An Overview of Bullectomies

A surgical procedure for people who have COPD and giant bullae

Pneumothorax illustration for which bullectomy is a treatment
Wikimedia Commons

A bullectomy is a surgical procedure used to remove lung bullae, (thin walled air filled spaces in the lung) that are found in some people with medical conditions such as chronic obstructive pulmonary disease (COPD), Marfan syndrome, alpha-1-antitrypsin deficiency, and more. 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 called video-assisted thoracoscopic surgery, in which the bullae is removed through small incisions in the chest. Complications may include bleeding, infections, blood clots, abnormal heart rhythms, and others.

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. A bulla differs from pulmonary blebs which are small collections of air that are found on the surface of the lungs between the lung and the visceral pleura (the inner of two membranes that surround the lungs).

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. 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 can occasionally occur rapidly. In some cases, spontaneous deflation may occur, usually after an infection in a bulla occurs.

Consequences of Bullae

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.

Symptoms

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

Causes of Bullae

There are a number of different medical conditions in which large lung bullae may occur. These include:

  • COPD: Conditions that fall under the heading COPD include emphysema, chronic bronchitis, and bronchiectasis. It's important to note that conditions such as emphysema have many causes, not just smoking. For example, even children with some conditions (such as alpha-1-antitrypsin deficiency) may develop emphysema. 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.
  • Vanishing lung syndrome: Vanishing lung syndrome is the name that has been coined for emphysema with idiopathic giant bullae (the term idiopathic means that the causes are unknown, but the condition 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.
  • Cocaine smoking
  • Sarcoidosis: Sarcoidosis is an inflammatory condition that results in granulomas being formed, often in multiple regions of the body.
  • HIV infection
  • IV drug abuse
  • Marijuana smoking has a possible, but small, causal role in the formation of bullae.

Purpose of a Bullectomy

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

  • To reduce symptoms such as dyspnea (the sensation of shortness of breath).
  • To improve respiratory function: A bullectomy may improve the FEV1/FVC ratio, a ratio that 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).

When used for people who are good candidates for the surgery, a bullectomy can result in tan improvement in symptoms that may last for several years. The procedure is most effective in people who are young, have large bullae (especially if only a single or a few), when bullae are located in only one region of the lungs, and when only minimal to moderate airway obstruction is present. The procedure is much less effective when a person has severe lung disease or diffuse bullae.

Indications

There are a number of reasons why your doctor may recommend a bullectomy (if you are a good candidate for the procedure), with the most common being symptoms such as:

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

Some people have no symptoms but may require surgery if the bullae are very large.

Other Procedures

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.

Bullae Groups

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. These include:

  • 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 conditions when 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. This includes people who are older or 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 (a low 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 such as bronchodilators, inhaled glucocorticoids, vaccinations, supplemental oxygen, 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:

  • Chest x-ray
  • Chest CT scan
  • Pulmonary function tests
  • Ventilation/perfusion scan or VQ scan
  • Lung angiography
  • Arterial blood gases (ABGs)
  • EKG
  • Cardiac stress test

Before surgery, you will be asked to not eat or drink anything after midnight (or for several hours). 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.

Your surgeon may perform the bullectomy in one of two ways. One is by thoracotomy, where a 4- to 6-inch incision is made below your armpit so that the surgeon can manually remove the bulla. The other option if video-assisted thoracoscopic surgery (VATS). In this procedure, 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 3 hours, but this can vary.

After Surgery and Recovery

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 2 days to 3 days.

A bullectomy can involve a significant amount of pain, and often pain control is given via a PCA pump (patient controlled anesthesia). 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.

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

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

You will be given pain medications, and your doctor will talk about how to use these. 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 and don't rub them with the towel. Bandages are often left in place for one two weeks, but doctors vary in how these are managed, and whether you will be asked to change these yourself, or to wait until your follow-up in the clinic.

You will want to slowly increase your activity, but should avoid heavy lifting (over 10 pounds) or strenuous activity for around 6 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 2 weeks, and you should not drive beyond this 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.

Doctors also vary with regard to when it's best for people to return to work, and this can vary depending on your job requirements. You will be able to return to a desk job much more quickly than a job that involves manual labor. Due to pressure changes in the air, air travel should be delayed for at least 3 months following surgery. For those who scuba dive, it may not be safe to resume diving if you have a history of bullae.

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 6 weeks. Your doctor may also recommend pulmonary rehabilitation after surgery.

When to Call Your Doctor

During this time, you should contact your doctor if you experience:

  • 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 F) 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
  • If you cough up blood

A Word From Verywell

A bullectomy, when a person is a good candidate for the procedure, can result in an improvement in symptoms related to emphysema and lung bullae that can sometimes last for 3 years to 5 years. Of note is that this surgery does not treat the underlying process that caused the bullae, and it's important to follow your doctor's recommendations to best control your condition. Many people are anxious to get back to their normal life following the surgery, especially if the surgery results in a significant improvement in symptoms, but it's important to give your body time to heal. The story of the tortoise and the hare offers a great example of how to have a successful recovery. Slow and steady will best get you where you want to be.

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