Patients likely to see the most benefit from surgery generally have moderate to severe dyspnea as well as clearly defined normal lung tissue distinct from a single large bulla. A single large, isolated bulla has the best success after surgery compared with surgery concerning many smaller bullae. By performing a resection, the compressed normal lung tissue should be able to expand fully, and oxygenation should improve. Some larger bullae can be asymptomatic; these patients should be followed up for observation before surgery is performed (see “Surgery in Nondyspneic Patients”). Surgery is also indicated for debilitating symptoms associated with a bulla, such as dyspnea, pneumothorax, empyema, or massive hemoptysis. Conversely, patients who do not quit smoking or those who have other symptoms, such as chronic bronchitis, bronchospasm, or recurrent infections, have a lower chance for a sustained benefit following surgery.

The decision for bullectomy is always predicated on a thorough assessment of risk and benefit. The most benefit will be seen with successful reduction of the compressive bulla on adjacent pulmonary parenchyma, greater concordance between the ventilation-perfusion ( ) ratio, and a reduction of dead space when dealing with cases involving communications between the bronchial terminals. The primary complaint for giant bullous emphysema is almost always dyspnea. Therefore, quantifying the patient’s degree of dyspnea both preoperatively and postoperatively helps to predict and verify surgical success. The modified scale created by the Medical Research Council of Great Britain ( Table 14-1 ) can be used to quantify dyspnea.

Chest computed tomography (CT) scanning is mandatory in determining the extent of surgical resection and provides the best dimensional assessment and extent of the dominant bulla. A chest CT can also be used during expiration (dynamic CT) for clarification of multiple issues with regard to the surgery. Pulmonary angiograms can also be helpful in determining the amount of compression ( Fig. 14-1 ). A good way to address the gained reperfusion after surgery is to perform both presurgical and postsurgical quantitative scanning. This test helps to demonstrate the amount of perfused lung parenchyma garnered after resection.

(From Dartevelle P, Macchiarini P, Chapelier A. Operative technique of bullectomy. Chest Surg Clin North Am 1995;5:735-749.)

The primary goal for all patients before surgery is smoking cessation; however, we are often conflicted in the clinic regarding smoking cessation. Ultimately, the patient benefits from smoking cessation, and we have professionals dedicated to this cause. However, most patients prefer to continue to smoke in the weeks before surgery. Surprisingly, the literature supports this practice.

Pulmonary function (spirometry, blood gas analysis, perfusion, and ventilation scintigraphy) testing should be gathered on all candidates for surgery. Bronchoscopy should be performed to exclude obstructive lesions. Outpatient pulmonary rehabilitation and education concerning methods for coughing, deep breathing, incentive spirometry, and chest physiotherapy should be required for all appropriate surgical candidates. Cardiac assessment should be considered, with electrocardiogram and echocardiography with concurrent measurement of pulmonary pressure.

Before beginning an operation, a thoracic epidural catheter should be inserted, with continuous administration of epidural narcotics perioperatively. During this procedure, the surgeon must be present because of the chance of an ipsilateral or contralateral pneumothorax that requires rapid decompression. Patients are ventilated and anesthesia is maintained with a double-lumen endotracheal tube so that the lung being operated on can be collapsed if the situation is warranted. To avoid the potentially life-threatening situation created by excessive positive pressure, namely, a tension pneumothorax, one must keep tidal volumes low and maintain a low inspiratory pressure. By allowing for long expiratory phases, trapped air in the bullae and compressed tissue is given a chance to escape. Postoperatively, assisted ventilation is discontinued when the patient regains consciousness and body temperature has returned to normal.

Although the primary symptom of giant bullous emphysema is dyspnea, surgery for complications in nondyspneic patients can be warranted in special circumstances. One instance is for the presence of carcinoma in the bulla. Carcinoma can be observed by particular radiographic patterns of neoplasm development, such as nodular opacity within or adjacent to the bulla; partial or diffuse thickening of the bulla wall; and, finally, secondary signs of the bulla, such as a changed diameter, fluid retention, or pneumothorax. Rarely, bullae become infected. The first choice should be conservative management with antibiotic treatment for a minimum of 6 weeks but is often not sufficient because of poor communication between the infected bulla and bronchial tree. If the patient does not improve, drainage via the modified Monaldi procedure should be considered. Hemoptysis can occur as the result of an eroded artery, although this is less common than an infection. Because of the rarity of this condition, lesions in other lung zones that could account for the bleeding should be suspected and ruled out before surgery.