From the Guidelines
Pulmonary bullae typically do not resolve spontaneously in most cases. These air-filled spaces in the lungs, which form due to destruction of alveolar walls, tend to persist once they develop. The natural history of pulmonary bullae generally involves stability or gradual enlargement over time, as explained by the underlying pathophysiology where elasticity has been lost and cannot regenerate 1.
Management and Treatment
Management typically focuses on treating the underlying cause (such as smoking cessation for emphysema), monitoring for complications like pneumothorax or infection, and in select cases, surgical intervention for large bullae causing significant symptoms or complications.
- Surgical removal or ablation of expanding or very large bullae may be indicated in some patients and can lead to prolonged improvements in FEV1, as noted in studies 2, 3.
- Lung volume reduction approaches may be a useful complement to standard medical therapy for a select number of patients with advanced COPD, particularly those with giant bullae surrounded by relatively normal parenchyma 1.
- Patients with bullae should have regular follow-up with pulmonary function tests and imaging to monitor for changes in size or complications.
Key Considerations
The decision for surgical intervention should be based on the individual patient's condition, including the size and location of the bullae, as well as their overall lung function and health status. The most recent and highest quality study 1 suggests that lung volume reduction surgery (LVRS) may be beneficial for patients with severe COPD and giant bullae, but the therapy is costly and associated with significant morbidity. Therefore, a thorough assessment and discussion of the potential benefits and risks are necessary before proceeding with any surgical intervention.
From the Research
Spontaneous Resolution of Pulmonary Bullae
- Spontaneous resolution of giant pulmonary bullae is a rare occurrence, with some studies suggesting that it can happen infrequently 4, 5.
- The mechanisms responsible for the natural elimination of giant bullae are variable, and may include factors such as smoking cessation and optimization of inhaled bronchodilator and anti-inflammatory therapies 4.
- Some cases have reported spontaneous total regression of giant bullae following intensification of inhaled bronchodilator and airway anti-inflammatory therapies 4, or without any specific treatment 5.
Treatment Options for Pulmonary Bullae
- Surgical treatments for emphysema, including bullectomy, lung transplantation, and lung volume reduction surgery (LVRS), are available for selected patients 6, 7.
- Bullectomy is typically offered to patients with giant bullae filling half the thoracic volume and compressing relatively normal adjacent parenchyma 6.
- LVRS is offered to patients with hyperinflation, heterogeneous distribution of destruction, forced expiratory volume in 1 second (FEV(1)) >20%, and a normal carbon dioxide tension (PCO(2)) 6.
- Lung transplantation is directed towards patients with diffuse disease, lower FEV(1), hypercapnia, and associated pulmonary hypertension 6.
Medical Management of Pulmonary Bullae
- Inhaled bronchodilators and corticosteroids may be used to decrease symptoms, improve lung function and quality of life, and prevent exacerbations in patients with chronic obstructive pulmonary disease (COPD) 8.
- Combination therapies, such as fluticasone propionate/salmeterol, may be effective in achieving these goals for some patients with COPD 8.