Forty years between contralateral bullectomies for giant pulmonary bullae: a case report

Giant pulmonary bullae (GPB) are a rare manifestation of emphysema that often requires procedural intervention. Operative management of GPB has been shown to significantly improve quality of life and pulmonary function test (PFT) parameters. These improvements have been shown to persist for years, with a gradual decline associated with the progression of emphysema. For those with GPB who have had a pneumothorax, a future contralateral pneumothorax is more common in those with contralateral blebs. We present the unique case of a patient with GPB who required contralateral bullectomy 40 years after his first.

A 63-year-old man with a history of left-sided bullectomy in 1986 who was lost to follow-up presented in 2021 with progressive dyspnea on exertion. Computed tomography (CT) demonstrated a giant bulla occupying >50% of the right thorax, causing ipsilateral atelectasis and contralateral tracheal shift. Also present was a right-sided pneumothorax and a left-sided hilar mass. Biopsy of this mass was negative for malignancy, and it self-resolved on subsequent imaging. He re-established as an outpatient, and four months later was directly admitted from clinic for hypoxic respiratory failure. Follow-up CT imaging demonstrated minimal interval change over 1.5 years. He continued outpatient follow-up, and by 2023, had reduced his smoking and participated in pulmonary rehab. PFT demonstrated a moderately severe obstructive ventilatory defect with evidence of heterogeneity of ventilation but remained stable from 1/2023 to 8/2024. His dyspnea on exertion and oxygen requirement (4 L/min) were stable in this interval. He presented in 8/2024 for elective video-assisted thoracic surgery (VATS) with right upper lobe bullectomy and right middle lobe wedge resection. At follow-up 4 months later, his O₂ requirement had reduced to 2.5 L/min with activity. He endorsed significant subjective improvement in his breathing. Follow-up PFT demonstrated improvement in 6-minute walk test (6MWT), forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), total lung capacity (TLC), and diffusing capacity of the lungs for carbon monoxide (DLCO).

Bullectomy remains an effective treatment for dyspnea in patients with GPB. Prophylactic management of contralateral blebs remains an ongoing debate, though primarily in the context of pneumothorax. Advancements in medical and surgical management of chronic obstructive pulmonary disease (COPD) have expanded the length of time patients should be closely monitored for consideration of procedural intervention for GPB.