Evaluation of Pulmonary Function Tests before and after of Bullodesis as A New and Less Invasive Procedure for Treating of Patients with Pulmonary Giant Bullae Who Admitted to Rasool Hospital from April 2020 till 2021; Series Report

Chronic pulmonary obstructive disease (COPD) is one of the most frequent diseases of respiratory system which is demonstrated with irreversible destruction of elastic fibers of the lungs. It has been estimated that COPD would affect one fourth of above 40 years of old population (1). Giant pulmonary bullae is one the most frequent consequences of COPD which is occurred due to elastic and alveolar destruction and air trapping. This condition would lead to serious dysfunction of the lungs (2).  Nowadays Surgical treatments are the principle methods for treatment of giant pulmonary bullae, but surgery always accompanies with adverse events and additional costs and hospitalization (4). Developing new non-surgical methods with non-inferiority efficacy for pulmonary giant bullae would be crucial to minimize side effects and costs and hospitalization (7). In current series report study, we describe results of three patients with giant bullae who have been treated with a new non-surgical method.

Cases report:

Case number 1: A 64 years old heavy smoker (40 pack / year) male patients who suffer from COPD and pulmonary emphysema for more than 12 years. The patient has been under treatment of inhaler corticosteroids, beta agonists, and anti-cholinergic sprays and he did not respond to the medical therapies. Silicon valves also were installed in emphysematous segments during the last years but it had no considerable effect. In last refer of the patient to the respiratory disease clinic of Rasul Akram hospital, a giant pulmonary bulla in superior lobe of left lung was seen in chest radiography. The patient became candidate for surgery but because of that the patient did not consent to the surgery, he became eligible for the treatment method of the current study. Before intervention, basic parameters including: spirometry, 6 minutes walk test (6MWT), and chest radiography were recorded. After that, a silicone valve was installed in the entrance of affected segment and next day, the giant bulla was decompressed by a catheter under the guidance of CT scan. Next day, bullodesis was done using Talc powder. After 48 hours, the catheter was removed and the patient was discharged with well condition. The patients did not demonstrate any adverse events during and after the procedure. Follow-up was done after 6 months and the results represented that the size of the bulla has considerably decreased and he has significant improvement in spirometry parameters and 6MWT.Case number 2: A 74 years old heavy smoker (30 pack / year) male patients who suffer from COPD and pulmonary emphysema for more than 10 years. The patient has been under treatment of inhaler corticosteroids, beta agonists, and anti-cholinergic sprays and he did not respond to the medical therapies. Silicon valves also were installed in emphysematous segments during the last years but it had no considerable effect. In last refer of the patient to the respiratory disease clinic of Rasul Akram hospital, a giant pulmonary bulla was founded in chest radiography in inferior lobe of right lung. The patient became candidate for surgery but because of that the patient did not consent to the surgery, he became eligible for the treatment method of the current study. Before intervention, basic parameters including: spirometry, 6 minutes walk test (6MWT), and chest radiography were recorded. After that, a silicone valve was installed in the entrance of affected segment and next day, the giant bulla was decompressed by a catheter under the guidance of CT scan. Next day, bullodesis was done using Talc powder. After 48 hours, the catheter was removed and the patient was discharged with well condition. The patients did not demonstrate any adverse events during and after the procedure. Follow-up was done after 6 months and the results represented that the size of the bulla has considerably decreased and he has significant improvement in spirometry parameters and 6MWT.Case number 3: A 35 years old female patient with no past medical history who referred to a clinic with complaint of sudden dyspnea and chest pain. The patients was diagnosed with spontaneous pneumothorax based on chest radiography and chest tube was installed for treatment. The patient was discharged with well condition, but one week later she demonstrated the symptoms again. This time she referred to respiratory disease clinic of Rasul Akram hospital and a giant bulla was found in chest radiography in middle and upper lobe of the right lung. The patient became candidate for surgery but because of that the patient did not consent to the surgery, she became eligible for the treatment method of the current study. Before intervention, basic parameters including: spirometry, 6 minutes walk test (6MWT), and chest radiography were recorded. After that, a silicone valve was installed in the entrance of affected segments and next day, the giant bulla was decompressed by a catheter under the guidance of CT scan. Next day, bullodesis was done using Talc powder. After 48 hours, the catheter was removed and the patient was discharged with well condition. The patients did not demonstrate any adverse events during and after the procedure. Follow-up was done after 6 months and the results represented that the size of the bulla has considerably decreased and she has improvement in spirometry parameters and 6MWT but not as great as the previous two patients.

non-surgical treatment options should be developed for treatment of pulmonary bulla because of lower rate of adverse events and hospitalization and lower costs (8). Bullodesis is one the suggested non-surgical methods which few studies have assessed the efficacy (19). the current study a new non-surgical method based on bulla decompression and following bullodesis with Talc powder was evaluated in three patients with pulmonary giant bullae. The results of the study demonstrate that this method would be non-inferior in efficiency with lower risk for adverse events in comparison with surgery. The improvements of clinical parameters were more prominent in the two patients with COPD. Designing and conducting clinical trials is suggested for establishment of more precise and powerful evidences.