Ann Thorac Surg 2006;82:2308-2309
© 2006 The Society of Thoracic Surgeons
How To Do It
Decompression of Giant Bulla in Acute Pneumonia: Surgical Palliation Prior to Definitive Management
Nathan M. Stewart, MBBS,
Pankaj Saxena, MCh, DNB,
Mark A.J. Newman, MD, FRACS,
Igor E. Konstantinov, MD, PhD*
Department of Cardiothoracic Surgery, Sir Charles Gardner Hospital, Perth, Australia
Accepted for publication March 9, 2006.
* Address correspondence to Dr Konstantinov, Cardiothoracic Surgery, Sir Charles Gardner Hospital, Perth, WA 6009 Australia (Email: igorkonst{at}hotmail.com).
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Abstract
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Giant bullae can be complicated by respiratory tract infection in the setting of emphysema. Herein we describe a technique of palliative decompression of the bullae that gives time to treat acute pulmonary infection prior to definitive surgical treatment.
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Introduction
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Severe persistent respiratory failure due to large bulla in an emphysematous lung in a patient with pneumonia presents a challenging problem, as the patient may not tolerate surgical resection of the bulla. A palliation may be required so that pneumonia can be treated with subsequent definitive resection of the bulla. Herein we discuss the surgical management of a large bulla in a patient with acute pneumonia and severe respiratory compromise.
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Technique
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A 38-year-old male chronic smoker was admitted to the intensive care unit after acute respiratory arrest after a 1-week history of dry cough, wheezing and dyspnea. He was intubated, and received bronchodilators and antibiotics. However, despite maximal ventilatory support, the patient only marginally improved and remained acidotic and hypercarbic with a pH of 7.2 and pCO2 of 57. A computerized tomographic scan demonstrated a large bulla in the right lung with pulmonary compression and a mediastinal shift to the left. He remained febrile and progressively difficult to ventilate. The bulla increased in size and prevented lung expansion. Acute pneumonia superimposed on the chronic emphysematous lung disease increased the risk of volume reduction surgery. To decompress the bulla, a Foley catheter was inserted into it (Fig 1) using a standard catheter introducer. The balloon was inflated and the tension was kept on the catheter to keep the balloon firmly against the chest wall. The catheter was placed on suction of 5 kPa. This was followed by improvement in ventilation, lung re-expansion and centralization of the mediastinum. Pneumonia resolved over the next 10 days and the patient was weaned off the ventilator.
The Foley catheter was removed 20 days post-insertion when adhesions had attached the bulla to the chest wall. The patient spent 25 days in intensive care unit and a total of 40 days in the hospital.
Three months later the patient was admitted with dyspnea. Chest roentgenogram demonstrated a tension pneumothorax. His respiratory function was much better this time and permitted a video-assisted thoracic surgery resection of the bullae.
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Comment
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Video-assisted thoracic surgery is an established approach in the treatment of bullous emphysema [1]. It is effective in patients with severe impairment of lung function [2–3]. However, video-assisted thoracic surgical resection of bulla is not without risk, even in the elective setting with reported mortality in patients with borderline pulmonary function [4]. Decompression of the severely hyperinflated bulla can dramatically improve respiratory function [5].
Superimposed infection in the patient with borderline pulmonary function may result in acute pneumonia and life-threatening pulmonary compromise of the residual pulmonary reserve when the lung is compressed by a large bulla. Furthermore, there is a potential risk for tension pneumothorax, especially with the use of positive pressure ventilation. A prompt decompression of the bulla is desirable in the setting of superimposed acute pneumonia, as such decompression would facilitate the re-expansion of the residual lung tissue. However, the means of decompression may not always be feasible. Namely the resection of the bulla through an open thoracotomy or video-assisted thoracic surgery approach would require one-lung ventilation and as such may not be tolerated by the patient. An attempt to decompress the bulla with a needle or chest tube would most likely result in a tension pneumothorax.
We believe that the use of a Foley catheter as a temporizing measure to decompress the bulla has not been reported. Insertion of a Foley’s catheter into the bulla allows a good seal of the wall of the bulla to the chest wall and thus permits continuos decompression of the bulla over a prolonged period of time. The simple technique described herein does not require computed tomographic guidance and can be performed at the bed side. This approach gives time to treat acute infection prior to definitive surgical treatment.
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References
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- Wang J, Chen H, Li J. Video assisted thoracoscopic bullectomy for giant bullous emphysema Zhonghua Wai Ke Za Zhi 1997;35:544-546.[Medline]
- De Giacomo T, Venuta F, Rendina EA, et al. Video-assisted thoracoscopic treatment of giant bullae associated with emphysema Eur J Cardiothoracic Surg 1999;15:753-756.[Abstract/Free Full Text]
- Greenber JA, Singhal S, Kaiser LR. Giant bullous lung disease: evaluation, selection, techniques and outcomes Chest Surg Clin N Am 2003;13:631-649.[Medline]
- Menconi GF, Melfi FM, Mussi A, et al. Treatment by VATS of giant bullous emphysema: results Eur J Cardiothoracic Surg 1998;13:66-70.[Abstract/Free Full Text]
- Wada H, Sekine Y, Yoshida S, et al. Dramatic improvement of respiratory condition after lobectomy for localized bullous emphysema Ann Thorac Cardiovasc Surg 2004;10:293-296.[Medline]
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Abstract
Introduction
