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The surgical management of bullous emphysema
The surgical management of bullous emphysema John Gunstensen, F.R.C.S., and R. J. M. McCormack, F.R.C.S., Edinburgh, Great Britain
Iamenable n our experience, large pulmonary bullae to surgery are uncommon. Only twenty-three patients with this condition have been operated upon in the Edinburgh Thoracic Unit in the sixteen year period from 1954 to 1970. For comparison, the same Unit performed well over 4,500 operations for bronchial carcinoma in this period. Some bullae are detected in asymptomatic patients and some are found in patients who complain of breathlessness. Dyspneic patients who are found to have bullae usually suffer from some other pulmonary disorder which is primarily responsible for the breathlessness.' Nevertheless, it may be possible in such patients to reduce the dyspnea by obliteration of the bullae. This may help the patient in two ways." First, the removal of a space-occupying lesion allows the remaining lung to expand; the elastic recoil pressure of the expanded lung may be increased and there may be less tendency for the airways to collapse during expiration. Second, the removal of a bulla which has significant ventilation (which is unusual) reduces the dead space of the lungs. The purpose of this paper is to record and assess the preoperative findings, the operative procedure, and the results of operation in 23 patients with bullous emphyFrom the Department of Thoracic Surgery. The Royal Infirmary. Edinburgh, Great Britain. Received for publication Feb. 27, 1973.
920
serna who were treated in the Edinburgh Thoracic Unit in the years 1954 to 1970. Clinical material Twenty-three patients are included in this report. There were 22 men and 1 woman, ranging in age from 33 to 61 years (average 49 years). The duration of symptoms before operation varied between I and 20 years. All patients were cigarette smokers, and all admitted to having a regular cough with the production of mucoid or occasionally purulent sputum. One of the men suffered from severe asthma, 2 men had pneumoconiosis, and 2 others had been treated for tuberculosis in the past. The postoperative follow-up period ranged from 2 to 18 years (average 6 years). At the time of review, 10 of the 23 patients had died. Information on these patients was obtained from the case records and the general practitioners, whereas the remaining 13 patients were interviewed. Preoperative assessment of patients Clinical assessment. The assessment of breathlessness was made on clinical grounds. The patients have been divided into 5 grades according to the Medical Research Council questionnaire on chronic bronchitis for 1960. The distribution of the patients into the various grades is shown in Table 1. Radiologic investigations. In all cases, standard posteroanterior and lateral chest
Volume 65 Number 6 June, 1973
92 1
Bullous emphysema
Table I. Distribution of patients into clinical grades and the radiologic appearances on chest x-ray in each grade
Clinical grade of symptoms
Grade I: Grade II: Grade III: Grade IV: Grade V:
No. with lung compression Oil plain chest x-ray
No. of patients
No. with unilateral bullae
No. with bilateral bullae
0 5 7
5 4
0 3
3 5
10
4
6
2
0
0
9
10
Normal Breathless on hills Breathless on level if keeping up with normal persons Unable to walk more than 100 yards Breathless on washing or dressing
Total No.
14
23
Table II. Preoperative clinical and investigative data FEV, range and mean (mi.)
FVC range and mean (mi.)
FEV'/FVC range and mean (per cent)
Residual volume
Clinical grade
No. of patients
II
5
1,900-3,200 2,300-5,300 (2,220) (3,900)
45-84 (59)
Not done
III
7
1,000-2,300 2,000-4,400 (1,350) (3,190 )
27-55 (44)
Not done Normal
IV
10
25-60 (39)
Normal 1.5-2 times normal More than twice normal
V
370-850 (730)
500
780-3,520 (1,840)
1,500
30
Finding
More than twice normal
I No.
Electrocardiogram Finding
I No.
Normal
5
5 2
Normal
7
2 5 3
RVH Normal
5 5
RVH
Legend: For description of grades, see Table I. FEV" Forced expiratory volume in 1 second. FVC, Forced vital capacity. RVH, Right ventricular hypertrophy.
radiograms were made. The size and position of the bullae, whether they were unilateral or bilateral, and the presence or absence of lung compression were noted (Table I). Tomography was used in 8 patients, bronchography in 6, and fluorodensitometry in 1, but none of these investigations added to the information already obtainable from a study of the plain chest radiograms. Respiratory function tests (Table II). In all patients, an estimation of ventilatory function was made by measurement of the forced vital capacity (FVC) and the forced expiratory volume over 1 second (FEV). All but 3 had evidence of airway obstruc-
tion, with the FEV/FVC ratio below 65 per cent, the lower limit of normal.' The 3 patients who did not have obstructive airway disease had minor symptoms in spite of having large bullae. Lung volumes were measured by the helium dilution method in 13 patients. The residual volume was more than twice the predicted value in 4 patients-l had asthma, 1 had widespread emphysema with bilateral basal bullae, and 2 had pneumoconiosis. In 5 patients the residual volume was 1.5 to 2 times the predicted value, and in the remaining 4 patients the residual volume was essentially normal. Differential bronchospirometry was per-
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The Journal of Thoracic nnd Cardiovascular Surgery
Gunstensen and McCormack
Table III. Operative procedures and complications No. of
Postoperative complications
Operative procedure Underwater-seal drainage Rib resection and underwater-seal drainage
Death on induction of anesthesia at 6 days 3
Segmental resection
Pneumothorax Severe pulmonary infection
I
2
None
Lobectomy
2
Pulmonary collapse causing death 12 hours after operation
Pneu monectomy
I
None
Resection of bullae
patients
15
formed in 2 patients, both in clinical Grade IV. In 1 patient with severe asthma and bullae of the left lower lobe, the investigation confirmed that the left lower lobe was poorly ventilated and that the generalized disturbance in ventilation and perfusion was more marked in this lobe. A similar confirmation of the radiologic features was obtained in another patient who had bilateral basal bullae. The distribution of pulmonary perfusion and ventilation was measured with radioactive with xenon in 1 young man who had widespread emphysema and bilateral basal bullae, which were of equal size radiologically. The investigation showed that there was severe impairment of function in both lower zones, the impairment being greater on the left. Electrocardiographic investigation. Electrocardiograms were recorded in all cases. Clinical evidence of cor pulmonale was present in 7, and in 6 of these the electrocardiogram showed features of right ventricular hypertrophy (Table II). Surgical procedures and postoperative complications The operative procedure used and the postoperative complications associated with the various types of procedure are shown in Table III. Underwater-seal drainage. One patient had an intercostal drain inserted into a large
Empyema Gross surgical emphysema
2
2
bulla in the belief that it was a pneumothorax. A continuous air leak developed, and the patient's condition deteriorated. After correcting the diagnosis, we decided to obliterate the bulla at thoracotomy. However, the patient died during the induction of anesthesia. Rib resection and underwater-seal drainage. Three patients, who were considered too dyspneic for thoracotomy, were treated by resection of a portion of rib overlying the bulla with a view to causing pleural adhesion prior to intubation of the bulla." The wound was packed with iodine gauze for 2 weeks, and thereafter an underwater-seal drain was inserted through the bed of the resected rib. In 1 patient, despite a wound infection which delayed intubation of the bulla for 21 days, the pleural space remained free and intubation produced a pneumothorax. Two of these 3 patients treated by intubation of the bulla developed severe pulmonary infection after this procedure, and 1 of them required tracheostomy. All 3 patients were treated early in this series. This method of therapy was subsequently abandoned. Pulmonary resection. In 4 patients, the bullae occupied the whole of a segment, lobe, or lung so that none of the involved part could be usefully preserved. Therefore, these 4 were treated by pulmonary resection -1 had segmental resection, 2 had lobar resections, and 1 had a pneumonectomy. One patient died 12 hours after middle lobectomy
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Bullous emphysema
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June, 1973
Table IV. Results of operation for bullous emphysema Improvement for less than 2 years
Clinical grade
No. of patients
Improvement for more than 2 years
II and III IV and V
12 II
10 3
2
o
o
4
2
Total
23
13
4
4
2
2
No change or worse: Dead with ill 2 years
Operative death
Legend: For description of grades, see Table I.
as a result of continued intrabronchial bleeding and pulmonary collapse despite repeated bronchoscopy. Resection of bullae. For the remaining 15 patients, treatment was as follows: Narrow-stalked bullae were ligated at the base, whereas broad-based bullae were resected. No deaths occurred after this procedure. Severe surgical emphysema complicated the postoperative recovery of 2 of these patients, and empyema occurred in 2 others. Results
The results of our surgical treatment of bullous emphysema are shown in Table IV. The postoperative assessment was similar to the preoperative and included clinical examination, simple volumetric lung tests, and chest radiograms. The 2 patients who died in the hospital have already been described. Of the 21 survivors, 4 were in unchanged or worse condition, 4 were in improved condition for less than 2 years, and 13 were in improved condition for more than 2 years. The status of 3 patients (all clinical Grade IV) was either unchanged or worse after surgery, and all died within 2 years of operation. Two of them suffered from pneumoconiosis and were treated by intubation of the bulla; I died 9 months and the other 18 months after operation. The status of a third patient, also managed by intubation of the bulla, was improved for only 6 months; thereafter, his condition gradually deteriorated, and he died 2 years postoperatively. The fourth patient, a 40-year-old man, had been a "respiratory cripple" for many years as a result of extensive post-tuberculous fibrosis of the lungs. Resection of a left
lower bulla resulted in slight improvement lasting only a few months, and he died 2 years after operation. Four patients were in improved condition for less than 2 years after operation. A 50year-old man in clinical Grade III required pneumonectomy and was improved for Ilh years, after which his condition gradually deteriorated. However, he lived for 13 years after operation, surviving several attacks of acute respiratory failure. A 57-year-old man (Grade III) suffering from chronic bronchitis and emphysema had resection of bullae in the middle lobe. His status was improved for only 7 months, and now (2lh years after operation) he is capable only of light work. One patient (Grade IV) with bilateral basal emphysema had left lower lobetcomy; at this time (3 112 years after operation), he is a respiratory cripple with radiologic evidence of a vanishing right lung. The fourth patient (Grade IV), who suffered from emphysema with bullae in the left lower lobe, was managed by resection of the bullae. His condition was subjectively improved for 18 months in spite of objective evidence to the contrary, as both the FEV 1 and FVC were less after operation than before. After 18 months his condition deteriorated, and he died 5 years after operation. The status of 13 patients was improved for more than 2 years. Twelve of these patients had been managed by obliteration of the bullae at thoracotomy without sacrifice of functioning lung tissue. One patient had had an apicoposterior segmental resection. Two of the 13 patients are now dead, 1 from carcinoma of the stomach and 1 from
924
The Journol of Thoracic and Cardiavascular
Gunstensen and McCormack
Surgery
Table V. Factors related to poor results in 6 patients who were dead within 2 years of operation High residual volume
No. of patients
1 2 3 4
5 6
IV
IV IV IV IV V
Not done Raised Twice normal Twice normal Raised Raised
RVH Oil electrocardiogram Bilateral bullae Yes Yes No Yes Yes Yes
Yes Yes Yes Yes No No
Lung compression
Time of death
No No No No Yes No
Operative Operative 9 months 18 months 2 years 2 years
Legend: For description of grades, see Table I. RVH, Right ventricular hypertophy.
bronchial carcinoma, both 5 years after operation. In all but I patient, subjective improvement after operation was associated with a rise in the FEV t and FVC. However, there was no correlation between subjective improvement and alteration in the FEVt/FVC ratio resulting from operation. In 4 of the 13 patients who said they felt much better after operation, the FEVdFVC ratio was reduced by more than 5 per cent, in 5 it was unchanged, and in 4 it was increased by more than 5 per cent. Correlation of results with the preoperative findings A satisfactory result of operation was much more common in those with less severe disability preoperatively (Table IV). Thus improvement was noted in 10 of the 12 patients in clinical Grades II and III, whereas only 3 of 11 patients in Grades IV and V were benefited by surgery for more than 2 years, and none of them could be reclassified into a lower grade of dyspnea. Patients with unilateral disease did better than those with bilateral bullae. Of the 10 patients with unilateral bulla whose status was improved, 8 had compression of lung adjacent to the bulla. Only 3 of the 9 patients with bilateral bullae obtained lasting benefit from operation, and 2 of them had compression of lung. Of the 4 patients in whom the residual lung volume was more than twice the predicted normal, 2 died within 2 years, 1 is now a respiratory cripple, and 1 has asthma and is in only slightly better condition.
Of the 6 patients with electrocardiographic evidence of right ventricular hypertrophy, 2 died in the hospital and 3 died within 2 years of operation. The last has previously been described as a respiratory cripple. The factors relating to poor results from surgery are given in Table V. Discussion The effect of a bulla on respiratory function is variable. If the bulla is an isolated lesion and the rest of the lung is normal, the bulla may have no effect detectable by the patient even if it occupies most of one side.. Some authors" recommend removal of bullae occupying more than one third of the hemithorax even in the absence of symptoms since a space occupying lesion of this size is productive of significant bronchopulmonary compression and will ultimately be associated with impaired drainage, infection, and permanent damage to adjacent compressed lung tissue. We have not adopted this policy and have observed several nondisabled patients with large bullae for many years. In breathless patients other lung disease is usually present, and the problem is one of deciding to what degree the bullae are responsible for the patient's disability. Several workers- G with special interest in this field have been aided by such investigations a bronchography, angiography, bronchospirometry, or radioactive xenon studies. In our experience, however, most investigations were disappointing in that they merely confirmed the presence of the bullae and
Volume 65
Bullous emphysema
Number 6
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June, 1973
did not provide information that helped us to assess the benefit likely to accrue from obliteration of the bullae. The most useful information was obtained from a study of the plain chest radiogram. Volumetric estimations of lung function in the form of total lung capacity, residual volume, FEV" and FVC were useful in a general way. A high residual volume was associated with a poor prognosis. Since bullae are usually not ventilated or are underventilated, the residual volume is usually underestimated by the helium dilution method." Measurement of total lung volume by whole body plethysmography may be more useful. 2 Although it has been suggested that resection of bullae may help patients by reducing airway obstruction," we found no evidence to support this contention, as there was no significant difference in the preoperative and postoperative FEV/FVC ratio in patients who noted clinical improvement. Although others" have reported good results in patients with cor pulmonale, our experience suggests that operation is not worthwhile if there is electrocardiographic evidence of right ventricular hypertrophy. As one would expect, patients with unilateral bullae have a better chance of obtaining lasting benefit than those with bilateral bullae. Pride and his colleagues" viewed with suspicion the presence of bilateral apical bullae in young men, since patients with rapidly advancing pan acinar emphysema may present with this localization of disease. It is possible that bilateral basal bullae in a young man are equally suspect. One of our patients, who was treated by left lower lobectomy, subsequently developed x-ray evidence of vanishing lung." The best method of surgical treatment is to obliterate the bullae at thoracotomy, provided that the patient can tolerate the procedure.
Summary The selection for operation of patients with emphysematous bullae is discussed with reference to 23 patients treated surgically in the years 1954 to 1970. The most useful preoperative information was obtained from a study of the plain chest radiogram. Detailed respiratory function tests helped little in the selection of patients. Measurement of ventilatory and static lung volumes were helpful only in a general way. Features suggesting a poor result from surgery were severe preoperative disability, bilateral bullae, no evidence of lung compression on straight chest roentgenography, a very high residual volume, and electrocardiographic evidence of right ventricular hypertrophy. The surgical procedure of choice is obliteration of the bullae at thoracotomy.
2
3
4 5
6
7
8
REFERENCES Crofton, J., and Douglas, A.: Respiratory Diseases, Edinburgh, 1969, Blackwell Scientific Publications. Pride, N. 8., Hugh-Jones, P., O'Brien, E. N., and Smith, L. A.: Changes in Lung Function Following the Surgical Treatment of Bullous Emphysema, Q. J. Med. 63: 49, 1970. Head, J. R., and Avery, E. E.: Intracavitary Suction (Monaldi) in the Treatment of Emphysematous Bullae and' Blebs, J. THoRAc. SURG. 18: 761, 1949. Reid, L.: The Pathology of Emphysema, London, 1967, Lloyd-Luke, Ltd. Spear, H. c., Daughty, D. c., Chesney, J. C., and Marks, A.: The Surgical Management of Large Pulmonary Blebs and Bullae, Am. Rev. Resp. Dis. 84: 186, 1961. Lopez-Majano, V., Kieffer, R. F., Marine, D. N., Garcia, D. A., and Wagner, H. N.: Pulmonary Resection in Bullous Emphysema, Ann. Rev. Resp. Dis. 99: 554, 1969. Foreman, S., Weill, H., Duke, R., George, R., and Ziskind, M.: Bullous Disease of the Lungs, Ann. Intern. Med. 69: 757, 1968. Burke, R. M.: Vanishing Lungs: A Case Report of Bullous Emphysema, Radiography 28: 367, 1937.
Iamenable n our experience, large pulmonary bullae to surgery are uncommon. Only twenty-three patients with this condition have been operated upon in the Edinburgh Thoracic Unit in the sixteen year period from 1954 to 1970. For comparison, the same Unit performed well over 4,500 operations for bronchial carcinoma in this period. Some bullae are detected in asymptomatic patients and some are found in patients who complain of breathlessness. Dyspneic patients who are found to have bullae usually suffer from some other pulmonary disorder which is primarily responsible for the breathlessness.' Nevertheless, it may be possible in such patients to reduce the dyspnea by obliteration of the bullae. This may help the patient in two ways." First, the removal of a space-occupying lesion allows the remaining lung to expand; the elastic recoil pressure of the expanded lung may be increased and there may be less tendency for the airways to collapse during expiration. Second, the removal of a bulla which has significant ventilation (which is unusual) reduces the dead space of the lungs. The purpose of this paper is to record and assess the preoperative findings, the operative procedure, and the results of operation in 23 patients with bullous emphyFrom the Department of Thoracic Surgery. The Royal Infirmary. Edinburgh, Great Britain. Received for publication Feb. 27, 1973.
920
serna who were treated in the Edinburgh Thoracic Unit in the years 1954 to 1970. Clinical material Twenty-three patients are included in this report. There were 22 men and 1 woman, ranging in age from 33 to 61 years (average 49 years). The duration of symptoms before operation varied between I and 20 years. All patients were cigarette smokers, and all admitted to having a regular cough with the production of mucoid or occasionally purulent sputum. One of the men suffered from severe asthma, 2 men had pneumoconiosis, and 2 others had been treated for tuberculosis in the past. The postoperative follow-up period ranged from 2 to 18 years (average 6 years). At the time of review, 10 of the 23 patients had died. Information on these patients was obtained from the case records and the general practitioners, whereas the remaining 13 patients were interviewed. Preoperative assessment of patients Clinical assessment. The assessment of breathlessness was made on clinical grounds. The patients have been divided into 5 grades according to the Medical Research Council questionnaire on chronic bronchitis for 1960. The distribution of the patients into the various grades is shown in Table 1. Radiologic investigations. In all cases, standard posteroanterior and lateral chest
Volume 65 Number 6 June, 1973
92 1
Bullous emphysema
Table I. Distribution of patients into clinical grades and the radiologic appearances on chest x-ray in each grade
Clinical grade of symptoms
Grade I: Grade II: Grade III: Grade IV: Grade V:
No. with lung compression Oil plain chest x-ray
No. of patients
No. with unilateral bullae
No. with bilateral bullae
0 5 7
5 4
0 3
3 5
10
4
6
2
0
0
9
10
Normal Breathless on hills Breathless on level if keeping up with normal persons Unable to walk more than 100 yards Breathless on washing or dressing
Total No.
14
23
Table II. Preoperative clinical and investigative data FEV, range and mean (mi.)
FVC range and mean (mi.)
FEV'/FVC range and mean (per cent)
Residual volume
Clinical grade
No. of patients
II
5
1,900-3,200 2,300-5,300 (2,220) (3,900)
45-84 (59)
Not done
III
7
1,000-2,300 2,000-4,400 (1,350) (3,190 )
27-55 (44)
Not done Normal
IV
10
25-60 (39)
Normal 1.5-2 times normal More than twice normal
V
370-850 (730)
500
780-3,520 (1,840)
1,500
30
Finding
More than twice normal
I No.
Electrocardiogram Finding
I No.
Normal
5
5 2
Normal
7
2 5 3
RVH Normal
5 5
RVH
Legend: For description of grades, see Table I. FEV" Forced expiratory volume in 1 second. FVC, Forced vital capacity. RVH, Right ventricular hypertrophy.
radiograms were made. The size and position of the bullae, whether they were unilateral or bilateral, and the presence or absence of lung compression were noted (Table I). Tomography was used in 8 patients, bronchography in 6, and fluorodensitometry in 1, but none of these investigations added to the information already obtainable from a study of the plain chest radiograms. Respiratory function tests (Table II). In all patients, an estimation of ventilatory function was made by measurement of the forced vital capacity (FVC) and the forced expiratory volume over 1 second (FEV). All but 3 had evidence of airway obstruc-
tion, with the FEV/FVC ratio below 65 per cent, the lower limit of normal.' The 3 patients who did not have obstructive airway disease had minor symptoms in spite of having large bullae. Lung volumes were measured by the helium dilution method in 13 patients. The residual volume was more than twice the predicted value in 4 patients-l had asthma, 1 had widespread emphysema with bilateral basal bullae, and 2 had pneumoconiosis. In 5 patients the residual volume was 1.5 to 2 times the predicted value, and in the remaining 4 patients the residual volume was essentially normal. Differential bronchospirometry was per-
922
The Journal of Thoracic nnd Cardiovascular Surgery
Gunstensen and McCormack
Table III. Operative procedures and complications No. of
Postoperative complications
Operative procedure Underwater-seal drainage Rib resection and underwater-seal drainage
Death on induction of anesthesia at 6 days 3
Segmental resection
Pneumothorax Severe pulmonary infection
I
2
None
Lobectomy
2
Pulmonary collapse causing death 12 hours after operation
Pneu monectomy
I
None
Resection of bullae
patients
15
formed in 2 patients, both in clinical Grade IV. In 1 patient with severe asthma and bullae of the left lower lobe, the investigation confirmed that the left lower lobe was poorly ventilated and that the generalized disturbance in ventilation and perfusion was more marked in this lobe. A similar confirmation of the radiologic features was obtained in another patient who had bilateral basal bullae. The distribution of pulmonary perfusion and ventilation was measured with radioactive with xenon in 1 young man who had widespread emphysema and bilateral basal bullae, which were of equal size radiologically. The investigation showed that there was severe impairment of function in both lower zones, the impairment being greater on the left. Electrocardiographic investigation. Electrocardiograms were recorded in all cases. Clinical evidence of cor pulmonale was present in 7, and in 6 of these the electrocardiogram showed features of right ventricular hypertrophy (Table II). Surgical procedures and postoperative complications The operative procedure used and the postoperative complications associated with the various types of procedure are shown in Table III. Underwater-seal drainage. One patient had an intercostal drain inserted into a large
Empyema Gross surgical emphysema
2
2
bulla in the belief that it was a pneumothorax. A continuous air leak developed, and the patient's condition deteriorated. After correcting the diagnosis, we decided to obliterate the bulla at thoracotomy. However, the patient died during the induction of anesthesia. Rib resection and underwater-seal drainage. Three patients, who were considered too dyspneic for thoracotomy, were treated by resection of a portion of rib overlying the bulla with a view to causing pleural adhesion prior to intubation of the bulla." The wound was packed with iodine gauze for 2 weeks, and thereafter an underwater-seal drain was inserted through the bed of the resected rib. In 1 patient, despite a wound infection which delayed intubation of the bulla for 21 days, the pleural space remained free and intubation produced a pneumothorax. Two of these 3 patients treated by intubation of the bulla developed severe pulmonary infection after this procedure, and 1 of them required tracheostomy. All 3 patients were treated early in this series. This method of therapy was subsequently abandoned. Pulmonary resection. In 4 patients, the bullae occupied the whole of a segment, lobe, or lung so that none of the involved part could be usefully preserved. Therefore, these 4 were treated by pulmonary resection -1 had segmental resection, 2 had lobar resections, and 1 had a pneumonectomy. One patient died 12 hours after middle lobectomy
Volume 65
Bullous emphysema
Number 6
923
June, 1973
Table IV. Results of operation for bullous emphysema Improvement for less than 2 years
Clinical grade
No. of patients
Improvement for more than 2 years
II and III IV and V
12 II
10 3
2
o
o
4
2
Total
23
13
4
4
2
2
No change or worse: Dead with ill 2 years
Operative death
Legend: For description of grades, see Table I.
as a result of continued intrabronchial bleeding and pulmonary collapse despite repeated bronchoscopy. Resection of bullae. For the remaining 15 patients, treatment was as follows: Narrow-stalked bullae were ligated at the base, whereas broad-based bullae were resected. No deaths occurred after this procedure. Severe surgical emphysema complicated the postoperative recovery of 2 of these patients, and empyema occurred in 2 others. Results
The results of our surgical treatment of bullous emphysema are shown in Table IV. The postoperative assessment was similar to the preoperative and included clinical examination, simple volumetric lung tests, and chest radiograms. The 2 patients who died in the hospital have already been described. Of the 21 survivors, 4 were in unchanged or worse condition, 4 were in improved condition for less than 2 years, and 13 were in improved condition for more than 2 years. The status of 3 patients (all clinical Grade IV) was either unchanged or worse after surgery, and all died within 2 years of operation. Two of them suffered from pneumoconiosis and were treated by intubation of the bulla; I died 9 months and the other 18 months after operation. The status of a third patient, also managed by intubation of the bulla, was improved for only 6 months; thereafter, his condition gradually deteriorated, and he died 2 years postoperatively. The fourth patient, a 40-year-old man, had been a "respiratory cripple" for many years as a result of extensive post-tuberculous fibrosis of the lungs. Resection of a left
lower bulla resulted in slight improvement lasting only a few months, and he died 2 years after operation. Four patients were in improved condition for less than 2 years after operation. A 50year-old man in clinical Grade III required pneumonectomy and was improved for Ilh years, after which his condition gradually deteriorated. However, he lived for 13 years after operation, surviving several attacks of acute respiratory failure. A 57-year-old man (Grade III) suffering from chronic bronchitis and emphysema had resection of bullae in the middle lobe. His status was improved for only 7 months, and now (2lh years after operation) he is capable only of light work. One patient (Grade IV) with bilateral basal emphysema had left lower lobetcomy; at this time (3 112 years after operation), he is a respiratory cripple with radiologic evidence of a vanishing right lung. The fourth patient (Grade IV), who suffered from emphysema with bullae in the left lower lobe, was managed by resection of the bullae. His condition was subjectively improved for 18 months in spite of objective evidence to the contrary, as both the FEV 1 and FVC were less after operation than before. After 18 months his condition deteriorated, and he died 5 years after operation. The status of 13 patients was improved for more than 2 years. Twelve of these patients had been managed by obliteration of the bullae at thoracotomy without sacrifice of functioning lung tissue. One patient had had an apicoposterior segmental resection. Two of the 13 patients are now dead, 1 from carcinoma of the stomach and 1 from
924
The Journol of Thoracic and Cardiavascular
Gunstensen and McCormack
Surgery
Table V. Factors related to poor results in 6 patients who were dead within 2 years of operation High residual volume
No. of patients
1 2 3 4
5 6
IV
IV IV IV IV V
Not done Raised Twice normal Twice normal Raised Raised
RVH Oil electrocardiogram Bilateral bullae Yes Yes No Yes Yes Yes
Yes Yes Yes Yes No No
Lung compression
Time of death
No No No No Yes No
Operative Operative 9 months 18 months 2 years 2 years
Legend: For description of grades, see Table I. RVH, Right ventricular hypertophy.
bronchial carcinoma, both 5 years after operation. In all but I patient, subjective improvement after operation was associated with a rise in the FEV t and FVC. However, there was no correlation between subjective improvement and alteration in the FEVt/FVC ratio resulting from operation. In 4 of the 13 patients who said they felt much better after operation, the FEVdFVC ratio was reduced by more than 5 per cent, in 5 it was unchanged, and in 4 it was increased by more than 5 per cent. Correlation of results with the preoperative findings A satisfactory result of operation was much more common in those with less severe disability preoperatively (Table IV). Thus improvement was noted in 10 of the 12 patients in clinical Grades II and III, whereas only 3 of 11 patients in Grades IV and V were benefited by surgery for more than 2 years, and none of them could be reclassified into a lower grade of dyspnea. Patients with unilateral disease did better than those with bilateral bullae. Of the 10 patients with unilateral bulla whose status was improved, 8 had compression of lung adjacent to the bulla. Only 3 of the 9 patients with bilateral bullae obtained lasting benefit from operation, and 2 of them had compression of lung. Of the 4 patients in whom the residual lung volume was more than twice the predicted normal, 2 died within 2 years, 1 is now a respiratory cripple, and 1 has asthma and is in only slightly better condition.
Of the 6 patients with electrocardiographic evidence of right ventricular hypertrophy, 2 died in the hospital and 3 died within 2 years of operation. The last has previously been described as a respiratory cripple. The factors relating to poor results from surgery are given in Table V. Discussion The effect of a bulla on respiratory function is variable. If the bulla is an isolated lesion and the rest of the lung is normal, the bulla may have no effect detectable by the patient even if it occupies most of one side.. Some authors" recommend removal of bullae occupying more than one third of the hemithorax even in the absence of symptoms since a space occupying lesion of this size is productive of significant bronchopulmonary compression and will ultimately be associated with impaired drainage, infection, and permanent damage to adjacent compressed lung tissue. We have not adopted this policy and have observed several nondisabled patients with large bullae for many years. In breathless patients other lung disease is usually present, and the problem is one of deciding to what degree the bullae are responsible for the patient's disability. Several workers- G with special interest in this field have been aided by such investigations a bronchography, angiography, bronchospirometry, or radioactive xenon studies. In our experience, however, most investigations were disappointing in that they merely confirmed the presence of the bullae and
Volume 65
Bullous emphysema
Number 6
925
June, 1973
did not provide information that helped us to assess the benefit likely to accrue from obliteration of the bullae. The most useful information was obtained from a study of the plain chest radiogram. Volumetric estimations of lung function in the form of total lung capacity, residual volume, FEV" and FVC were useful in a general way. A high residual volume was associated with a poor prognosis. Since bullae are usually not ventilated or are underventilated, the residual volume is usually underestimated by the helium dilution method." Measurement of total lung volume by whole body plethysmography may be more useful. 2 Although it has been suggested that resection of bullae may help patients by reducing airway obstruction," we found no evidence to support this contention, as there was no significant difference in the preoperative and postoperative FEV/FVC ratio in patients who noted clinical improvement. Although others" have reported good results in patients with cor pulmonale, our experience suggests that operation is not worthwhile if there is electrocardiographic evidence of right ventricular hypertrophy. As one would expect, patients with unilateral bullae have a better chance of obtaining lasting benefit than those with bilateral bullae. Pride and his colleagues" viewed with suspicion the presence of bilateral apical bullae in young men, since patients with rapidly advancing pan acinar emphysema may present with this localization of disease. It is possible that bilateral basal bullae in a young man are equally suspect. One of our patients, who was treated by left lower lobectomy, subsequently developed x-ray evidence of vanishing lung." The best method of surgical treatment is to obliterate the bullae at thoracotomy, provided that the patient can tolerate the procedure.
Summary The selection for operation of patients with emphysematous bullae is discussed with reference to 23 patients treated surgically in the years 1954 to 1970. The most useful preoperative information was obtained from a study of the plain chest radiogram. Detailed respiratory function tests helped little in the selection of patients. Measurement of ventilatory and static lung volumes were helpful only in a general way. Features suggesting a poor result from surgery were severe preoperative disability, bilateral bullae, no evidence of lung compression on straight chest roentgenography, a very high residual volume, and electrocardiographic evidence of right ventricular hypertrophy. The surgical procedure of choice is obliteration of the bullae at thoracotomy.
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REFERENCES Crofton, J., and Douglas, A.: Respiratory Diseases, Edinburgh, 1969, Blackwell Scientific Publications. Pride, N. 8., Hugh-Jones, P., O'Brien, E. N., and Smith, L. A.: Changes in Lung Function Following the Surgical Treatment of Bullous Emphysema, Q. J. Med. 63: 49, 1970. Head, J. R., and Avery, E. E.: Intracavitary Suction (Monaldi) in the Treatment of Emphysematous Bullae and' Blebs, J. THoRAc. SURG. 18: 761, 1949. Reid, L.: The Pathology of Emphysema, London, 1967, Lloyd-Luke, Ltd. Spear, H. c., Daughty, D. c., Chesney, J. C., and Marks, A.: The Surgical Management of Large Pulmonary Blebs and Bullae, Am. Rev. Resp. Dis. 84: 186, 1961. Lopez-Majano, V., Kieffer, R. F., Marine, D. N., Garcia, D. A., and Wagner, H. N.: Pulmonary Resection in Bullous Emphysema, Ann. Rev. Resp. Dis. 99: 554, 1969. Foreman, S., Weill, H., Duke, R., George, R., and Ziskind, M.: Bullous Disease of the Lungs, Ann. Intern. Med. 69: 757, 1968. Burke, R. M.: Vanishing Lungs: A Case Report of Bullous Emphysema, Radiography 28: 367, 1937.