SURGICAL MANAGEMENT OF BASILAR BULLOUS EMPHYSEMA

Purpose: Emphysema is an abnormal enlargement of the air spaces distal to the terminal respiratory bronchioles. This enlargement is caused by destruction of the alveolar wall and can lead to the formation of bulla. Bullae are defined as large air-filled spaces with a diameter of 1 cm or greater. Formation of emphysematous bulla can occupy more than one third of the hemithorax and compress adjacent structures. This is significant because these large bulla lack alveolar-capillary interface leading to decreased oxygenation. Bulla is commonly found in the apical location of the upper lung lobes. We present this unusual case of a 67-year old male with a severe history of COPD secondary to smoking is considered for bullectomy of the basilar lung lobe instead of the common apical lobe. Methods: The patient was seen by a pulmonologist and failed medical treatment. After work-up, CT scan showed giant bullae in the basilar lobe instead of the most common apical location. Even with surgery, pulmonary function may not improve. The patient accepts the risks and continued with bullectomy. Results: During the operation, significant bullous lung disease was found, removed, and submitted to pathology. Significant anthracosis was also noted with lung hyperinflation. Following surgery, a post-operative air leak was found and patient developed atrial fibrillation. These complications were managed and inpatient rehabilitation was suggested. Patient preferred to go home and a personalized rehab program was designed for him. Conclusions: In conclusion, despite numerous medical treatments for the COPD patient, surgery may be of benefit to the patient with end-stage COPD. Of the many surgical procedures, giant bullectomy is shown to produce significant immediate functional improvement which persists for at least 3 years in individuals who are carefully selected.