What are the indications for bullectomy (surgical removal of a bulla) in patients with chronic obstructive pulmonary disease (COPD)?

Indications for Bullectomy in COPD

Bullectomy is indicated in COPD patients with large bullae that occupy more than 30% of the hemithorax and compress adjacent functional lung tissue, causing symptoms such as dyspnea or complications including infection, rupture, or bleeding. 1

Primary Indications

• Large bulla size: Bullectomy should be considered when a bulla occupies more than 30% of the hemithorax, resulting in compression of healthy adjacent lung tissue 2, 1
• Symptomatic disease: Patients with incapacitating dyspnea related to the compression effect of giant bullae 1
• Complications: Surgical intervention is indicated when bullae cause complications such as infection, rupture (pneumothorax), or bleeding 2, 1

Patient Selection Criteria

• Evidence of compressed functional lung tissue: CT imaging should demonstrate that the bulla is compressing otherwise viable lung tissue that could re-expand after bullectomy 1
• Smoking cessation: Patients should demonstrate commitment to smoking cessation prior to surgical intervention 1
• Pulmonary rehabilitation: Completion of outpatient pulmonary rehabilitation is recommended before surgery 1

Preoperative Assessment

• Pulmonary function testing: Complete assessment including lung volumes by whole body plethysmography, spirometry, diffusion capacity, and arterial blood gas analysis 1
• CT imaging: Essential for evaluating the extent of bullous disease and quality of surrounding lung tissue 1
• Assessment of surgical risk: Evaluation of comorbidities and overall surgical candidacy 1

Surgical Approaches

• Video-assisted thoracoscopic surgery (VATS): Preferred minimally invasive approach that may allow quicker recovery and less postoperative pain 2, 1
• Modified Monaldi-type drainage procedures: Effective alternative for high-risk patients who cannot tolerate excisional procedures 1
• Limited resection: Whenever possible, surgeons should perform limited resections that spare all surrounding functional pulmonary parenchyma 1
• Avoidance of lobectomy: Lobectomies should be avoided when possible to preserve lung tissue 1

Alternative Approaches for High-Risk Patients

• Bronchoscopic bullectomy with endobronchial valves (EBVs): Emerging alternative for patients with poor lung function who cannot undergo surgical bullectomy 3, 4
• Percutaneous bullectomy: May be combined with EBV placement in selected cases where surgery is contraindicated 3

Expected Outcomes

• Improved pulmonary function: Bullectomy can improve lung function by allowing compressed viable lung to re-expand 5
• Enhanced gas exchange: Removal of bullae may improve ventilation-perfusion matching 5
• Reduced dyspnea: Patients typically experience symptomatic relief after successful bullectomy 2, 5
• Improved diaphragmatic function: Reduction in end-expiratory lung volume can enhance diaphragmatic pressure generation 5

Potential Complications

• Prolonged air leak: One of the most common complications, may require extended chest tube drainage 2
• Wound infection: Can occur but typically responds to conservative treatment 2
• Residual space: May develop in the area previously occupied by the bulla 1

Special Considerations

• Diffuse emphysema: In patients with bullous disease in the presence of diffuse emphysema, surgical decisions should be individualized based on potential functional benefit 1
• Pleurodesis: Additional pleurodesis or suturing reinforcement during surgery can help prevent air leak complications 2
• Postoperative care: Aggressive tracheobronchial toilet, chest physiotherapy, adequate pain control, and early ambulation are essential to minimize complications 1