Bullous emphysema: clinical, roentgenologic and physiologic study of 49 patients

Mounier-Kuhn syndrome: A variable course disease

Mounier-Kuhn syndrome or tracheobronchomegaly is a rare disease characterized by marked dilation of the trachea and proximal bronchi with recurrent lower tract respiratory infections. Computed tomography and bronchoscopy are the key tools to accomplish the diagnosis. This is a condition with a clinical polymorphism, symptoms vary from minor with preserved respiratory function, to very severe with life threatening exacerbations leading to respiratory failure and premature death. The treatment is mainly symptomatic, stenting or surgery are reserved to extreme cases.Herein, we report two cases of the same condition with different clinical signs and diverse outcome.

Complete spontaneous resolution of a giant bulla without rupture or infection: a case report and literature review

We report a case of complete spontaneous resolution of a giant bulla without ipsilateral pneumothorax or overt infection accompanied by contralateral recurrent pneumothorax. A 67-year-old man visited the emergency room with dyspnea. Chest computed tomography revealed spontaneous pneumothorax on the right side and a giant bulla in the left anterior lung. Closed thoracostomy was performed and the patient was discharged. Two years later, right pneumothorax recurred. Bullectomy in the right lung and pleurodesis were performed. On monthly follow up, the giant bulla in the left lung had abruptly disappeared without any episode of pneumothorax or infection at one year after the operation.

Giant bulla mimicking pneumothorax

It is usually thought by emergency physicians that the diagnosis of a pneumothorax is straightforward and easy to make and to treat, but the diagnosis may sometimes pose a challenge. The present report describes a case of a giant pulmonary bulla in a 40-year-old man that progressed to occupy almost the entire left hemithorax and also subsequently ruptured to produce a large left pneumothorax. The giant bulla was diagnosed only as a pneumothorax, and initially managed with a chest tube only. The differentiation between pneumothorax and a giant bulla can be very difficult, and often leads to inaccurate diagnosis and management. This case report demonstrates the clinical presentation of giant bulla and its complications such as pneumothorax and also highlights the difficulty in making this diagnosis and appropriately treating it. In this article, we emphasized how to differentiate between giant bulla and pneumothorax utilizing history, physical examination, and radiological studies including computed tomography (CT) scan.

Spontaneous regression of pulmonary bullae

The natural history of pulmonary bullae is often characterized by gradual, progressive enlargement. Spontaneous regression of bullae is, however, very rare. We report a case in which complete resolution of pulmonary bullae in the left upper lung occurred spontaneously.

Advances in radiologic assessment of chronic obstructive pulmonary disease

Chest radiography allows detection of moderate and severe emphysema but does not allow quantitation of severity of disease or detection of mild emphysema. Chest radiography is helpful in assessing complications of emphysema such as pneumothorax or secondary infection of a bulla. HRCT provides a detailed image of emphysematous lung disease comparable to that of macroscopic pathologic appearance. The main role of HRCT in patients with COPD is in the preoperative assessment of patients being considered for bullectomy or LVRS.

Spontaneous regression of a giant pulmonary bulla

Gradual expansion of a lung bulla is common and may be associated with debilitating pulmonary symptoms. The aetiology of bulla expansion is unclear. Spontaneous regression, on the other hand, is rarely observed. The case is presented of a man in whom near complete spontaneous resolution of a giant pulmonary bulla occurred. This event was associated with dramatic improvement in the radiographic picture and pulmonary function.

Surgical treatment of bullous emphysema: experience with the Brompton technique

The technique first described by Monaldi has been modified for the treatment of discrete emphysematous bullae. Fifty-eight patients (median age, 56 years) underwent this procedure between 1983 and 1992. The operative mortality was 6.9% (4 patients). Fifty-two patients (89.6%) noted symptomatic improvement, as measured using the modified Medical Research Council of Great Britain dyspnea scale, from a mean value of 3.7 preoperatively to 2.1 postoperatively. Two patients remained unchanged symptomatically. In all patients, amelioration of symptoms was accompanied by an objective improvement in lung function. A mean increase of 28% was noted in the forced expiratory volume in 1 second (p < 0.05), and a 12.3% improvement in the total lung capacity was observed (p < 0.002). The residual lung volume-total lung capacity ratio declined from a mean of 70% to 57% after operation. A forced expiratory volume in 1 second of less than 500 mL (p < 0.05) and carbon dioxide tension of greater than 6.5 kPa (p < 0.05) were significant predictors of poor prognosis. The median follow-up period has been 1.9 years (range, 0.5 to 9 years). Two patients have returned for further drainage of new bullae on the operated side, and this was carried out percutaneously in both. We conclude that this technique offers a simple, safe, and effective method for the treatment of discrete bullous disease in patients with emphysema.

Prediction of postoperative performance status in patients with giant bulla

To predict the postoperative improvement in performance status after bullectomy, preoperative pulmonary function and dyspneic grade were evaluated in 20 patients with giant bulla. The patients were divided into two groups, based on postoperative performance status: group 1 consisted of 15 patients with improved status after surgery; and group 2 of five patients with worsened status after temporary improvement. To determine correlation with the groups, preoperative functional measurements such as %VC, FEV1%, MMF, PEFR, RV/TLC, delta N2, LCI, and PNCD were then analyzed by the multivariate statistic method; results of delta N2 and FEV1% showed significant correlation with the groups. Prediction of the groups based on the two measurements agreed with the actual results except in one patient. These results show that postoperative improvement in performance status of patients with giant bulla can be predicted on the basis of preoperative pulmonary function.

Functional results of surgery for bullous emphysema

Forty-six patients with bullous emphysema were operated on. Respiratory function was investigated before and immediately after surgery, and during the follow-up to five years. The larger the volume of the bullae, the less disturbances of lung function caused by their removal immediately after operation. Respiratory function improved significantly during the long-term follow-up after removal of the bullae that were more than one third of the hemithorax, but it did not change when the bullae were less than one third of the hemithorax and deteriorated after pulmonary resection for the bullae associated with long-term pneumonia. No new bullae were revealed roentgenographically at five years postoperatively.

Cystic disease of the lungs

Cystic disease of the lung should be considered in the differential diagnosis of any patient presenting with respiratory symptoms. The most important aids available to the thoracic surgeon for the evaluation of cystic disease are history, physical examination, and chest radiograph. Confirmation of diagnosis often requires computed tomography, pulmonary and thoracic aortic angiography, and upper gastrointestinal barium series.

Surgical treatment of bullous emphysema

Between 1974 and 1981, 20 patients had surgical treatment for bullous emphysema. There were 15 males and five females with a mean age of 40 years. The majority of patients had symptomatic respiratory disease, were smokers and had a past history of lung disease. In all cases bullae were visible on chest X-ray, the primary diagnostic investigation, and simple spirometry was used to assess lung function pre- and postoperatively. Cyst resection was performed in 14 cases (two bi-laterally) and pleurodesis was added in six of these cases. Lobectomy was performed in four patients and in two a pedunculated cyst was simply ligated and excised. There were no deaths and morbidity was acceptably low. Vital capacity (VC), Forced expiratory volume in 1 s (FEV1) and FEV1:VC ratio were all significantly improved with surgery though the correlation of subjective and objective results was variable. Surgery is appropriate for symptomatic patients with bullae visible on chest X-ray and asymptomatic patients with rapidly enlarging bullae occupying more than 30% of a hemithorax.

Surgical treatment of bullous lung disease

Clear guidelines for the selection of patients with large pulmonary bullae and severely impaired lung function for surgery remain to be defined. Twenty-one such patients operated on between 1971 and 1977 are reviewed in an attempt to shed some light on this difficult problem. Four of six patients with preoperative hypercapnia survived and were improved by surgery. There was no mortality among the remaining 15 patients of whom 14 were improved symptomatically by surgery (with improvement in FEV1 and vital capacity in 9). Preoperative bronchograms were used to help identify patients suitable for surgery. The presence of bronchiectasis was predictive of postoperative complications. Better results were obtained in those patients in whom plication of bullectomy could be performed than in those requiring lobectomy.

Anaesthesia for the patient with a coincidental giant lung bulla: a case report

The anaesthetic management of a patient with a coincidental giant lung bulla who underwent lumbar discectomy and laminectomy is described. The specific problems associated with anaesthesia in patients wih bullae, such as acute enlargement or rupture of the bullae, are discussed. Precautionary measures which may be taken during anaesthesia include the avoidance of nitrous oxide, the prophylactic use of a double-lumen tube, and the immediate availability of chest drains in the anaesthetizing area. Monitoring during operation may involve bilateral chest auscultation and arterial blood gas analysis.

Radiological distribution of pulmonary emphysema. Clinical and physiological features of patients with emphysema of upper or lower zones of lungs

Martelli, N. A., Hutchison, D. C. S., and Barter, C. E. (1974).Thorax, 29, 81-89. Radiological distribution of pulmonary emphysema: clinical and physiological features of patients with emphysema of upper or lower zones of lungs. Pulmonary emphysema exists in two main pathological forms, centrilobular and panlobular (panacinar) emphysema, the lesions predominantly affecting the upper and lower zones of the lungs respectively. There is disagreement among authors as to the clinical and physiological differences between these two forms, and direct evidence of the pathological type is seldom available during life. Patients with emphysema can, however, be divided on radiological criteria into an `upper zone' and a `lower zone' group, and it can be argued that these groups relate respectively to the centrilobular and panlobular forms of the disease. The evidence is far from conclusive but it was thought that a comparison of the two radiological groups would be of value. Patients in whom there was no obvious zonal preponderance were not included in the study.

Fifty patients with definite radiological evidence of pulmonary emphysema have been studied, those with α₁-antitrypsin deficiency being excluded. Thirty-one patients (62%) had emphysema which predominantly affected the upper zones of the lungs; the lower zones were the more severely affected in the remainder. Bullae were found in approximately equal proportions in each group. All the patients were, or had been, cigarette smokers. There was no significant difference between the mean ages of the two groups; only seven patients were free from exertional dyspnoea, all being in the upper zone group. Chronic bronchitis occurred with equal frequency in the two groups but started on average about 10 years earlier in those with lower zone disease; the latter patients had rather more severe airflow obstruction and more severe blood-gas abnormalities. The presence or absence of chronic bronchitis per se, however, did not appear to have any significant effect upon the common respiratory function tests. No data emerged from this study which suggested that there were differing aetiological factors in the two groups.