An Overview of Bullectomy

What to expect when undergoing this procedure

Illustration of a plexus lung
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A bullectomy is a surgical procedure to remove bullae—air-filled spaces in the lungs that can compress healthy lung tissue and cause symptoms such as dyspnea (shortness of breath), repeated infections, and pneumothorax (lung collapse). Bullae can result from lung diseases such as chronic obstructive pulmonary disease (COPD), as well as lifestyle habits that affect the lungs. Although performed under general anesthesia and requiring a short hospital stay, a bullectomy is a minimally invasive procedure.

Purpose of Procedure

To understand why a bullectomy may be necessary, it's important to have a grasp of how bullae develop and the effect they can have on the lungs and breathing.

Bullae result when small air sacs in the lungs called alveoli are damaged, losing elasticity and coalescing (combining) to form larger air sacs.

Size Matters

An enlarged air sac is considered a bulla when it reaches one centimeter (about a half an inch) in size. A bulla that takes up at least 30 percent of either the right or left hemithorax (i.e., right or left side of the chest) is categorized as a giant bulla.

There are numerous reasons damage to air sacs can occur, among them:

  • Chronic obstructive pulmonary disease, any of an array of lung conditions including emphysema (particularly when the upper parts of the lungs are involved), chronic bronchitis, and bronchiectasis, a type of COPD in which large airways in the lungs become permanently dilated
  • Alpha-1-antitrypsin deficiency (AAT deficiency), an inherited disorder in which the lack of a protein normally produced by the liver causes progressive damage to the lungs
  • Vanishing lung syndrome (idiopathic giant bullous emphysema), a rare condition in which a giant bulla appears on an X-ray to be a collapsed lung
  • Certain connective tissue disorders, including Marfan syndrome and Ehlers Danlos syndrome. According to The Marfan Foundation, 5 percent to 10 percent of people with this disease also have emphysema

Whatever causes them, bullae of any size—but especially giant ones—can press on adjacent healthy lung tissue, reducing the flow of blood and oxygen to the lungs.

In addition, large bullae can interfere with how effectively the diaphragm can contract and draw air into the lungs, as well impede the normal expansion of the lungs, reducing the amount of air that can be inhaled.

Indications

A bullectomy may be necessary for a variety of reasons:

  • To reduce symptoms, such as dyspnea, fatigue, bloating in the chest area, exercise intolerance, pain, or hemoptysis (coughing up of blood that often is associated with bronchiectasis )
  • To improve the FEV1/FVC ratio, a measure of the degree of airway obstruction in the lungs
  • To lower the risk of a pneumothorax (collapsed lung with air leak)
  • To reduce the risk of infection that can lead to a lung abscess and/or empyema (a buildup of pus in the pleural cavity—the area between the membranes that line the lungs).

Before a bullectomy is indicated...

... other measures may be tried to manage an enlarged bulla. For example, for someone who smokes, kicking the habit may be effective. If symptoms persist, other options include bronchodilators, inhaled glucocorticoids, vaccinations, supplemental oxygen, and/or pulmonary rehabilitation. If these still don't work, surgery is often the next course of action.

Risks and Contraindications

As with any medical procedure, bullectomy is associated with certain risks and complications, as well as contraindications (conditions under which it should not be performed).

Risks

Although bullectomy is regarded as minimally invasive surgery, it must be performed under general anesthesia, which carries certain risks that are separate from those directly related to the procedure.

Other potential risks associated with bullectomy include:

  • Bleeding
  • Infection (such as pneumonia)
  • Abnormal heart rhythm (arrhythmia)
  • Heart attack (myocardial infarction)
  • Respiratory failure
  • Prolonged need for a ventilator after surgery
  • Prolonged air leak
  • Blood clots (deep vein thromboses and pulmonary emboli)
  • Wound infection
  • Pain
  • Need for a tracheostomy
  • Bronchopleural fistula (formation of an abnormal passageway between the bronchi and the pleural cavity)

Contraindications

For certain people, including older individuals, a bullectomy may not be advisable, including those who have:

  • A major medical condition such as severe heart disease
  • Small bullae
  • Pulmonary hypertension (increased pressure in the pulmonary arteries)
  • Diffuse emphysema
  • An FEV1 of less than 35 percent to 40 percent
  • A low diffusing capacity as determined by a DLCO (diffusion across the lungs of carbon monoxide) test, which measures how well oxygen and carbon dioxide are transferred between the lungs and the blood
  • Hypercapnia (an excess level of carbon dioxide in the blood)
  • Cor pulmonale (right-sided heart failure associated with COPD)

Conversely, bullectomy is most likely to be safe and effective for younger people who have:

  • Large bullae (especially if only a single or a few) and normal underlying lung tissue
  • Bullae located in only one region of the lungs
  • Minimal to moderate airway obstruction

For someone in this group, a bullectomy can result in an improvement in symptoms that may last for three to five years, according to UpToDate (an online resource for health care providers, other medical professionals, and patients).

Before the Procedure

If your doctor suspects you need a bullectomy, he or she will take a careful history, do a physical exam, and perform other tests, such as:

In order to prepare for surgery, you may need to stop taking certain medications such as blood thinners or aspirin for a week or two prior to your bullectomy.

You also will be directed to not eat or drink anything after midnight the day before the procedure (or several hours beforehand).

During Surgery

On the day of your surgery, you will be asked to sign a consent form to indicate that you understand the purpose of the procedure and any potential side effects. A nurse will place an IV so that you can receive medication and fluids and hook up electrodes to monitor your heart and lungs.

When you are ready for surgery, you will be given a general anesthetic and a breathing tube will be placed.

Your surgeon may perform the bullectomy in one of two ways:

  • Thoracotomy, in which a 4- to 6-inch incision is made below your armpit through which the bulla or bullae can be removed manually
  • Video-assisted thoracoscopic surgery (VATS), a procedure in which several small incisions are made in the chest near the region of the bullae so that they can be removed via a thoracoscope and special instruments that are monitored via a video screen

Once the bullae are removed, the incisions will be closed and covered with a sterile dressing.

The average bullectomy procedure takes around three hours, but this can vary.

After Surgery

When your surgery is completed, you will be monitored in the recovery room for a few hours and then be transferred to a hospital room. If your breathing tube needs to be left in place, you will be given a sedative to make you comfortable.

You may require oxygen after the breathing tube is removed. A chest tube will be left in place until any air leak is resolved.

A bullectomy can involve a significant amount of pain. To control it, you may be given patient-controlled anesthesia (PCA) pump, a device that will allow you to press a button at specified intervals to receive a dose of IV pain medication. Once your pain is well-controlled, you will be switched over to oral pain medications.

A respiratory therapist will work with you to help you take deep breaths, and you will also be asked to get up and move around as soon as possible to reduce the risk of blood clots.

It's likely the incisions on your chest were closed with absorbable stitches that will not need to be removed. However, the suture holding your chest tube in place will need to be removed.

Once this has happened, and you're stable, breathing well, and no longer need IV pain medication or a chest tube, you will be allowed to go home. The typical hospital stay after a bullectomy is two or three days.

Recovery

Know that you will feel sore and tired after your bullectomy and that it will be important to take it easy as your body recovers.

Pain Relief and Wound Care

So you can deal with pain after you go home, you will be given oral pain medications and detailed instructions for how and when to take them. Because pain medication can cause constipation, you'll likely be instructed to drink plenty of water; your doctor also may recommend a stool softener and/or laxative.

It's important to keep incisions dry and covered. Most surgeons recommend sponge baths and shampooing hair in the sink until bandages are removed. Soaking in a tub will be discouraged. If you are allowed to shower, lightly dab your incisions with a towel instead of rubbing them.

Bandages are often left in place for one to two weeks. You may be instructed to change yours on your own or to wait until your follow-up visit so that a nurse can do it.

Exercise and Daily Activities

You will want to slowly increase your activity. However, you should not lift anything over 10 pounds or engage in strenuous activity for at least six weeks after your bullectomy. However, moderate physical activity can help you recover more quickly and also reduces your risk of complications such as blood clots.

Many people notice an improvement in their symptoms after the surgery, especially with exercise. Your doctor also may recommend you undergo pulmonary rehabilitation after surgery.

Doctors differ in their recommendations about driving, but many recommend waiting for two weeks—and longer if you continue to need pain medications.

If you quit smoking prior to the procedure, continue to abstain. Smoking can delay wound healing and more.

It's best not to fly in an airplane for at least three months after having a bullectomy due to pressure changes in the air.

Returning to Work

When you'll be given the green light to return to work will depend on your doctor's discretion. The type of work you do will be a factor as well: You will be able to return to a desk job much more quickly than to a job that involves manual labor, for example.

Follow-Up

You may be expected to come in for a follow-up exam anywhere from shortly after your bullectomy until up to six weeks post-surgery. However, if you develop any of these symptoms before you are scheduled for your follow-up appointment, call your doctor:

  • Bleeding
  • Redness, increased tenderness, or swelling around your incisions
  • Drainage from your incisions
  • Increased shortness of breath (especially if it comes on suddenly)
  • Chest pain
  • Pain or swelling in your calves
  • A fever (greater than 101 degrees) or chills
  • Signs of an allergic reaction including redness, swelling, and trouble breathing
  • Pain that is worsening or is not well-controlled with pain medications
  • Coughing up blood

A Word From Verywell

If you develop a bulla or bullae and experience the uncomfortable, unpleasant side effects that often are associated with these enlarged air sacs, a bullectomy may be called for. However, this procedure will not cure the condition that caused you to develop bullae in the first place. If they are the result of COPD or some other lung disease, for example, you will need treatment targeted to manage that condition. At the very least, however, having a bullectomy can effectively relieve many of your symptoms.

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