An Overview of Bullectomy

This surgical procedure is for people who have lung bullae

Pneumothorax illustration for which bullectomy is a treatment
Wikimedia Commons

A bullectomy is a surgical procedure used to remove lung bullae, air-filled spaces in the lung that are found in some people with medical conditions such as chronic obstructive pulmonary disease (COPD) and Marfan syndrome. Bullae may compress healthy lung tissue, causing symptoms of shortness of breath, repeated infections, or episodes of lung collapse (pneumothorax). Treatment usually involves a minimally invasive surgery in which the bullae is removed through small incisions in the chest.

Understanding Lung Bullae

A bulla is a thin-walled, air-filled space in the lungs that is larger than 1 centimeter (about half an inch) in diameter. Giant bullae are classified as those that occupy at least 30 percent of the hemithorax (the thorax is divided into a right and left hemithorax), and some can grow up to a foot in diameter.

Bullae occur when lung diseases, especially emphysema, destroy the small air sacs (alveoli) through which the exchange of oxygen and carbon dioxide occurs. As more alveoli lose their elasticity and coalesce, larger air sacs develop.

As normal lung tissue is compressed, people may note increasing shortness of breath, difficulty breathing, fatigue, and bloating of the chest region.

At the same time that these large air sacs develop, the inability to exhale fully results in captured air accumulating in the sacs (hyperinflation). Most often, this process is gradual, but it occasionally occurs rapidly. In some cases, spontaneous deflation may occur, usually after an infection in a bulla occurs.

The Need for Treatment

Giant bullae cause substantial compression of the underlying, healthy lung tissue, which in turn, reduces both the flow of blood and oxygen to the lungs. Large bullae can also interfere with contractions of the diaphragm that are needed to draw air into the lungs. In addition, the presence of giant bullae can interfere with the normal expansion of the lungs, reducing the amount of air that can be inhaled.

Bullectomy is the treatment of choice. The only other lung procedures that may significantly improve lung function with conditions such as emphysema are lung volume reduction surgery or a lung transplant.

Purpose

The purpose of a bullectomy depends on a person's specific situation, but may be:

  • To reduce symptoms such as dyspnea (the sensation of shortness of breath)
  • To improve respiratory function: A bullectomy may improve the FEV1/FVC ratio, which describes the amount of air that can be forcefully exhaled in one second over the amount of air that can be exhaled completely. This ratio is a measure of a degree of airway obstruction in the lungs.
  • To reduce the risk of a pneumothorax (collapsed lung with air leak) if a bulla should burst
  • To reduce the risk of an abscess and empyema: An infected bulla can lead to the formation of a lung abscess and, if it extends into the pleural space (the area between the membranes surrounding the lungs), can lead to an empyema (an infection in the pleural cavity that is challenging to treat).

Indications

There are a number of reasons why your doctor may recommend a bullectomy, with the most common being symptoms such as:

  • Shortness of breath (often due to a large bulla)
  • A collapsed lung, usually for recurrent pneumothorax (two or more episodes)
  • Repeated respiratory infections
  • Exercise intolerance
  • Pain
  • Coughing up blood (hemoptysis)

That said, some people have no symptoms and still require surgery if bullae are very large.

Large lung bullae may occur with a variety of different medical conditions. Bullectomy may, therefore, end up becoming part of a management plan for:

  • COPD: Conditions that fall under this umbrella include emphysema, chronic bronchitis, and bronchiectasis. Bullae are most common when emphysema involves the upper parts (apical region) of the lungs.
  • Alpha-1-antitrypsin deficiency: This is an inherited disorder in which the lack of a protein results in progressive damage to the lungs—possibly even emphysema.
  • Vanishing lung syndrome: This describes emphysema with giant bullae for which the cause is unknown (idiopathic). It occurs more commonly in young, thin, male smokers.
  • Marfan syndrome: This is an inherited disorder of connective tissue often seen in men who are tall and thin and are at risk of developing conditions such as a dissecting aortic aneurysm.
  • Ehlers Danlos syndrome: Another inherited disorder of connective tissue, most often recognized due to joint hypermobility
  • Sarcoidosis: Sarcoidosis is an inflammatory condition that results in granulomas being formed, often in multiple regions of the body.
  • HIV infection
  • IV drug abuse
  • Cocaine smoking
  • Marijuana smoking has a possible, but small, causal role in the formation of bullae.

Success

When used for people who are good candidates for the surgery, a bullectomy can result in an improvement in symptoms that may last for three to five years.

The procedure is most effective in people who:

  • Are young
  • Have large bullae (especially if only a single or a few)
  • Have bullae located in only one region of the lungs
  • Have only minimal to moderate airway obstruction

Bullae can be broken down into four groups, with people who have group I or group II disease being much more likely to benefit from a bullectomy than people with severe cases:

  • Group I: Normal underlying lung tissue with a single giant bulla
  • Group II: Normal underlying lung tissue with several giant bullae
  • Group III: Diffuse emphysema with multiple bullae
  • Group IV: Diffuse lung involvement with other lung diseases with multiple bullae

Risks and Contraindications

Like other surgical procedures, there are potential risks and complications of a bullectomy, as well as situations in which the procedure should not be performed (contraindications).

Potential Risks

In addition to the risks of general anesthesia, potential risks associated with a bullectomy may include:

  • Bleeding
  • Infection (such as pneumonia)
  • Abnormal heart rhythms (arrhythmias)
  • Heart attack (myocardial infarction)
  • Respiratory failure
  • Prolonged need for a ventilator after surgery
  • Prolonged air leak (When an air leak persists after surgery, a chest tube will need to be left in place until the air leak resolves.)
  • Blood clots (deep vein thromboses and pulmonary emboli)
  • Wound infection
  • Pain
  • Need for a tracheostomy
  • Bronchopleural fistula (an abnormal passageway between the bronchi and the pleural cavity)

Contraindications

In certain circumstances, a bullectomy may not be a good choice. Older individuals are typically advised against the surgery, as are people who have:

  • Other major medical conditions, such as severe heart disease
  • Small bullae
  • Pulmonary hypertension (increased pressure in the pulmonary arteries)
  • Diffuse emphysema
  • An FEV1 less than 35 percent to 40 percent
  • A low diffusing capacity (DLCO)
  • Hypercapnia (an excess level of carbon dioxide in the blood)
  • Cor pulmonale (right-sided heart failure associated with COPD)

Before Surgery

Before surgery is indicated, your doctor may try to manage your enlarged bullae without it. If you're asymptomatic, quitting smoking may be enough to manage the condition. If you still have symptoms after quitting smoking, medications and care options such as bronchodilators, inhaled glucocorticoids, vaccinations, supplemental oxygen, and/or pulmonary rehabilitation may help. If these still don't work, surgery is often the next course of action.

If your doctor suspects you need a bullectomy, she will take a careful history and perform a physical exam. Further tests may include:

You will be asked to not eat or drink anything after midnight the day before your procedure (or several hours beforehand). Medications such as blood thinners and aspirin may need to be discontinued for a week or more prior to surgery.

During Surgery

On the day of your surgery, you will be asked to sign a consent form, indicating that you understand the purpose of the procedure and any potential side effects. A nurse will place an IV 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, where a 4- to 6-inch incision is made below your armpit so that the surgeon can manually remove the bulla
  • Video-assisted thoracoscopic surgery (VATS), a procedure in which several small incisions are made in the chest near the region of the bullae and the bullae 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 will then be transferred to your room. If the breathing tube needs to be left in place for a while, you will be given a sedative medication 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. Most people will need to stay in the hospital for two days to three days.

A bullectomy can involve a significant amount of pain, and often pain control is given via a patient-controlled anesthesia (PCA) pump. These devices allow you to press a button at certain intervals to receive a dose of IV pain medication. When your pain is well-controlled, you will be switched over to oral pain medications.

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

When you are stable, breathing well, and do not require IV pain medications or a chest tube, you will be allowed to go home.

Most of the time, incisions are closed with absorbable stitches that will not need to be removed, but the suture holding your chest tube in place will be removed before you leave the hospital. If you do have sutures that will need to be removed, talk to your doctor about when this should be done.

Recovery

It's important to realize that you will feel sore and tired, and it's important to take it easy as your body recovers. There is no magic amount of time that it takes to recover, and everyone is different.

Pain Relief and Wound Care

You will be given oral pain medications, which your doctor will tell you how to use. Keep in mind that these medications can be very constipating, so it's important to drink plenty of water. Your doctor will probably also recommend a stool softener and/or laxative.

It's important to keep your incisions dry and covered. Some physicians recommend showers, while others recommend sponge baths (and washing hair in a sink) until the bandages are removed. You should avoid soaking in a tub. 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 two weeks. Some doctors advise patients to change them on their own, while others prefer that this be done by a nurse during a follow-up visit.

Exercise and Daily Activities

You will want to slowly increase your activity, but should avoid heavy lifting (over 10 pounds) or strenuous activity for around six weeks.

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.

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.

Due to pressure changes in the air, air travel should be delayed for at least three months following surgery. For those who scuba dive, it may not be safe to resume diving if you have a history of bullae.

Returning to Work

When it's considered OK to return to work depends on your doctor's opinion and your job requirements. You will be able to return to a desk job much more quickly than a job that involves manual labor, for example. Be sure to ask your physician what she advises.

Follow-Up

Your doctor will let you know when you should be followed up in the clinic, and this can vary from shortly after surgery up to six weeks. Your doctor may also recommend pulmonary rehabilitation after surgery.

If you experience any of the following before you are seen, contact your doctor:

  • Bleeding
  • Redness, increased tenderness, or swelling around your incisions
  • Any drainage from your incisions
  • Increased shortness of breath (especially if sudden)
  • 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

While a bullectomy can result improve symptoms related to lung bullae, it does not treat the underlying process that caused them. It's important to follow your doctor's recommendations to best control your condition.

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