Interactive Cardiovascular and Thoracic Surgery 3:283-285(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Computed tomography-guided drainage for large pulmonary bullae
Hiromitsu Takizawa,
Kazuya Kondo*,
Shoji Sakiyama and
Yasumasa Monden
Department of Oncological and Regenerative Surgery, University of Tokushima School of Medicine, 3-18-15 Kuramotocho, Tokushima 770-8503, Japan
* Corresponding author. Tel.: +81-88-633-7143; fax: +81-88-633-7144
kondo{at}clin.med.tokushima-u.ac.jp
Received September 17, 2003;
received in revised form December 7, 2003;
accepted December 15, 2003
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Abstract
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Patients with large pulmonary emphysematous bullae often present therapeutic problems because of their poor respiratory function. We performed computed tomography (CT)-guided drainage in two patients with large pulmonary bullae who were considered poor surgical candidates. This method could be safely accomplished in a few minutes under local anesthesia and sufficient collapse of the bullae was obtained in both cases. We could control prolonged air leak from the catheter with bronchofiberoptic bronchial occlusion in one patient. CT-guided bulla drainage is a simple, speedy and minimally invasive treatment method for inoperable patients with large pulmonary bullae.
Key Words: Bullae; Computed tomography; Emphysema; Minimally invasive surgery
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1. Introduction
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Emphysematous bullae compress the adjacent lung tissue and thereby impair respiratory function [1,2,4–7]. There are many surgical methods available to treat emphysematous bullae [1,2]. However, there are still many cases considered to be poor risks for surgery despite surgical and anesthesiological technical progress [3]. Intracavitary suction and drainage methods have been described as less invasive treatments for such cases [4–7]. In the present report, we describe a simple, speedy and minimally invasive method using computed tomography (CT)-guided drainage that was performed in two patients with large bullae who were considered unfit for surgery.
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2. Case reports
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2.1. Case 1
A 57-year-old woman had an 11-year history of bilateral diffuse pulmonary emphysema and bullae in both lungs. Excision of a large bulla in the left lower lobe had been performed 8 years earlier, and her dyspnea had improved. Thereafter, a right lung bulla gradually enlarged causing worsening dyspnea and was excised 1 year before the present admission. Postoperatively, long-term assisted mechanical ventilation led to re-enlargement of the bulla in the left lower lobe. Severe respiratory failure forced her to become bedridden and required assisted mechanical ventilation almost all day.
Chest roentgenogram and CT showed emphysematous change in both lungs and large bulla occupying the left lower lobe (Fig. 1A). Arterial blood gas values under inhalation of oxygen (3 l/min via tracheostomy) were pH 7.368, pCO2 57.2, pO2 78.8. Because postoperative adhesion was expected, she was considered a poor surgical candidate. Thus, CT-guided bulla drainage was performed.
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Fig. 1 (A) Chest roentgenogram before drainage showing emphysematous change in both lungs and bulla occupying the left lower lung field. (B) Chest roentgenogram during drainage showing complete collapse of the bulla.
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The site of puncture was determined under CT scan. An 18-gauge needle was inserted into the bulla under local anesthesia. A guide wire was introduced into the bulla through the needle. A 9F introducer was then placed in the bulla along the guide wire. A 6F balloon catheter was passed through the introducer and the balloon was inflated with contrast medium. The balloon catheter was fixed to the chest wall with slight traction to prevent air leak. The balloon catheter was connected to a water-sealed tube and continuous negative pressure (–10cmH2O) was applied. CT scan was performed again to check the position of the catheter.
OK-432 (an immunoactivator commonly used as an adhesive agent in Japan) and minocycline were injected into the bulla for the purpose of promoting inflammatory adhesion of the collapsed bulla-wall on the 10th and 32nd postoperative day because air leak from the catheter persisted. However, the air leak did not disappear. On the 35th postoperative day, we occluded the bronchus of the left lower lobe bronchoscopically using fibrin glue. The air leakage stopped on the 37th postoperative day, and the catheter was removed. Chest roentgenogram demonstrated complete collapse of the bulla (Fig. 1B). And improvements in arterial blood gas values were obtained: pH 7.439, pCO2 44.1, pO2 125.8 (O2 3 l/min via tracheostomy). Finally, the patient died of worsening respiratory dysfunction 1 year and 9 months after drainage. However, she remained free from the respirator for 1 year after drainage. Thus, her quality of life was improved.
2.2. Case 2
A 72-year-old man presented with worsening dyspnea (Hugh-Jones 5). On admission, chest roentgenogram demonstrated emphysematous change in both lungs and a large bulla in the right lower lobe. Because of high pulmonary artery pressure (48/9 mmHg) and hypercapnea (pCO2 84 mmHg), he was considered a poor risk for surgery. We performed the same procedure as described in case 1 (Fig. 2A and B).
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Fig. 2 (A) Chest computed tomography before drainage showing a large bulla in the right lower lobe. (B) Chest computed tomography during drainage showing remarkable collapse of the bulla.
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Air leak stopped the following day. However, because the patient had dementia due to severe hypercapnea, he cut the drainage tube on the third postoperative day. Thereafter, we clamped the tube immediately and observed the course, checking the chest roentgenogram regularly to confirm that the bulla did not enlarge again. Thereafter, we removed the drainage tube 1 month later. Shrinkage of the bulla on chest roentgenogram and CT was observed and symptomatic improvement was obtained.
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3. Comment
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Many aggressive surgical treatments that provide good results for large bullae have been reported [1]. And bullectomy by video-assisted thoracic surgery was reported to be a good alternative to thoracotomy because of its lower invasiveness [2]. However, the two patients in this report were considered inoperable due to postoperative adhesion in one patient and severe pulmonary hypertension and hypercapnea in the other patient. A variety of methods for intracavitary drainage of emphysematous bullae without surgery have been developed for poor risk cases [4–7]. In 1949, Head reported a two-stage procedure to avoid the risk of pneumothorax [4]. An advanced one-stage procedure using a urethral catheter was reported by Macarthur et al. [5]. This method was performed under thoracotomy with rib resection. More recently Oizumi reported tube drainage with small thoracotomy under epidural anesthesia [6]. Both these methods require thoracotomy. Damage to the chest wall and postoperative pain due to thoracotomy have the potential to further worsen respiratory function in patients with poor respiratory reserve. However, our method does not require either muscle incision or rib resection. The patients in this report did not experience pain or worsening dyspnea throughout the treatment. Under CT monitoring, we could perform the drainage accurately and safely. Moreover, our method was so simple that it only took a few minutes to accomplish all procedures. Sufficient collapse of the bulla was observed and the reduction persisted after the drain was removed. Subjective symptoms and arterial blood gas values improved in our patients.
Drainage often ends in failure because of prolonged air leakage following drainage [5]. We experienced prolonged air leakage in one of our patients. Initially, we injected OK-432 and minocycline into the bullae as adhesive agents. Uyama et al. speculated that abacterial inflammation facilitated closure of the bronchial communication with bullae and hardening of the wall, thus resulting in shrinkage of the bullae [7]. In our case, air leakage persisted after treatment with OK-432 and minocycline. Therefore, we injected fibrin glue bronchofiberscopically into the bronchus that was considered responsible for the air leakage. There were no complications such as pneumonia or atelectasis encountered. Combination of intracavitary drainage and endobronchial occlusion can support earlier recovery.
In conclusion, CT-guided bulla drainage is an alternative treatment method for inoperable patients with large pulmonary bullafce.
doi:10.1016/j.icvts.2003.12.007
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References
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Abstract
1. Introduction