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• When compression of the adjacent lung by the giant bullae is thought to contribute to the patient's breathing difficulties.
• In patients with severe emphysema who develop hemoptysis (spitting-up blood from the lungs).
• If the giant bullae repeatedly cause a pneumothorax (collapsed lung).
• If the presence of the giant bullae results in the patient developing repeated lung infections.

In many cases, it is not possible to surgically remove the giant bullae and, therefore, careful patient selection is critical to ensure a successful outcome with a bullectomy.

Lung-Volume Reduction Surgery

Lung-volume reduction surgery (LVRS) is a surgical procedure during which the surgeron removes about 25% of the diseased upper lobe of the lung so that the remaining healthier areas can function better. This procedure is usually reserved for patients with severe emphysema and has been shown to improve breathing, lung capacity, and quality of life.

Lung-volume reduction surgery may be performed by one of the following two surgical techniques:

• Midline sternotomy - open chest surgery that enables the surgeon to visualize the lungs directly and remove the diseased areas.

• Video-assisted thoracoscopy (VATS) - this is a less-invasive type of surgery whereby the surgeon creates a series of small incisions in the lateral chest wall and then surgically removes the diseased areas of the lung using a laser under video-assisted guidance.

The effectiveness of LVRS was demonstrated by a large randomized, controlled clinical trial known as the National Emphysema Treatment Trial the results of which were published in the May 22, 2003 issue of the New England Journal of Medicine. The study found that, compared to patients who were managed by medical therapy, patients with severe emphysema who underwent LVRS had:

• Improvement in lung function
• Improvement in the 6-minute walk distance test
• Improvement in exercise capacity as determined by peddling on a stationary bicyle
• Improvement in dyspnea (shortness of breath)

In general, patients who are most ideally suited for LVRS are people with severe emphysema of the upper lobe of the lung who also have impaired exercise tolerance and the most successful outcomes have been reported for patients with these characteristics.

Lung Transplantation

Lung transplantation is usually considered as a treatment of last resort for patients with severe emphysema. The major factor limiting the widespread use of lung transplantation is the shortage of lung donors. Once a suitable donor has been found, lung transplantation may be undertaken with replacement of either a single lung or both lungs. Studies have shown that lung transplantation for severe emphysema results in improved lung function, better exercise capacity, and an overall improvement in quality of life. Survival rates for patients undergoing lung transplantation of severe emphysema have been reported to be as follows:

• One-year = 90%
• Between one to two years = 65% to 90%
• Five-years = 41% to 53%

In general, patients with severe emphysema may be considered for lung transplantation if they are under age 65 and are otherwise healthy without any other serious underlying medical conditions.