LETTERS
A Case of Giant Bulla Successfully Treated by Bronchoscopic Lung Volume Reduction Therapy To the Editor: There are various definitions of giant bullae: a large bulla occupying at least one third of a hemithorax, or at least one half, or >10 cm in diameter.1 Giant bullae do not contribute to gas exchange, as occupying a large space within the thorax results in increased work of breathing and eventually exercise limitation and dyspnea.2,3 The standard management of a giant bulla is not yet established.1 Patients with giant bulla are mostly heavy smokers, elderly, and complicated with chronic obstructive pulmonary disease. Therefore, it is common that the patients are not ideal candidates for surgical intervention. Recently, the efficacy of a variety of bronchoscopic
TO THE
EDITOR
lung volume reduction therapies (BVRT), such as endobronchial blockers, airway bypass stents, endobronchial valves, thermal vapor ablation, and airway implants/coils has been reported in the treatment of inoperable patients with giant bullae.4 However, none described the usefulness of ultrathin bronchoscope in the management of a giant bulla. We report the first case of giant bulla successfully treated by BVRT using ultrathin bronchoscope. A 68-year-old man presented with progression of dyspnea. He had had a giant bulla of 23.5 cm in diameter, occupying half of his left hemithorax for several years. He was considered a poor candidate for surgical resection due to multiple medical comorbidities. An ultrathin bronchoscope was inserted through the trachea into the bronchus leading to the bulla, in an effort to reduce the hyperinflation. Wall suction was applied for duration of 5 minutes once the scope was positioned within the bullae as confirmed by fluoroscopy. There
was no immediate change in the size of the bulla, or the patient’s overall clinical status or pulmonary functions. There were no complications either. However, the bulla became smaller (Fig. 1) and the pulmonary functions showed significant improvement 2 months after completion of BVRT, as shown in Table 1. During observation for these 4 years, his condition has remained stable. There has been no other therapeutic maneuver carried out during this period. This clinical course is reasonable according to the Ingenito article demonstrating that 4 to 8 weeks are needed for the pathologic improvements of alveolar and collateral in the animal model. On the basis of this it is reasonable that the improvement of pulmonary functions and size of bulla were observed at 4 months after BVRT in our case.5 We could hypothesize that partial contraction of collateral vessels by BVRT resulted in promoting localized fibroblast proliferation, collagen synthesis, and scar formation in the
FIGURE 1. A, Chest x-ray reveals the giant bulla in the left lung before the procedure. B, Endobronchial scope inserted into the giant bulla. C, The giant bulla diminished after the procedure. Disclosure: There is no conflict of interest or other disclosures.
J Bronchol Intervent Pulmonol
Volume 21, Number 1, January 2014
www.bronchology.com |
101
Letters to the Editor
J Bronchol Intervent Pulmonol
TABLE 1. Improvement Before and After the Volume Reduction Treatment Variables
BW (kg) VC (L) VC (%) FVC (L) FEV1.0 (L) FEV1.0% %FEV1.0 V25/50 (%)
Before the Therapy
4 mo After the Therapy
2 y After the Therapy
49 2.1 65.4 2.06 0.68 33.0 30.0 1.77
51 2.94 92.2 2.96 1.15 38.85 51.6 2.67
54 3.72 118.1 3.59 1.59 44.29 73.3 2.75
%FEV1.0 indicates percent predicted forced expiratory volume in 1 s; BW, body weight; FEV1.0%, forced expiratory volume percent in 1 s; FEV1.0, forced expiratory volume in 1 s; FVC, forced vital capacity; VC, vital capacity.
targeted territory without causing acute hypoxemia, and sterile abscess formation. Although BVRT for giant bulla still remains experimental and its benefit unproven, there is a potential benefit and it should be studied as a prospective trial or a compassionate therapy in selected patient. The procedure is safe, simple, and relatively inexpensive and has sustained benefits. In conclusion, we report a case of giant bullae in a patient who experienced significant and sustained subjective as well as objective improvement after bronchoscopic suction. The underlying pathophysiological mechanism remains to be studied. Nobuhiro Asai, MD Yoshihiro Ohkuni, MD Norihiro Kaneko, MD, PhD Department of Pulmonology Kameda Medical Center Chiba, Japan
ACKNOWLEDGMENT The authors thank John Wocher, Executive Vice President and Director, International Affairs/International Patient Services, Kameda Medical Center (Japan), for the diligent and thorough critical reading of the manuscript.
REFERENCES 1. Asai N, Ohkuni Y, Matsunuma R, et al. Infectious giant bulla
102 | www.bronchology.com
2. 3.
4. 5.
associated with lung cancer. J Bras Pneumol. 2011;3:404–408. Kitahara T. Vanishing lung. Nihon Rinsho Meneki Gakkai Kaishi. 1994;1(suppl):496. Harada K, Soyama N, Izumi K, et al. Pathophysiology and surgical therapy for giant bulla. Nihon Kyoubugeka Gakkai Zasshi. 1981; 29:661–663. Ernst A, Anantham D. Bronchoscopic lung volume reduction. Pulm Med. 2011;2011:610802. Ingenito EP, Berger RL, Henderson EA, et al. Bronchoscopic lung volume reduction using tissue engineering principles. Am J Respir Crit Care Med. 2003;167:771–778.
Broncholithiasis An Uncommon Cause of Chronic Cough To the Editor: Broncholiths are calcified material within a bronchial tree. Patients with broncholiths might remain asymptomatic or develop a variety of pulmonary symptom including cough, dyspnea, chest pain, and hemoptysis. However, the diagnosis is often overlooked as physicians are generally not familiar with Disclosure: There is no conflict of interest or other disclosures.
Volume 21, Number 1, January 2014
the condition, and chest x-ray often fails to demonstrate the characteristic calcification. Bronchoscopy can be diagnostic and sometimes provide a definitive treatment in uncomplicated cases with easily movable broncholiths. An otherwise healthy 64year-old woman presented with a 4-week history of nonproductive cough accompanied by dyspnea on exertion. She denied any history of fever, night sweat, weight loss, or aspiration. Physical examination was remarkable for decreased breath sound in the right upper lung. Chest x-ray revealed atelectasis in the right upper lobe (RUL) (Fig. 1A) and subsequent computed tomography of chest demonstrated a small soft-tissue mass with peripheral highdensity foci in the RUL bronchus (Fig. 1B). The patient underwent bronchoscopy which revealed a yellow mass in the RUL bronchus (Fig. 1C). The mass was easily removed with forceps and was identified as calcified degenerated vegetable matter by microscopic examination (Fig. 1D). The patient’s symptoms resolved after bronchoscopy and repeated chest x-ray showed resolution of the atelectasis. Broncholithiasis is an unusual condition characterized by the presence of calcified or ossified material within the bronchial lumen with an incidence of only 0.1% to 0.2% of all lung diseases.1 A broncholith is usually formed by compression and erosion of calcified peribronchial lymph nodes, as a result of respiratory movement and cardiac pulsation, into the lumen of the bronchus. These calcified lymph nodes are usually a result of chronic granulomatous infection with r
2014 Lippincott Williams & Wilkins
A Case of Giant Bulla Successfully Treated by Bronchoscopic Lung Volume Reduction Therapy To the Editor: There are various definitions of giant bullae: a large bulla occupying at least one third of a hemithorax, or at least one half, or >10 cm in diameter.1 Giant bullae do not contribute to gas exchange, as occupying a large space within the thorax results in increased work of breathing and eventually exercise limitation and dyspnea.2,3 The standard management of a giant bulla is not yet established.1 Patients with giant bulla are mostly heavy smokers, elderly, and complicated with chronic obstructive pulmonary disease. Therefore, it is common that the patients are not ideal candidates for surgical intervention. Recently, the efficacy of a variety of bronchoscopic
TO THE
EDITOR
lung volume reduction therapies (BVRT), such as endobronchial blockers, airway bypass stents, endobronchial valves, thermal vapor ablation, and airway implants/coils has been reported in the treatment of inoperable patients with giant bullae.4 However, none described the usefulness of ultrathin bronchoscope in the management of a giant bulla. We report the first case of giant bulla successfully treated by BVRT using ultrathin bronchoscope. A 68-year-old man presented with progression of dyspnea. He had had a giant bulla of 23.5 cm in diameter, occupying half of his left hemithorax for several years. He was considered a poor candidate for surgical resection due to multiple medical comorbidities. An ultrathin bronchoscope was inserted through the trachea into the bronchus leading to the bulla, in an effort to reduce the hyperinflation. Wall suction was applied for duration of 5 minutes once the scope was positioned within the bullae as confirmed by fluoroscopy. There
was no immediate change in the size of the bulla, or the patient’s overall clinical status or pulmonary functions. There were no complications either. However, the bulla became smaller (Fig. 1) and the pulmonary functions showed significant improvement 2 months after completion of BVRT, as shown in Table 1. During observation for these 4 years, his condition has remained stable. There has been no other therapeutic maneuver carried out during this period. This clinical course is reasonable according to the Ingenito article demonstrating that 4 to 8 weeks are needed for the pathologic improvements of alveolar and collateral in the animal model. On the basis of this it is reasonable that the improvement of pulmonary functions and size of bulla were observed at 4 months after BVRT in our case.5 We could hypothesize that partial contraction of collateral vessels by BVRT resulted in promoting localized fibroblast proliferation, collagen synthesis, and scar formation in the
FIGURE 1. A, Chest x-ray reveals the giant bulla in the left lung before the procedure. B, Endobronchial scope inserted into the giant bulla. C, The giant bulla diminished after the procedure. Disclosure: There is no conflict of interest or other disclosures.
J Bronchol Intervent Pulmonol
Volume 21, Number 1, January 2014
www.bronchology.com |
101
Letters to the Editor
J Bronchol Intervent Pulmonol
TABLE 1. Improvement Before and After the Volume Reduction Treatment Variables
BW (kg) VC (L) VC (%) FVC (L) FEV1.0 (L) FEV1.0% %FEV1.0 V25/50 (%)
Before the Therapy
4 mo After the Therapy
2 y After the Therapy
49 2.1 65.4 2.06 0.68 33.0 30.0 1.77
51 2.94 92.2 2.96 1.15 38.85 51.6 2.67
54 3.72 118.1 3.59 1.59 44.29 73.3 2.75
%FEV1.0 indicates percent predicted forced expiratory volume in 1 s; BW, body weight; FEV1.0%, forced expiratory volume percent in 1 s; FEV1.0, forced expiratory volume in 1 s; FVC, forced vital capacity; VC, vital capacity.
targeted territory without causing acute hypoxemia, and sterile abscess formation. Although BVRT for giant bulla still remains experimental and its benefit unproven, there is a potential benefit and it should be studied as a prospective trial or a compassionate therapy in selected patient. The procedure is safe, simple, and relatively inexpensive and has sustained benefits. In conclusion, we report a case of giant bullae in a patient who experienced significant and sustained subjective as well as objective improvement after bronchoscopic suction. The underlying pathophysiological mechanism remains to be studied. Nobuhiro Asai, MD Yoshihiro Ohkuni, MD Norihiro Kaneko, MD, PhD Department of Pulmonology Kameda Medical Center Chiba, Japan
ACKNOWLEDGMENT The authors thank John Wocher, Executive Vice President and Director, International Affairs/International Patient Services, Kameda Medical Center (Japan), for the diligent and thorough critical reading of the manuscript.
REFERENCES 1. Asai N, Ohkuni Y, Matsunuma R, et al. Infectious giant bulla
102 | www.bronchology.com
2. 3.
4. 5.
associated with lung cancer. J Bras Pneumol. 2011;3:404–408. Kitahara T. Vanishing lung. Nihon Rinsho Meneki Gakkai Kaishi. 1994;1(suppl):496. Harada K, Soyama N, Izumi K, et al. Pathophysiology and surgical therapy for giant bulla. Nihon Kyoubugeka Gakkai Zasshi. 1981; 29:661–663. Ernst A, Anantham D. Bronchoscopic lung volume reduction. Pulm Med. 2011;2011:610802. Ingenito EP, Berger RL, Henderson EA, et al. Bronchoscopic lung volume reduction using tissue engineering principles. Am J Respir Crit Care Med. 2003;167:771–778.
Broncholithiasis An Uncommon Cause of Chronic Cough To the Editor: Broncholiths are calcified material within a bronchial tree. Patients with broncholiths might remain asymptomatic or develop a variety of pulmonary symptom including cough, dyspnea, chest pain, and hemoptysis. However, the diagnosis is often overlooked as physicians are generally not familiar with Disclosure: There is no conflict of interest or other disclosures.
Volume 21, Number 1, January 2014
the condition, and chest x-ray often fails to demonstrate the characteristic calcification. Bronchoscopy can be diagnostic and sometimes provide a definitive treatment in uncomplicated cases with easily movable broncholiths. An otherwise healthy 64year-old woman presented with a 4-week history of nonproductive cough accompanied by dyspnea on exertion. She denied any history of fever, night sweat, weight loss, or aspiration. Physical examination was remarkable for decreased breath sound in the right upper lung. Chest x-ray revealed atelectasis in the right upper lobe (RUL) (Fig. 1A) and subsequent computed tomography of chest demonstrated a small soft-tissue mass with peripheral highdensity foci in the RUL bronchus (Fig. 1B). The patient underwent bronchoscopy which revealed a yellow mass in the RUL bronchus (Fig. 1C). The mass was easily removed with forceps and was identified as calcified degenerated vegetable matter by microscopic examination (Fig. 1D). The patient’s symptoms resolved after bronchoscopy and repeated chest x-ray showed resolution of the atelectasis. Broncholithiasis is an unusual condition characterized by the presence of calcified or ossified material within the bronchial lumen with an incidence of only 0.1% to 0.2% of all lung diseases.1 A broncholith is usually formed by compression and erosion of calcified peribronchial lymph nodes, as a result of respiratory movement and cardiac pulsation, into the lumen of the bronchus. These calcified lymph nodes are usually a result of chronic granulomatous infection with r
2014 Lippincott Williams & Wilkins
