Case Study: Bullous Emphysema

Surgery and multidisciplinary therapy allow a return to independence

LEAD PHYSICIAN
Sean Duffy, MD
Associate Professor of Pulmonary and Critical Care Medicine
Lewis Katz School of Medicine at Temple University

A 59-year-old man presented to the pulmonary clinic at Temple Lung Center for initial evaluation of shortness of breath. He had had minimal contact with healthcare providers over the prior 30 years. He reported a 40 pack-year smoking history and stated that he had quit smoking about one year prior to his presentation. He noted difficulty breathing with minimal exertion and was unable to do his own grocery shopping. He also complained of an associated dry cough and unintentional 35 lb weight loss over about a decade.

Diagnostic Findings

Initial evaluation included chest X-ray, noncontrast CT of the thorax, 6-minute-walk test, and lung function testing.

• PFT results:

  • FEV1 was 0.87 L or 24% of predicted
  • FEV1/FVC was 30%
  • Total lung capacity (TLC) was 9.44 L or 132% of predicted
  • Residual volume (RV) was 6.5 L or 281% of predicted
  • DLCO was 23% of predicted
  • 6-minute-walk testing: 313-meter walk distance with a 3 LPM oxygen requirement with exertion

Imaging: CT thorax showed giant bulla at right lower lobe amidst a background of severe emphysema.

Treatment

The patient was started on LAMA/LABA inhaler therapy and referred for pulmonary rehab. He was also sent for evaluation with Thoracic Surgery for possible surgical resection of his right-sided bulla. He participated in pulmonary rehab and was able to remain exacerbationfree with LABA/LAMA therapy, but due to his exercise limitation, the decision was made for him to undergo surgery.

During his surgical workup, he was found to have coronary artery disease. Surgery was delayed, as he required a stent to the right coronary artery. However, a year after his stent placement, he was able to hold antiplatelet therapy in order to have surgical resection of his bulla.


CT scan of thorax showing giant bulla at lower right lung lobe (left) and postoperative improvement of bullous lung disease (right)

Outcomes

  • Postoperative CT thorax revealed considerable improvement in bullous lung disease and hyperinflation.
  • Postoperative PFT
    – FEV1 = 1.6 L (43%)
    – TLC = 8.73 L (122%)
    – RV = 4.86 L (210%)
  • Postoperative 6-minute walk: 420-meter walk distance with no exertional oxygen requirement.
  • The patient has been able to recover a great deal of independence with the combination of appropriate medical and surgical therapy for his bullous emphysema. He has begun walking for exercise and has been able to complete his own grocery shopping since the operation.

Discussion

With a multidisciplinary approach to managing this patient’s severe bullous emphysema, the patient was able to have significant recovery of lung function as well as improved quality of life.