Prospective Observation Study for Primary Spontaneous Pneumothorax: Incidence of and Risk Factors for Postoperative Neogenesis of Bullae

PURPOSE

Details of the neogenesis of bullae (NOB), which causes recurrent primary spontaneous pneumothorax (PSP) following bullectomy, have not been reported and risk factors for NOB remain unclear. We aimed to clarify the details of NOB.

METHODS

We conducted a prospective study using three computed tomography (CT) examinations performed 6, 12, and 24 months after bullectomy to identify the incidence of and risk factors for NOB. We enrolled 50 patients who underwent bullectomy for PSP.

RESULTS

After excluding 11 patients who canceled the postoperative CT examination at 6 months after bullectomy, only 39 patients were analyzed. The incidence of NOB at 6, 12, and 24 months after bullectomy was 38.5%, 55.2%, and 71.2%, respectively. The rate of NOB in the operated lung was almost 2 times higher than that in the contralateral nonoperative lung. Male sex, multiple bullae on preoperative CT, long stapling line (≥7 cm), deep stapling depth (≥1.5 cm), and heavier resected sample (≥5 g) were suggested to be risk factors for NOB.

CONCLUSIONS

We recognized a high incidence of postoperative NOB in PSP patients. Bullectomy itself seems to promote NOB. Postoperative NOB occurs frequently, especially in patients who require a large-volume lung resection with a long staple line.

Long-Term Follow-Up of Intralobar Bullae After Endobronchial Valve Treatment for Emphysema

Endoscopic lung volume reduction using unidirectional endobronchial valves is a new technique in the treatment of patients with severe emphysema. However, the movements of the thoracic structures after endobronchial valves insertion are still unpredictable We report the unusual outcome of six patients after valves insertion in the left upper lobe. They all developed a complete atelectasis of the target lobe, a pneumothorax and sequential genuine bullae in the treated left lung of unknown etiology. The chest CT scan prior to the valves insertion was unremarkable. Three patients developed an air–liquid level in the bullae the day before a bacterial infection of their left lower lobe. The three other patients had an uneventful spontaneous resolution of their bullae at long-term follow-up. Therefore, a conservative attitude should be followed in this particular setting.

Bronchoscopic Treatment of Giant Emphysematous Bullae with Endobronchial Silicone Plugs

Purpose

Surgical bullectomy is the standard treatment of giant emphysematous bulla (GEB). However, bronchoscopic treatment should be considered as an alternative approach for patients who are unfit for surgical treatment. The study aimed to evaluate the clinical efficacy of endobronchial occlusion for the treatment of GEB using silicone plugs.

Methods

This retrospective study recruited four patients with GEB who were unsuitable for surgery. Preoperative planning was performed using high-resolution computed tomography and a virtual bronchoscopic navigation system. Customized silicone plugs were then placed in the target airway via bronchoscopy to cause GEB regression and atelectasis.

Results

All procedures were completed successfully in four patients. Three months after the procedures, compared with baseline, increases in the mean forced expiratory volume in 1 s (from 1.20 L/s to 1.33 L/s), forced vital capacity (from 2.63 L to 2.90 L), diffusion lung capacity for carbon monoxide (from 29% to 41% of the predicted value) and 6-minute walking test (from 412 m to 474 m) were observed. Additionally, the mean total lung capacity (from 6.80 L to 6.35 L), residual volume (from 3.97 L to 3.52 L), and St. George’s Respiratory Questionnaire scores (from 67 to 45) were all lower than baseline data.

Conclusion

Our preliminary results demonstrated that the endobronchial placement of silicone plugs could be a low-cost, safe, and effective choice for the treatment of GEB in surgically unfit patients.

Expeditious Resolution of Giant Bullae with Endobronchial Valves and Percutaneous Catheter Insertion

As bullae contribute to decreased lung function in chronic obstructive pulmonary disease (COPD) patients, effective decompression of large bullae is important. Bronchoscopic lung volume reduction via endobronchial one-way valves is less invasive and has a lower mortality rate than lung volume reduction surgery. We report the case of a 48-year-old male who presented with giant bullae that were expeditiously resolved with endobronchial valves and percutaneous catheter insertion. Three days later, imaging revealed marked decreases in the extent of bullae and atelectasis of the contralateral lung without any complications, including air leakage or pneumothorax. Combination of endobronchial valves and percutaneous catheter insertion might be helpful to accelerate the release of large bullae and to achieve improved lung function and higher levels of physical activity in patients with COPD.

Computed tomography features of COVID-19 in children: A systematic review and meta-analysis

BACKGROUND

There are few reports on the chest computed tomography (CT) imaging features of children with coronavirus disease 2019 (COVID-19), and most reports involve small sample sizes.

OBJECTIVES

To systematically analyze the chest CT imaging features of children with COVID-19 and provide references for clinical practice.

DATA SOURCES

We searched PubMed, Web of Science, and Embase; data published by Johns Hopkins University; and Chinese databases CNKI, Wanfang, and Chongqing Weipu.

METHODS

Reports on chest CT imaging features of children with COVID-19 from January 1, 2020 to August 10, 2020, were analyzed retrospectively and a meta-analysis carried out using Stata12.0 software.

RESULTS

Thirty-seven articles (1747 children) were included in this study. The heterogeneity of meta-analysis results ranged from 0% to 90.5%. The overall rate of abnormal lung CT findings was 63.2% (95% confidence interval [CI]: 55.8%-70.6%), with a rate of 61.0% (95% CI: 50.8%-71.2%) in China and 67.8% (95% CI: 57.1%-78.4%) in the rest of the world in the subgroup analysis. The incidence of ground-glass opacities was 39.5% (95% CI: 30.7%-48.3%), multiple lung lobe lesions was 65.1% (95% CI: 55.1%-67.9%), and bilateral lung lesions was 61.5% (95% CI: 58.8%-72.2%). Other imaging features included nodules (25.7%), patchy shadows (36.8%), halo sign (24.8%), consolidation (24.1%), air bronchogram signs (11.2%), cord-like shadows (9.7%), crazy-paving pattern (6.1%), and pleural effusion (9.1%). Two articles reported 3 cases of white lung, another reported 2 cases of pneumothorax, and another 1 case of bullae.

CONCLUSIONS

The lung CT results of children with COVID-19 are usually normal or slightly atypical. The lung lesions of COVID-19 pediatric patients mostly involve both lungs or multiple lobes, and the common manifestations are patchy shadows, ground-glass opacities, consolidation, partial air bronchogram signs, nodules, and halo signs; white lung, pleural effusion, and paving stone signs are rare. Therefore, chest CT has limited value as a screening tool for children with COVID-19 and can only be used as an auxiliary assessment tool.

Hemoptysis and a Newly Formed Lung Bulla in a Case of Convalescent COVID-19 Pneumonia

Coronavirus disease 2019 (COVID-19) is a novel infectious disease affecting the general population worldwide. A fever and cough are the common clinical presentations of COVID-19. In most of these patients, computed tomography (CT) shows bilateral peripheral ground-glass opacities. We herein report a case of hemoptysis and lung bulla in the convalescent phase of COVID-19. Based on the clinical observations, alveolar destruction was likely associated with hemoptysis and bulla formation. Therefore, we suggest the follow-up of COVID-19 patients whose clinical parameters indicate alveolar damage, even after their symptoms improve.

Generalized pruritic blisters and bullous lesions

In a patient with no history of skin disease, a recent change provided a clue to his condition.

Secondary spontaneous pneumothorax and bullous lung disease in cannabis and tobacco smokers: A case-control study

Background

The notion that smoking cannabis may damage the respiratory tract has been introduced in recent years but there is still a paucity of studies on this subject. The aim of this study was to investigate the relationship between cannabis smoking, pneumothorax and bullous lung disease in a population of operated patients.

Methods and findings

We performed a retrospective study on patients operated on for spontaneous pneumothorax. Patients were divided into three groups according to their smoking habit: cannabis smokers, only-tobacco smokers and nonsmokers. Cannabis lifetime exposure was expressed in dose-years (1d/y = 1 gram of cannabis/week for one year). Clinical, radiological and perioperative variables were collected. The variables were analyzed to find associations with smoking habit. The impact of the amount of cannabis consumption was also investigated by ROC curves analysis.

Of 112 patients, 39 smoked cannabis, 23 smoked only tobacco and 50 were nonsmokers. Median cannabis consumption was 28 dose/years, median tobacco consumption was 6 pack/years. Cannabis smokers presented with more severe chronic respiratory symptoms and bullous lung disease and with a higher incidence of tension pneumothorax than both tobacco smokers and nonsmokers. Cannabis smokers also developed a larger pneumothorax, experienced prolonged postoperative stay and demonstrated a higher incidence of pneumothorax recurrence after the operation than nonsmokers did. The risk of occurrence of chronic respiratory symptoms and bullous lung disease in cannabis smokers was dose-related.

Conclusions

Cannabis smoking seems to increase the risk of suffering from respiratory complaints and can have detrimental effects on lung parenchyma, in a dose-dependent manner. Cannabis smoking also negatively affected the outcome of patients operated for spontaneous pneumothorax. A history of cannabis abuse should always be taken in patients with pneumothorax. There may be need for a specific treatment for pneumothorax in cannabis smokers.

Pulmonary barotrauma: assessment and investigation in divers

Decompression illness (DCI) is an uncommon problem but can be significant in terms of morbidity and, very rarely, mortality. The mechanisms of DCI are pulmonary barotrauma and decompression sickness due to inert gas supersaturation. After the initial management phase, identification of predisposing factors is important to help advise divers regarding future risk and avoidance. Here we present four cases of DCI where pulmonary barotrauma was the likely causative mechanism. We highlight the important features in assessment for pulmonary barotrauma and advising divers on the risk of a recurrence.

Unilateral single-port thoracoscopic surgery for bilateral pneumothorax or pulmonary bullae

BACKGROUND

Rapid rehabilitation surgery has become a widely accepted approach. Thoracic surgeons have attempted in many ways to make surgery less invasive. We combined tubeless technology, single-port technology and mediastinum approach for the treatment of simultaneous bilateral primary spontaneous pneumothorax(PSP)or pulmonary bullae. And we evaluated its therapeutic effect. This study aimed to investigate if tubeless single-port video-assisted thoracic surgery (Tubeless-SPVATS) via anterior mediastinum can be used as an alternative surgical treatment for bilateral lung diseases, especially for concurrent or contralateral recurrence PSP.

METHODS

From November 2014 to December 2016, 18 patients with simultaneous bilateral PSP or pulmonary bullae were treated with tubeless -SPVATS via anterior mediastinum. They were 13 males and 5 females with an average age of 20.2 ± 2.3 years (17 to 24 years). They all had preoperative chest CT and were diagnosed with simultaneous bilateral PSP or pulmonary bullae.

RESULTS

Fifteen patients underwent bilateral bullae resection with Tubeless-SPVATS via anterior mediastinum. Three patients underwent bilateral single-port video-assisted thoracic surgery. No thoracotomy was performed. No death and grade 3-4 mobidity were found. All the patients started eating 6 hours after surgery. The average operation time was 44.56±17.8min. The patients were discharged 3. 5±1.0 days postoperatively.

CONCLUSIONS

Tubeless-SPVATS via anterior mediastinum is a safe and feasible treatment for patients with simultaneous bilateral PSP or pulmonary bullae. However,contralateral thoracic is not explored fully enough. And when contralateral lung bullae are located near the hilum, endoscopic linear stapler cannot be easily used to conduct suture. Thus, the recurrence rate after performing Tubeless-SPVATS may be increased compared to performing thoracotomy. However, compared to bilateral thoracic surgery, this method reduced postoperative pain. And it took significantly less time than bilateral thoracic surgery. Thus, this method has some clinic value.

Microsurgical clipping and endovascular flow diversion of ruptured anterior circulation blood blister-like aneurysms

BACKGROUND

Detection and treatment of blister-like intracranial aneurysms as a source of subarachnoid hemorrhage (SAH) can be challenging. In the past the results of both microsurgical and endovascular treatment were difficult. We present our experience with the treatment of blister-like aneurysms in the acute phase of SAH using microsurgical clipping, endovascular parent vessel occlusion or flow diversion.

METHODS

A retrospective analysis of the cases of eight consecutive patients presenting in the acute phase after SAH from an intracranial blister aneurysm was performed. The demographic data of the patients, aneurysm characteristics, the clinical results of the treatment and the follow-up examinations were recorded. Procedural safety margins and aneurysm occlusion on follow-up digital subtraction angiography were the main interest of this evaluation.

RESULTS

Between January 2012 and November 2017 a total of eight ruptured blister aneurysms were treated in our center, six patients endovascularly. Five patients were treated in the acute phase of SAH, four by flow diversion. All endovascular procedures were feasible and no procedure-related complications were observed, especially no recurrent hemorrhage. In the first angiographic follow-up all blood blister-like aneurysms were completely occluded; two of the six patients treated by flow diverter implantation showed mild, transient intimal hyperplasia without clinical symptoms or the need for treatment.

CONCLUSIONS

Endovascular flow diversion is a viable option in the acute phase after SAH due to the rupture of a blister aneurysm. Implants with reduced thrombogenicity, obviating dual-platelet function inhibition, and flow diverters for vessel bifurcations would extend the indications for this treatment modality.

Use of ultrasonography for differentiation between bullae and pneumothorax

PURPOSE

Modern lung ultrasound (US) is mainly applied not only in critical care, emergency medicine, and trauma surgery, but also in pulmonary and internal medicine. In some cases, pneumothorax (PTX) distinguishes with bullous diseases. In this study, we aimed to discuss the success of US on detecting PTX versus bullae.

METHODS

We performed a prospective blinded study. Patients underwent thorax computed tomography (CT) if bullae or pneumothorax could not be differentiated from the chest radiography. An emergency medicine specialist trained in lung US and unaware of x-ray and CT findings performed US. All patients US performed from anterior and lateral wall.

RESULTS

Final study population included 81 patients. The sensitivity of the presence of pleural sliding in the diagnosis of bullae was 97.50% (86.84-99.94%), and specificity was 100.0% (91.4-100.0%).

CONCLUSION

In conclusion, direct visualisation of ultrasonographic pleural sliding can be a good tool for differentiating bullae and pneumothorax.

High-Frequency Ultrasound in Blistering Skin Diseases: A Useful Method for Differentiating Blister Locations

Bullous pemphigoid and pemphigus vulgaris, which belong to the group of subepidermal and intraepidermal bullae, respectively, are two potentially devastating blistering skin diseases. We used high-frequency ultrasound (US) in 3 cases of these diseases as prototypes to study the value of high-frequency US in discriminating blister locations. Our findings showed that high-frequency US has a strong correlation with histomorphometric findings because of its high resolution, and we hope that it will be helpful for differentiating blister locations.

Localized Hyperlucency in an Acutely Dyspneic Patient: Always a Pneumothorax?

BACKGROUND

Every emergency physician encounters acutely dyspneic patients with localized hyperlucency on chest x-ray study. Although most commonly due to pneumothorax, alternative diagnosis in selected cases with atypical features includes bullae and cystic lesions, especially in childhood. Presence of atypical radiology shouId alert an emergency physician to rule out any alternative diagnosis. Computed tomography is usually diagnostic in such cases and a double-wall sign on computed tomography aids to distinguish between pneumothorax and bullous disease.

CASE REPORT

A 60-year-old male presented with sudden increase in dyspnea and a localized hyperlucency on chest x-ray study. A review of his medical records and evaluation of atypical radiology by computed tomography revealed increase in size of bulla to be the cause for distress rather than a pneumothorax. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Every emergency physician encountering acutely dyspneic patients should be aware of these potential mimickers of pneumothorax and ways to distinguish them to avoid inadvertent tube thoracostomy and possible complications.

A new perspective on the treatment of complicated giant emphysematous bulla A case report

We report a case of 31 years-old female suffering from complicated giant bulla in the right upper pulmonary lobe. The patient was admitted to our hospital with a radiologic diagnosis of hydro - pneumothorax treated by chest tube in a first time, and later, for prolonged air leaks, by uniportal VATS with a single 4-cm skin incision. We have observed a giant ruptured bulla in right upper lobe, so we have performed bullectomy and mechanical pleurodesis. This case, in our knowledge, represents the first giant bulla resection performed by uniportal VATS.

KEY WORDS

Giant bulla, Giant bullous emphysema, Uniportal VATS.

[SEM visualization of corneal epithelium through lanthanoid staining based on Ca/Nd isomorphous substitution in Ca-dependent molecular systems]

Cumulative biomicroscopic evidence is usually sufficient for the diagnosis of recurrent corneal erosion or bullous keratopathy, however, exploration of the disease pathogenesis requires subcellular-level visualization of corneal structure. In the current study, lanthanoid staining and scanning electron microscopy were employed to visualize quite a number of structures responsible for epithelium organization. In particular, the study proves possible the use of Ca/Nd isomorphous substitution at Ca2+ sites of cytoadherence proteins for visualization of corresponding cellular structures.

AIM

To assess the value of information provided by scanning electron microscopy of corneal epithelium that involves lanthanoid staining based on the Ca/Nd isomorphous substitution in Ca-dependent molecular systems.

MATERIAL AND METHODS

Anterior corneal epithelial scrapes were obtained from patients with recurrent corneal erosion or bullous keratopathy and cadaver eyes with no signs of any ophthalmic disease. Samples were then studied under a scanning electron microscope (Zeiss EVO LS10, BSE, EP - 79 Pa, 20-28 kV, Ln-staining with the BioREE assay kit).

RESULTS

In all cases, lanthanoid staining of biopsy material provided high-contrast SEM images with well-recognizable structural and ultrastructural elements associated with Ca2+ sites of cytoadherence proteins.

CONCLUSION

Lanthanoid staining of biopsy material and subsequent SEM enabled detailed visualization of structural features of the corneal epithelium in various pathologies. Due to the Ca/Nd isomorphism we were able to evaluate structural position of the majority of protein molecules engaged in Ca-dependant processes and, consequently, in cytoadherence. Basing on the neodymium distribution within the basal membrane, we have described local effects of different substances on the lamina densa in the projection of basal layer cell borders that occur after unidirectional ultrafiltration. The results confirm the failure of the junctional adhesion complex in recurrent corneal erosion.

Quantitative assessment of emphysematous parenchyma using multidetector-row computed tomography in patients scheduled for endobronchial treatment with one-way valves†

OBJECTIVES

To investigate the role of volume quantitative assessment using multidetector-row computed tomography to select patients scheduled for endobronchial one-way valves treatment.

METHODS

Twenty-five consecutive patients (15 with heterogeneous emphysema and 10 with giant emphysematous bulla) undergoing endobronchial valves treatment were enrolled. All patients were studied pre- and postoperatively with standard pulmonary functional tests and quantitative volume assessment of target lobe and entire lung. Emphysematous parenchyma was obtained applying density thresholds of -1.024/-950 Hounsfield units. Among different subtype of patients, we evaluated: (i) the differences between preoperative versus postoperative data; (ii) the correlation between functional and volumetric quantification changes and (iii) the critical threshold value of volumetric quantification of the target lobe in close association with clinical effects.

RESULTS

Among heterogeneous emphysematous and giant emphysematous bulla patients, a significant improvement of flow-expiratory volume in 1 s (from 36.9 ± 15.3 to 43.9 ± 10.4; P = 0.01; and from 35.8 ± 6.0 to 47.5 ± 7.9; P < 0.0001, respectively); and of forced vital capacity (from 41.9 ± 5.9 to 47.3 ± 9.3; P = 0.0009 and from 40.7 ± 5.9 to 48.8 ± 4.9; P = 0.0002, respectively); and a significant reduction of residual volume (from 185 ± 14 to 157 ± 14.7; P = 0.005; and from 196 ± 13.5 to 137 ± 21; P < 0.0001, respectively) and of total lung volume (from 166.7 ± 13 to 137 ± 18 ; P = 0.0003, and from 169 ± 15 to 134 ± 18; P < 0.0001, respectively) were seen after treatment. The volumetric measurements showed a reduction of volume of the treated lobe among heterogeneous emphysematous patients (from 1448 ± 204 to 1076 ± 364; P = 0.0008); and in those with giant emphysematous bulla (from 1668 ± 140 to 864 ± 199; P < 0.0001). The entire lung and target lobe volume changes were inversely correlated with change in forced expiratory volume in 1 s in patients with heterogeneous emphysematous (r = -0.7; P = 0.0006; and r = -0.7; P = 0.0009, respectively) and giant emphysematous bulla (r = -0.8; P = 0.001; and r = -0.7; P = 0.009, respectively). Among patients with heterogenous emphysematous and giant emphysematous bulla, the value of sensitivity and specificity were 66.6 and 83%, respectively (for a volumetric qunatification >1.5239), and of 60 and 100%, respectively (for a volumetric qunatification >1.762).

CONCLUSIONS

Our study showed that the volumetric quantification adds further informations to the routine evaluation for optimizing the selection of patients scheduled for endobronchial valve treatment.

Can preoperative imaging studies accurately predict the occurrence of bullae or blebs? Correlation between preoperative radiological and intraoperative findings

BACKGROUND

Radiological findings of patients with primary spontaneous pneumothorax (PSP) undergoing surgery have not been well analyzed. The aim of this study was to evaluate the accuracy of imaging studies for predicting the presence of emphysema-like changes (ELCs) detectable during surgery.

METHODS

Ninety-three PSP patients who underwent surgery from September 2005 to October 2009 were included in the study. We analyzed preoperative chest radiographic and computed tomographic (CT) findings, and compared the findings with intraoperative detection of ELCs. Chest radiographic findings were analyzed by classifying the PSP size into three categories: small, moderate, and complete.

RESULTS

Seventy-six of the 93 patients (82%) had ELCs detected during surgery. The size of the PSP on a radiograph was significantly correlated with the presence of ELCs (p=0.0121). Preoperative CT revealed 64 of the 76 ELCs (sensitivity, 84%; specificity, 100%; accuracy, 87%). Twenty-nine patients without ELCs detected by preoperative CT were analyzed separately. In this group, a larger PSP size also increased the likelihood of ELCs being present (p=0.0049). Seven patients (8%) experienced a recurrence after surgery. No factor could significantly predict recurrence.

CONCLUSIONS

Chest CT analysis alone was associated with a false-negative rate of about 15% for ELCs. Combining the analysis of chest radiographic and CT findings could improve sensitivity.

[Bullectomy of giant bullae gave significant improvement of lung function]

A 49-year-old male smoker experienced acute deterioration of a progressive breathlessness. Spontaneous pneumothorax was diagnosed, and drainage was applied. Subsequent computed tomography revealed severe bilateral emphysematous bullae with right-sided predominance, and basal atelectasis. A lung function test showed severe obstructive disease. Right-sided bullectomy was performed through anterior thoracotomy with removal of giant bullae. Postoperative examination revealed markedly improved lung function and expansion of right-sided, previously consolidated lung tissue.

Giant pulmonary bulla with mediastinal shift in a 12 1/2 year old girl

Pulmonary bulla in children represent interesting entities. Mostly congenital bronchopulmonary foregut malformations and acquired cysts like pneumatocoeles have also been described. We present a case of a 12 1/2 years old girl with acute onset respiratory distress symptoms harbouring a huge pulmonary cyst exhibiting mass effects, resulting in mediastinal deviation. Following initial workup, cyst excision was carried out which revealed presence of fungal hyphae that was susceptible to Fluconazole therapy post operatively. The case points out how a pulmonary cyst can present in older children with symptoms of respiratory distress and mass effects.

[Foreign body which resembles concha bulloza in the middle meatus: a case report]

Diagnosis of foreign body in the nasal cavity may be difficult because it has a wide variety of presentations. Concha bullosa is defined as the pneumatization of the middle concha in various degrees. A 43-year-old female patient was admitted to our clinic with the complaint of breathing difficulty through her right nostril which had been going on for the last year. She had had some medical treatments previously in some different medical centers, there wasn't purulent discharge with unpleasant odour, bleeding and halitosis in the nose and there wasn't a history of a blow to the nose or a history of previous facial, nasal or dental surgery. In the computed tomography there was an image resembling concha bullosa. Transnasal endoscopic approach was used, under general anesthesia, in the patient, whose physical examination results, laboratory findings and allergy test results were normal. Endoscopic sinus surgery was performed including polypectomy, right uncinektomy and the foreign body was removed from the middle meatus using a forceps. No complications were observed in the follow-up control one month later.

[A 49 year old male with a giant pulmonary bulla--a case report and review of the literature]

A 49 year old previously healthy smoker was diagnosed with a giant bulla in his right lung, following a history of dry cough, repeated upper airway infections and increasing dyspnea for several years. Computed tomography (CT) confirmed the presence of a giant bulla in the right inferior lobe and several smaller bullae in the right superior lobe. The giant bulla was 17 cm in diameter, occupying more than half of the right hemithorax. On spirometry a moderate restrictive and a mild obstructive pattern was observed. Lung volume was measured with two different techniques, nitrogen washout and plethysmography, with volume of the bullae estimated at 2.9 L, similar to the 3.2 L determined by CT. The patient underwent thoracotomy, where the giant bulla together with the inferior lobe were removed with lobectomy and the small bullae in the superior lobe with wedge resection. Five months postoperatively the patient is in good health and is back at work. Postoperatively significant improvements in spirometry values and lung volume measurements have been documented. This case demonstrates that giant bullae can be successfully managed with surgical resection and their size can be determined by different techniques, including lung volume measurements and chest CT.

[Usefulness of computed tomography in determining risk of recurrence after a first episode of primary spontaneous pneumothorax: therapeutic implications]

OBJECTIVE

The main cause of primary spontaneous pneumothorax is the rupture of subpleural blebs or bullae. The presence of bullae may also lead to an increased risk of recurrence. The best way to detect them is by means of computed tomography (CT). Our objective in the present study was to determine whether bullae detected by CT represent an increased risk of recurrence after a first episode of primary spontaneous pneumothorax. We also evaluated therapeutic implications.

PATIENTS AND METHODS

We carried out a prospective study that included 55 patients (41 men and 14 women) with primary spontaneous pneumothorax. For all patients, the therapeutic recommendations of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) were followed. After resolution of the episode, a chest CT was performed and the presence, location, number, and size of bullae were evaluated. Subsequently, the number of recurrences in each group was evaluated.

RESULTS

The mean follow-up period was 30.7 months (95% confidence interval, 24-37 months). Twenty-six patients presented bullae, and 6 of these experienced recurrence. Of the 29 patients without bullae, 7 experienced recurrence. No association was found between the presence or absence of bullae and recurrence (P=.92). Bullae in the right lung led to more frequent recurrence of pneumothorax (P=.03). The number and size of the bullae had no significant influence on recurrence (P=.51).

CONCLUSIONS

The present study could not demonstrate that the presence, size, or number of bullae on CT scans has any influence on recurrence rate. We cannot recommend surgery after a first episode of primary spontaneous pneumothorax based on the presence of bullae on the CT scan.

CT findings for blebs and bullae in children with spontaneous pneumothorax and comparison with findings in normal age-matched controls

BACKGROUND

Spontaneous pneumothorax (SPTX) is a relatively common condition. In patients with SPTX, CT has been advocated to identify blebs and bullae (BB) to help in management planning.

PURPOSE

The study was designed to assess our experience with CT evaluation for underlying BB in children with SPTX as compared to normal controls.

MATERIALS AND METHODS

Forty-three children (mean age 16 years, range 13-19 years) with 50 SPTX events with both chest radiographs and CT scans were reviewed. CT findings were compared with those seen in 29 age- and gender-matched controls without SPTX. The parameters evaluated included size, number, location, and ipsi-/contralateral BB; apical lines; and surgical correlation.

RESULTS

In the study group, BB were identified in 14 imaged events (28%) (size 2.5-45 mm, one to six BB) with contralateral BB in 11 of the 14 (78.6%). All BB were confined to the apices. BB were sometimes difficult to differentiate from "apical lines"--a suspected normal variant seen in 28 imaged events (56%). Of blebs seen at surgery, 59% were identified on CT, and there were no false-positive CT findings. In the control group, no BB were identified but "apical lines" were seen in eight children (28%).

CONCLUSION

BB were seen by CT in 28% of imaged events in children with SPTX and were always confined to the apices. When present, BB were commonly bilateral (78.6%). BB should not be confused with "apical lines," which were not only seen in 56% of imaged events in the SPTX group but also in 28% of the normal controls.

Transbronchial decompression of emphysematous bullae: a new therapeutic approach

Bullae are common accompaniments of chronic obstructive pulmonary disease especially emphysema. They contribute to increased lung volume and worsen the mechanical disadvantage of the inspiratory muscles by increasing the residual volume (RV) and RV/total lung capacity ratio. Thus effective decompression of a large bulla or bullae is thus important to improve the lung function of affected patients and also to provide symptomatic relief. Surgery and thoracoscopy are two commonly performed procedures used to treat bullae. Although bronchoscopic lung volume reduction has been successfully accomplished for emphysema, isolated decompression of bullae bronchoscopically has not been tried to date. A large emphysematous bulla in the left lower lobe of a surgically unfit patient was bronchoscopically punctured with a transbronchial aspiration needle; the position of the needle inside the bulla was confirmed and the air from the bulla was aspirated slowly to allow collapse. Finally, some autologous blood was instilled into the bulla before the needle was withdrawn. The patient had immediate and sustained symptomatic relief with significant improvement in lung function. Bronchoscopic transbronchial decompression of emphysematous bullae can be an effective therapeutic option and warrants further investigation.

Ultrasound biomicroscopy study of direct and oblique 25-gauge vitrectomy sclerotomies

PURPOSE

To study 25-gauge sclerotomy healing process in vivo with ultrasound biomicroscopy (UBM) in direct and oblique incisions.

DESIGN

Prospective interventional case series report.

METHODS

At our institution, we performed UBM studies on 53 sclerotomies during the first 30 days after 25-gauge vitrectomy, looking for conjunctival bleb development, sclerotomy healing signs, and vitreous incarceration in the wound.

RESULTS

Echographical healing signs were completed in 77% of patients by day 15 with no differences between direct and oblique sclerotomies. By day 30, all but one sclerotomy were closed. Conjunctival blebs developed over 64% of direct sclerotomies, and 25% of oblique (P = .0059), but all resolved spontaneously by day 15. Vitreous incarceration appeared in 72% of sclerotomies.

CONCLUSIONS

Twenty-five gauge sclerotomies heal by day 15 in most cases with no difference between direct and oblique sclerotomy construction. Conjunctival blebs developed more frequently over direct than oblique sclerotomies.

Use of Indocyanine Green During Excision of an Overhanging Filtering Bleb

BACKGROUND

We report the use of an indocyanine green (ICG) injection during the safe removal of an overhanging filtering bleb after trabeculectomy.

CASE

A 63-year-old man with a history of trabeculectomy 5 years previously in his left eye complained of foreign body sensation in this eye and decreased vision from induced astigmatism. Slit-lamp examination revealed an expanding overhanging filtering bleb on the cornea.

OBSERVATIONS

With a 30-G needle, 0.25% ICG was injected into the overhanging bleb. Use of ICG visualization of the inner space of the overhanging filtering bleb provided visualization of the border with the original bleb, allowing for safe excision of the overhanging filtering bleb without injury to the thin surface of the original bleb.

CONCLUSION

Injection of ICG into an overhanging filtering bleb during excision can be useful in the prevention of damage to the original bleb.

Successful Treatment of a Giant Emphysematous Bulla by Bronchoscopic Placement of Endobronchial Valves

Surgical bullectomy is the treatment of choice for giant emphysematous bulla. We report a case of successful nonsurgical treatment with bronchoscopic placement of one-way endobronchial valves that are currently under investigation for the treatment of end-stage emphysema. In patients who are poor surgical candidates, this noninvasive bronchoscopic treatment may represent a valuable alternative.

Cutaneous thermal injury after endovenous laser ablation of the great saphenous vein

Herein a case of cutaneous thermal injury in the leg of a patient who underwent endovenous laser (EVL) ablation of an incompetent great saphenous vein (GSV) is reported. Follow-up ultrasonography (US) of the site of skin burn showed that the burn was directly over thrombosed superficial tributaries originating from the GSV, but medial to the treated GSV. At the level of skin burn, the thrombosed GSV was 22 mm deep, but the tributaries were 1 mm deep. In addition, US showed echogenic fat surrounding and conforming to the superficial thrombosed tributaries. Based on the clinical scenario and follow-up US findings, it was concluded that the cutaneous thermal injury resulted from heated blood traveling from the 22-mm-deep GSV to the superficial tributaries directly beneath the site of skin burn.

Upper eyelid extension of a filtering bleb following glaucoma shunt surgery

The authors describe a case of a filtering bleb that extended into the eyelid of a 71-year-old man following glaucoma surgery with a shunt implant. The patient presented with a left upper eyelid mass and had ocular surface and mechanical sequelae. Computed tomography scan demonstrated a fistula between the original filtering tract and the eyelid, creating an inadvertent filtering bleb. Cytology revealed fluid consistent with aqueous humor. Intraocular pressure remained normal and symptoms improved with conservative management. The patient deferred any surgical revision. Glaucoma tube shunts may lead to ocular and rare orbital complications from inadvertent bleb extension, as seen in this case.

Filtering blebs imaging by optical coherence tomography

PURPOSE

To assess the ability of standard optical coherence tomography to visualize filtering blebs after glaucoma surgery.

METHODS

A prospective interventional case series was conducted in a private practice. Twenty-nine eyes of 24 patients (21 with good, 2 with fair and 6 with poor intraocular pressure [IOP] control) were investigated. After the focus was manually adjusted on the conjunctiva, blebs were scanned perpendicularly to the limbus.

RESULTS

Hyporeflective fluid-filled spaces were detected in 19 out of the 21 eyes with good IOP. Within this group, blebs were classified into three different categories according to their optical coherence tomography pattern: type A (featuring a thick wall and a single large fluid-filled space), type B (featuring a thin wall and multiple large fluid-filled spaces) and type C (featuring multiple, irregular and flattened fluid-filled spaces). Fluid-filled spaces were not observed in three out of the six eyes with poor IOP control. Trabeculectomy without antimetabolites was associated with type A blebs (P = 0.015, Fisher's exact test), mitomycin-C trabeculectomy with type B blebs (P = 0.0025) and mitomycin-C phacotrabeculectomy with type C blebs (P = 0.0173).

CONCLUSIONS

Although it was not developed to evaluate the anterior segment of the eye, standard optical coherence tomography can visualize filtering blebs and reveal interesting details of their morphology. Clinicians using optical coherence tomography to diagnose glaucoma can take advantage of this ability of the instrument to obtain more information about their patients in the postoperative course of trabeculectomy and phacotrabeculectomy.

Massive concha bullosa pyocele with orbital extention

Concha bullosa is the most common anatomic variant of the middle turbinate. It remains usually asymptomatic. Pyocele occurs when concha bullosa becomes infected. In the formation of a pyocele, middle turbinate may become expanded and occupy the surrounding structures with local bone destruction. Direct extension of mass from the nose into the orbit may occur, because the orbital contents are separated from the ethmoidal labyrinth only by the thin lamina papyracea. We report a case of concha bullosa pyocele with orbital extension. Orbital involvement is also associated with ocular functional loss. In this case, ocular motion and vision remained normal despite of the presence of orbital extension for 2 years.