Bullous Lung Disease
Giant bullae, vanishing lung, and lung volume reduction — surgical options in advanced emphysema.
A bulla is a thin-walled, air-filled space in the lung parenchyma exceeding 1 cm in diameter in the distended state. Bullae arise from destruction of alveolar walls and coalesce over time. Bullous lung disease refers to the presence of multiple or giant bullae causing significant functional impairment.
Classification — Reid (1967)
| Type | Description | Lung function |
|---|---|---|
| Type I | Vanishing lung — giant bulla occupying >1/3 of hemithorax in otherwise normal lung; narrow neck communicating with bronchus | Normal (compressed normal lung around bulla) |
| Type II | Bullae in diseased lung — multiple bullae with areas of emphysema; widespread parenchymal disease | Moderately reduced |
| Type III | Generalised emphysema — diffuse disease with widespread small bullae | Severely reduced |
Giant bulla = bulla occupying >30% of one hemithorax. The most surgically important entity.
Clinical features
Progressive dyspnoea, reduced exercise tolerance, and chest pain. Recurrent pneumothorax is common. Superimposed infection within the bulla produces a fluid level. Giant bullae compress surrounding viable lung and mediastinal structures, causing a vicious cycle of worsening hyperinflation.
PFT pattern: Obstructive pattern — reduced FEV1/FVC ratio, elevated TLC and RV; DLCO reduced with widespread emphysema.
Surgical indications — bullectomy
- Giant bulla occupying >1/3 of hemithorax
- Progressive dyspnoea with evidence of compressed normal lung
- Recurrent pneumothorax
- Haemoptysis or recurrent infection within the bulla
- Rapidly expanding bulla
The ideal candidate for bullectomy is a patient with a TYPE I (vanishing lung) giant bulla — surrounded by functionally normal compressed lung that will re-expand after bullectomy. Predictors of poor outcome include: FEV1 <35% predicted, diffuse bilateral emphysema (Type III), heavy smoking with ongoing decline, and significant CO2 retention (pCO2 >45 mmHg).
Operative technique
VATS bullectomy is preferred for accessible bullae. Key technical principles: staple the base of the bulla to close the bronchial communication; avoid drainage of bulla contents into the airway during deflation; oversew the staple line for air-tight closure; inspect for satellite bullae. Pleurodesis may be added to prevent pneumothorax recurrence.
Lung volume reduction surgery (LVRS)
LVRS removes 20–30% of lung volume from the most emphysematous regions (typically upper lobes), aiming to improve lung mechanics, diaphragm function, and elastic recoil. It is distinct from bullectomy and is appropriate only for diffuse upper-lobe predominant emphysema where bullectomy is not the primary goal. Patient selection based on the NETT trial criteria: upper-lobe predominant disease, low exercise capacity after pulmonary rehabilitation, FEV1 20–45% predicted. Bronchoscopic lung volume reduction (endobronchial valves, coils) has emerged as a less invasive alternative for selected patients.
Medical management of COPD
The majority of patients with bullous lung disease have underlying COPD. Medical management aims to slow progression and reduce exacerbations:
- Smoking cessation — most important single intervention
- Inhaled bronchodilators (LABA, LAMA) and corticosteroids
- Pulmonary rehabilitation
- Vaccination (influenza, pneumococcal)
- Long-term oxygen therapy for chronic hypoxaemia
For pharmacological management, exacerbation prevention, and long-term oxygen therapy thresholds, refer to the GOLD COPD guidelines (updated annually).
All clinical content should be verified against current guidelines before clinical application. This resource is intended for revision and educational purposes only.
Standard textbooks
- Shields TW, LoCicero J, Reed CE, Feins RH. General Thoracic Surgery. 7th ed. Lippincott Williams & Wilkins.
- Sellke FW, del Nido PJ, Swanson SJ. Sabiston & Spencer Surgery of the Chest. 9th ed. Elsevier.
- Pearson FG, et al. Thoracic Surgery. 3rd ed. Churchill Livingstone.