From the Guidelines
For patients with severe pulmonary emphysematous bullae, bullectomy is a recommended treatment option, as it can significantly improve lung mechanics, symptoms, functional performance, and health status, particularly in those with giant bullae occupying one-third of the ipsilateral hemithorax surrounded by relatively normal parenchyma 1.
Treatment Options
- Bronchodilators like albuterol (2-4 puffs every 4-6 hours) and tiotropium (18 mcg once daily) can help open airways and improve breathing.
- Inhaled corticosteroids such as fluticasone (100-500 mcg twice daily) may be added to reduce inflammation.
- Oxygen therapy is recommended for patients with low blood oxygen levels, typically at 1-5 liters per minute as needed.
- Pulmonary rehabilitation programs combining exercise training, education, and support can significantly improve quality of life.
Surgical Options
- Lung volume reduction surgery (LVRS) may be considered for patients with severe COPD and a predominance of emphysema in the upper lobes, as it can improve symptoms, health status, lung mechanics, exacerbation rates, and survival 1.
- Bullectomy is a recommended option for patients with giant bullae, as it can improve lung mechanics, symptoms, functional performance, and health status 1.
- Lung transplantation may be considered for patients with very severe COPD and without relevant contraindications 1.
Bronchoscopic Interventions
- Endobronchial valve placement has shown statistically significant improvements in FEV1 and 6-minute-walk distance, but the magnitude of the observed improvements was not clinically meaningful 1.
- Nitinol coils implanted into the lung have reported increases in 6-minute-walk distance and smaller improvements in FEV1 and quality of life measured by SGRQ 1.
Lifestyle Modifications
- Smoking cessation is the most important step to prevent further damage.
- Lifestyle modifications are crucial to improve quality of life and reduce disease progression.
From the Research
Treatment Options for Severe Pulmonary Emphysematous Bullae
- Medical treatment is the mainstay of therapy and consists of smoking cessation, pulmonary rehabilitation, administration of bronchodilators and, when indicated, steroids and supplemental oxygen 2
- Lung volume reduction surgery (LVRS) has been shown to be beneficial to selected patients with end-stage emphysema when medical therapy has failed, particularly those with upper-lobe predominant emphysema and low-baseline exercise capacity 2, 3, 4, 5
- Bronchoscopic alternatives to the surgical approach have been proposed, including airway bypass and bronchoscopic lung volume reduction with one-way valves, which may play an important role in the future 2, 4
- Endobronchial valve implantation has demonstrated comparable outcomes to LVRS in selected individuals and has recently received approvals by the National Institute of Clinical Excellence in the United Kingdom and the Food and Drug Administration in the United States of America 4
- Endobronchial coils are proving a viable treatment option in severe hyperinflation in the presence of collateral ventilation in selected cases of homogeneous disease 4
Considerations for Treatment
- Patients with a most advanced functional deterioration show a higher surgical mortality and less impressive functional results, suggesting that LVRS should be considered more carefully in these situations 2
- The quality of evidence for LVRS ranged from low to moderate owing to an unclear risk of bias across many studies, lack of blinding and low participant numbers for some outcomes 5
- Adverse events were more common with LVRS than with control, specifically the occurrence of (persistent) air leaks, pulmonary morbidity (e.g. pneumonia) and cardiovascular morbidity 5