Transbronchial decompression of emphysematous bullae: a new therapeutic approach

Abstract

Bullae are common accompaniments of chronic obstructive pulmonary disease especially emphysema. They contribute to increased lung volume and worsen the mechanical disadvantage of the inspiratory muscles by increasing the residual volume (RV) and RV/total lung capacity ratio. Thus effective decompression of a large bulla or bullae is thus important to improve the lung function of affected patients and also to provide symptomatic relief. Surgery and thoracoscopy are two commonly performed procedures used to treat bullae. Although bronchoscopic lung volume reduction has been successfully accomplished for emphysema, isolated decompression of bullae bronchoscopically has not been tried to date.A large emphysematous bulla in the left lower lobe of a surgically unfit patient was bronchoscopically punctured with a transbronchial aspiration needle; the position of the needle inside the bulla was confirmed and the air from the bulla was aspirated slowly to allow collapse. Finally, some autologous blood was instilled into the bulla before the needle was withdrawn.The patient had immediate and sustained symptomatic relief with significant improvement in lung function.Bronchoscopic transbronchial decompression of emphysematous bullae can be an effective therapeutic option and warrants further investigation. KEYWORDS: Bronchoscopic lung volume reduction, emphysematous bulla, fibreoptic bronchoscopy, lung volume reduction surgery A 50-yr-old male nonsmoker, presented with incapacitating shortness of breath, cough, fever and increased expectoration of mucoid sputum for 2 weeks. The patients had been suffering from progressive shortness of breath with episodic exacerbations associated with cough, expectoration and occasional history of wheeze over the previous 15 yrs. The patient had stopped smoking 7 yrs earlier, prior to which he had smoked heavily for .20 yrs.On examination the patient was poorly nourished (body mass index 16.75 kg?m -2 ) and grossly dyspnoic (orthopnoic on supplemental oxygen and incapable of getting out of bed), with a cardiac frequency of 130 bpm and blood pressure of 120/80 mmHg. The chest was emphysematous, however, there was no clubbing, raised jugular venous pressure or pedal oedema, but the accessory muscles of inspiration were working vigorously. The chest bellow was bilaterally symmetrical with reduced expansion (¡1 cm) and obliteration of the liver dullness. Breath sounds were grossly diminished on both sides, especially so on the left base. All other systems were essentially normal on examination.The laboratory investigations revealed haemoglobin of 11.20%, total leukocyte count was 9,800 per mm 3 with neutrophils and lymphocytes consisting 77 and 20%, respectively, and an erythrocyte sedimentation rate of 62 mm. Except initial hypokalaemia (3.2 mEq?L -1 ), serum electrolytes, blood urea nitrogen, creatinine and liver-function test results were all normal. The sputum did not reveal any acid-fast bacilli on three occasions but sputum culture showed growth of Klebsiella species sensitive t...

Percutaneous Bullectomy in Conjunction with Endobronchial Valve Placement as an Alternative to Surgical Management of Giant Bullae

“…There has also been the description of intrabullous bronchoscopic delivery of autologous blood in a nonemergent context [10]. In our patient, the location of the bulla, the use of positive pressure ventilation, the risks of a persistent air leak, and the development of persistent bronchopleural or alveolar-pleural fistula were considered to be too high to employ transbronchial decompression [11]. …”

Chronic Obstructive Pulmonary Disease: Emphysema Revisited

“…The ideal surgical treatment o f e m p h y s e m a i s d i c t a t e d b y a r i g o r o u s s e lection criteria for each of the possible interventions described and can dramatically improve the quality of life of individuals inflicted with this disease. New and innovative methods for treating crippling emphysemic patients who are not candidates for surgical treatments include bronchoscopic placement of one-way valves into diseased segments of lung tissue or airway bypass by means of inserting stents between bronchi and adjacent lung tissue [75][76][77][78], however, these emergent techniques necessitate further exploratory and long term studies. …”

Endobronchial treatment of giant emphysematous bullae with one-way valves: a new approach for surgically unfit patients

“…However, there are still many cases considered to be high risk for surgery, despite surgical and anaesthesiological technical progress. In such patients, the optimal treatment is not still found despite a variety of less invasive strategy having been proposed [4][5][6][7]. The Zephyr endobronchial valves (EBVs; Zephyr; Pulmonx Inc., Redwood City, CA, USA) have recently emerged as a possible alternative to lung volume reduction surgery (LVRS) in selected patients, resulting in relief of dyspnoea and improved functional status [8][9][10].…”