in the prophylaxis of complications.
Most problems specific to bullectomy operations relate to delayed expansion of the remaining lung, prolonged air leaks, or pleuropulmonary infections. All of these complications are troublesome, but eventually most lungs reexpand and virtually every air leak stops. Billing and associates (1968) noted that of seven patients with persistent postoperative spaces, only one developed an empyema that required a second procedure. Air leakage is a frequent and often troublesome complication of bullectomies. It occurs because small staple or needle holes in abnormal emphysema lung tear as the lung is reexpanded, creating air leaks that can persist for many weeks postoperatively. Most air leaks can be prevented intraoperatively by the use of meticulous surgical technique. Treatment includes patience, proper suction drainage to promote full lung reexpansion, or the use of a Heimlich valve, as described by McKenna and co-workers (1996).
Respiratory failure is uncommon because with proper selection, pulmonary function should improve with removal of giant bullae. Elective tracheotomy should be avoided, but for debilitated patients, nutritive support may be required before and after surgery.
Functional Results
Assessing surgical results is difficult because most reported series are small, and as Gaensler and colleagues (1986) pointed out, bulla size, preoperative evaluation, indications for surgery, type of surgery, and quality of follow-up vary among the various series. In addition, no randomized prospective clinical trial comparing standard medical therapy with surgery has been conducted, and all articles dealing with bullectomy are retrospective case series. From our review of more than 100 articles written since 1960, it is obvious that only general concepts can be outlined.
One of the difficulties in reporting results is the choice of parameters considered representative of good results. Certainly, decreased dyspnea and improved exercise tolerance are the primary objectives of operative intervention. Such
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improvement may translate into a return to useful levels of activity or even a return to full-time employment. For some patients, a decrease in the severity of chronic bronchitis also may be noted, as well as better overall quality of life. As mentioned previously, substantial weight gain can be expected after bullectomy.
Table 84-5. Operative Mortality | |||||||||||||||||||||||||||||||||
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Objective improvement is more difficult to quantitate, and it is well known that there is often a poor correlation between relief of dyspnea and documented improvement in pulmonary function. For most patients, pulmonary function studies improve only marginally, whereas considerable relief of dyspnea is noted. In general, the degree of clinical improvement correlates reasonably well with increased air flow as measured by FEV1, improved arterial oxygen saturations, and decreased trapped gas as measured by plethysmography. Anatomic improvement is easier to demonstrate because the expanded lung usually fills the hemithorax and isotopic studies show increased activity over previously radiolucent areas.
Early Results
With proper selection, approximately two thirds of patients experience significant postoperative relief of dyspnea, whether they have widespread emphysema, or this improvement can be documented by pulmonary function studies. As Capel and Belcher (1957) observed, improvement is noted within 3 months of operation and is generally sustained for 2 to 3 years postoperatively.
Determining the best predictors of early good results is more difficult (Table 84-6). Bulla size is an important variable in determining clinical and physiologic outcome. Capel and Belcher (1957) reported that patients with larger cysts benefited more from operations. Gaensler and associates (1986) showed that when bullae had occupied less than one third of the lung, no postoperative improvement was noted. With large bullae, however, postoperative increase of FEV1 ranged from 50% to 200%. Patients likely to benefit from operation have well-documented and enlarging apical bullae occupying at least 50% of the volume of their hemithoraces. Cases of smaller bullae or multiple bullae disseminated throughout both lungs are less favorable. Laros and associates (1986) showed that patients with vanishing lungs, as recognized by prune vessels and septae within the bullous zone, should not have surgery, because soon after operation, the preoperative situation reappears in the remaining parenchyma with loss of pulmonary function.
Table 84-6. Best Predictors of Good Postoperative Outcome | |
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Many researchers regard the degree of compression, as documented by chest radiography, angiography, or CT scanning, as the most significant predictive variable. Gunstensen and McCormack (1973) noted that the worst results were in patients who did not have signs of compression. Brochard and colleagues (1986) showed that when the index of compression was greater than or equal to 3, all patients had significant postoperative clinical and functional improvement. No patients with an index lower than 2 improved. Laros and associates (1986) reported that 27 patients with bullous emphysema improved after bullectomy, and their mean survival was longer than 7 years. Patients were selected for surgery based on the size of the bulla (50%) or well-documented and definite displacement of adjacent structures and on the exclusion of the presence of a vanishing lung. Connolly and Wilson (1989) and Potgieter and co-workers (1981) also showed that better results were obtained in patients with convincing evidence of compression of normal lung parenchyma.
Foreman and co-workers (1968) showed that perhaps the most useful information for selecting patients was given by the assessment of the underlying lung; it should be adequately perfused, as demonstrated by angiography, and have continued ability to wash out inhaled gas. Nakahara and associates (1983) observed that patients who did not benefit from bullectomy had disturbed ventilatory function in all lung regions, regardless of the location of the bulla. Patients with good results had relatively normal washout at the base.
By comparing initial contribution of the involved lung with postoperative increase in FEV1, FitzGerald and colleagues (1974) noted a good correlation between regional imbalance and postoperative functional results. When the lung operated on contributed less than 10% of total function, FEV1 always increased by more than 50% postoperatively. With a lung that initially contributed near normal perfusion, small or no increases in postoperative FEV1 were noted.
Plication of bullae results in larger increases in FEV1 and better clinical results than lobectomy. Rogers and colleagues (1968) investigated the effect of surgical resection on airway conductance. They observed an increase in airway conductance in all patients who underwent bullectomy. These researchers attributed this increase to improved lung elastic recoil. In four of five patients who had lobectomy for carcinoma, a reduction was observed both in the airway conductance and in the functional residual capacity with relatively little change in the conductance-to-volume ratio. Woo-Ming and associates (1963) noted that 12 of 28 patients who had a bullectomy had a good result, whereas only 2 of 15 patients who had lobectomy could maintain a
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good result for any length of time. In a series reporting long-term results in 84 patients who underwent 95 procedures over 23 years, FitzGerald and associates (1974) showed that better results were obtained with giant bullae simply excised in patients with lesser degrees of chronic obstructive lung disease. Poorest results were seen in patients with smaller bullae, diffuse emphysema, and severe bronchitis who underwent lobectomy.
Other factors that may be less predictive of early good results are a large amount of trapped air in the bulla as measured by plethysmography, a severe disability before surgery, and the absence of diffuse emphysema in the remaining lung.
From a physiologic standpoint, Snider (1996) showed that early postoperatively, hypoxemia and hypercapnia appeared to be the measurements most frequently improved by surgery. Increases in FEV1 are generally modest, while residual volume and total lung capacity generally decreased.
Late Results
Although most series have shown good to excellent initial postoperative results, dyspnea gradually returns to preoperative levels after the fifth postoperative year. The severity of emphysema seems to be the main limiting factor for sustained good results. In a series of 18 patients with bullous emphysema treated surgically, Pride and co-workers (1973) showed that increases in FEV1 were largest in patients who preoperatively had had the least severe generalized airway obstruction. These results imply that when expiratory volumes suggest widespread emphysema, the chances of bullectomy leading to a significant and long-lasting improvement are decreased.
In the series of Witz and Roeslin (1980), patients were divided into two groups. In group I patients (n = 151) with localized bullous disease and near normal underlying lung, 73% improved with surgery and most were able to return to work. In most cases, this improvement persisted during the years of follow-up. In group II patients (n = 272) with more diffuse emphysema, only 50% were still improved after 5 years and 20% after 10 years. The degree of degradation paralleled the severity of emphysema.
In the series of FitzGerald and associates (1974), 47 long-term survivors with a mean follow-up time of 9 years were divided into three groups. Group I patients (n = 16), with small and well-demarcated bullae of the paraseptal emphysema type, had sustained good results, and their long-term decline in function differed little from that of normal aging. In group II patients (n = 16), with larger but still localized bullae, initial good results were sustained for approximately 4 to 5 years, but then function declined, only to return to preoperative levels within 7 to 10 years. In 15 patients with diffuse emphysema (group III) the average decline in FEV1 during the follow-up period was 101 mL per year, and the functional improvement persisted for only 1 to 2 years. This annual decline is more than the expected 80 mL per year for patients with chronic obstructive lung disease and 28 mL per year for normal individuals.
Pearson and Ogilvie (1983) reviewed nine patients 5 to 10 years after surgery, and all had gradual return of their initial symptoms, with an annual decline in FEV1 of 82 mL per year. They found no new bullae on chest radiography and no enlargement of preexisting bullae. Similarly, Nickoladze (1992) showed no new bullae in over 40 patients studied radiographically 5 years postoperatively.
This clinical information suggests that surgery for bullous disease associated with diffuse emphysema is worthwhile for short-term relief, but that sustained improvement is highly unusual. Laros and colleagues (1986) have also shown that in bullectomy patients, FEV1 and Dlco declined more rapidly in patients who continued to smoke than in those who stopped underlying the importance of smoking cessation after surgery.
CONCLUSION
Proper understanding of the physiologic changes associated with bullous lung disease is of paramount importance in the selection of patients for surgical intervention. In general, better results are observed in patients with large compressive bullae and in those with only moderate signs of chronic obstructive pulmonary disease. In recent years, refinements in operative approaches (VATS), surgical techniques (control of air leaks), and postoperative care (epidural pain control) have widened the indications for bullectomy. However, selection of patients for surgery in the presence of diffuse emphysema remains difficult and controversial.
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- Chapter I e-Search: A Conceptual Framework of Online Consumer Behavior
- Chapter IV How Consumers Think About Interactive Aspects of Web Advertising
- Chapter X Converting Browsers to Buyers: Key Considerations in Designing Business-to-Consumer Web Sites
- Chapter XIII Shopping Agent Web Sites: A Comparative Shopping Environment
- Chapter XV Customer Trust in Online Commerce