Intracavitary Drainage Followed by Lobectomy for a Giant Bulla Causing Respiratory Failure due to Severe Mediastinal...

We present the case of a giant emphysematous bulla resulting in deteriorating respiratory condition due to severe mediastinal compression that was successfully treated with emergency intracavitary drainage followed by elective right upper lobectomy.

A 57-year-old man was admitted to our hospital because he developed progressive dyspnea over 1 month and was eventually unable to ambulate. His oxygen saturation was 89% in room air. A chest radiograph showed the disappearance of vascular markings in the entire right lung and upper left field, a severe mediastinal shift to the left, and a bilaterally flattened diaphragm. Chest CT revealed a giant emphysematous bulla occupying the right hemithorax, compressing almost the entire right lung parenchyma, and extending across the anterior mediastinum into the left hemithorax. Despite the administration of medication, his respiratory condition deteriorated further on Day 3 after hospitalization. Since the compression of the mediastinum by the expanding giant emphysematous bulla was thought to be the cause of the respiratory deterioration, a small-diameter tube was inserted percutaneously into the giant bulla for decompression. The intracavitary drainage relieved symptoms immediately and dramatically; however, a follow-up chest radiograph obtained 1 h after showed a mild right pneumothorax, requiring insertion of a chest tube into the right thoracic cavity to prevent further deterioration of the respiratory condition. His respiratory condition improved, but air leakage still persisted. CT after intracavitary drainage showed atelectasis of the right middle and lower lobes, which were expected to be reinflated by the removal of the giant bulla. Therefore, radical surgery was performed 9 days after the drainage. The giant bulla had herniated into the left hemithorax through the anterior mediastinum and was adhering to the left mediastinal pleura. Right upper lobectomy was successfully performed after dividing the fibrous adhesions and pulling the giant bulla into the right hemithorax. He was discharged on Day 13, remained asymptomatic, and had returned to normal daily activities by 10 months postoperatively.

We conclude that intracavitary drainage can serve as an effective bridge to secure surgery in patients with giant emphysematous bullae causing the deterioration of respiratory condition.