Lung Volume Reexpansion Surgery
A Surgical Secret
Am J Respir Crit Care Med Vol 187, Iss. 5, p 552, Mar 1, 2013
Pankaj Saxena1,2, Nur Azri Bin Haji Mohd Yasin1,2, and Ivor F. Galvin1,2
1Department of Cardiothoracic Surgery, Dunedin Hospital, Dunedin, New Zealand; and 2Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
A 71-year-old woman was breathless at rest. She had a background of severe chronic obstructive pulmonary disease (30 pack-years, quit smoking 25 years ago) and hypertension. Chest radiograph and computed tomographic scan revealed a giant emphysematous bulla of the right upper lobe (Figures 1A and 1C). FEV1 was 0.49 L, and diffusion lung capacity for carbon monoxide (DLCO) was 7.72 ml/min/mm Hg (25% and 39% of predicted, respectively). She underwent a non–muscle-splitting minithoracotomy via the auscultatory triangle, and had resection of: a giant 13-cm bulla from the right upper lobe; and two small bullae, one each from the middle and lower lobes, measuring 5 and 6 cm, respectively. Staple lines were reinforced with BioGlue and felt strips. The operation relieved compressive atelectasis of viable lung, improved oxygenation, and abolished shunt. The surgery is high risk, and success mandates preoperative chest physiotherapy, epidural pain relief, mini–muscle-sparing thoracotomy, bullectomy, avoidance of air leaks, and on-table extubation. Postoperative images (Figures 1B and 1D) at 11 weeks revealed a well-expanded right lung. FEV1 was 0.93 L, and DLCO was 8.8 ml/min/mm Hg. Diminished residual lung function after surgery is a consequence of generalized emphysema as evidenced by several smaller bullae on the left side. Fortuitously, she can now walk 1 km.
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