Thorax 1988;43:998-1002

Intracavity drainage for bullous, emphysematous lungdisease: experience with the Brompton techniqueG E VENN, P R WILLIAMS, P GOLDSTRAW

From Brompton Hospital, London

ABSTRACT Twenty two operations have been performed on 20 patients for the relief of symptomsdue to bullous lung disease. Open intubation drainage of the bullae was used in all patients, thetechnique initially devised by Monaldi for the treatment of intrapulmonary tuberculous abscesseshaving been modified. Three patients died after surgery. Mortality was associated with lowpreoperative FEV1 (median 350 ml) and higher preoperative arterial carbon dioxide tension (Paco2)(median 7-8 kPa). Symptomatic improvement was reported by 16 of the remaining 17 patients andwas maintained over a median follow up period of 1-6 years. This was accompanied by objectiveimprovement in lung function with a 22% median improvement in FEVy, an 11% median reductionin total lung capacity, and a 26% median reduction in residual volume. In one patient symptoms were

unchanged after surgery. The technique described provides a simple method for decompressingbullae by means ofa minimally invasive surgical procedure. It also allows for the treatment offurtherbullae at a later date by closed intubation under local anaesthetic. It has proved a suitable approachfor all but those with the poorest lung function and is now our treatment of choice.

Introduction

Dominant bullae are well recognised in associationwith advanced and generalised emphysematous lungdisease. Various surgical techniques have beendeveloped in an attempt to excise the dominant bullae,to allow any underlying compressed and potentiallyfunctional lung tissue to re-expand. Techniques thathave been used include simple ligation, plication, andsegmental or lobar resection, though none of these isideal. Many patients benefit from surgery, sometimesdramatically; but it has sometimes proved difficult toequate symptomatic improvement with improvementin respiratory function.

Patients referred as potential candidates for surgeryfrequently have substantial respiratory impairmentand surgery is therefore not without risk, from sputumretention, pneumonia, and respiratory failure.Mortality in some series has been as high as 26%.'

Intracavity intubation and drainage, initiallyintroduced in 1938 by Monaldi to drain pulmonary

Address for reprint requests: Mr P Goldstraw, Department ofThoracic Surgery, Brompton Hospital, London SW3.

Accepted 26 September 1988

cavities after tuberculous infection,2 was later adaptedfor the treatment of any localised pyogenic intra-pulmonary abscess34 and Monaldi's personal series ofcases exceeded 2000.5 The technique has more recentlybeen advocated for the treatment of bullousemphysema."5

Techniques using intracavity intubation havepotential advantages for the treatment of bullousdisease. No lung tissue is removed, and this is impor-tant for patients with generalised and progressive lungdisease; moreover, emphysematous lung tissue isdifficult to suture. In addition, the limited incision andbrief anaesthesia needed for the procedure are bettertolerated by patients with poor lung function.The technique described was originally devised for

patients whose lung function was thought too poor toallow major thoracotomy and formal excision of thebullae. We have been anxious to explore the limits ofthe technique and have therefore treated "all comers."

Methods

PATIENTS AND INVESTIGATIONSTwenty two operations have been performed on 20patients, of whom 12 were male and eight female; themedian age was 56 (range 43-71 ) years. In all cases the

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Intracavity drainagefor bullous, emphysematous lung disease: experience with the Brompton technique

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drainage under local anaesthesia. We were initiallyconcerned that the intrapulmonary insufflation ofsclerosant might produce bronchoconstriction asbullae may be ventilated by a major bronchus, but thishas not occurred.

n = 20

Fig 1 Preoperative arterial carbon dioxide tension (Paco2)and FE V,for survivors ( 0 ) and those dying (0 ) aftersurgery. p < 0 05, (a) and (b).

indication for surgery was debilitating dyspnoea in thepresence of dominant discrete bullous disease. Allpatients had simple respiratory function tests, includ-ing routine spirometry and measurement of arterialblood gas tensions, and in most cases more detailedrespiratory function tests and assessment of lungvolumes were available. All patients had routineposteroanterior and lateral chest radiography, andmore recently computed tomography has been usedfor assessing multiple bullae and planning surgery.Computed tomography may also allow accurate threedimensional measurement of the bullae, both beforeand after surgery. The earlier patients in the series didnot have computed tomography evaluation of bullasize.

SURGERYWe have modified the original technique of Monaldi,incorporating suggestions from other surgeons. Weuse a single stage technique, as advocated byMacArthur,6 instilling sclerosant directly into thebulla to produce rapid contraction and fibrosis withinthe bulla (McCluskie, personal communication) andinducing pleurodesis to minimise the immediate effectofany air leak in the pleural space. The latter will allowother bullae to be treated later by percutaneous

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Operative procedureA limited thoracotomy (10 cm) is performed, to resecta portion of the underlying rib. The site of the incisionis determined according to the site of the bulla and thedisposition of adjacent compressed lung tissue. Weaim to position the base of the decompressed bulla sothat it is as close to the incision as possible. The pleurais opened and the bulla incised, and two concentricpolypropylene purse string sutures are inserted aroundthis incision. The interior of the bulla is inspected andthe septa perforated to allow free communication withadjacent loculae or bullae. lodised talc is liberallyinsufflated into the bulla cavity. A large Foley catheter(size 32 FG) is inserted into the cavity via a separatestab incision in the chest wall, and the balloon isinflated with 30-40 ml air to function as a self retainingintrapulmonary drain. The purse string sutures aresecured. The remaining free pleural cavity is liberallyinsufflated with talc to obtain a thorough post-operative pleurodesis. An intrapleural drain is insertedat the most dependent part ofthe pleural space and thewound closed. Slight traction on the intrapulmonarydrain causes the bulla to lie adjacent to the chest wall.Postoperatively the Foley catheter, lying within thebullae, remains on free underwater seal drainage. Theair leak from this drain is frequently brisk. Theintrapleural drain remains on underwater seal suctionat 2-5 kPa. It is removed when any air leak hasstopped, usually within 48 hours. The Foley catheter isremoved at 8 days, irrespective ofresidual air leak. Thepatient is able to mobilise during this time with a singleunderwater seal drain carried in a suitable transporter.This period allows a secure bronchocutaneous fistulato form. After removal ofthe drain this bronchocutan-eous fistula spontaneously closes within the ensuing24-48 hours, after which the patient is discharged from

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Fig 2 FEV,, total lungcapacity, and residualvolume (RV) before (0)and after (0) surgery (dataexpressed as percentages ofpredicted values). p < 0-02(a), < 0 05 (b), and 0 01(c) .

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Fig 3 Preoperative chest radiograph from apatient with

bilateral bullous disease.

Fig 4 Postoperative chest radiographfrom the same patientafter left sided surgery.

Venn, Williams, Goldstraw

hospital.The data were not normally distributed. Paired data

were analysed with the Wilcoxon signed rank test andunpaired data with the Mann-Whitney U test.

Results

Three of the 20 patients died in the postoperativeperiod. Two of the deaths were due to progressiverespiratory failure and the third to staphylococcalsepticaemia.The preoperative FEV, ranged from 220 to 2130

(median value 740) ml. Fifteen patients had an FEV,of less than 1 litre. The median FEV,/FVC ratio was34% (range 17-50%). The preoperative arterialcarbon dioxide tension (Paco2) ranged from 4-2 to 8-2kPa with a median value of 5-2 kPa. Patients who diedafter surgery were more likely to have had a lowpreoperative FEV1 (p < 0.05*) and a higherpreoperative Paco2 (p < 0.05*) (fig 1). The twopatients dying of respiratory failure had severe impair-ment of lung function before operation with FEV,values of 220 and 350 ml, the former having a,antitrypsin deficiency. In the remaining 17 patientsthere was a 22% median improvement in FEV,(p < 0 02)t, fig 2), an 11% median reduction in totallung capacity expressed as a percentage of the predic-ted value (p < °°St, fig 2), and a 26% medianreduction in residual volume (p < 0-0lt, fig 2). Theresidual volume (expressed as a percentage of the totallung capacity) fell from a median of69% to 59% aftersurgery (p < 0 05t). Radiological improvement wasseen in all patients (figs 3 and 4). Subjectiveimprovement was reported by all but one patient, whoremained unchanged. The improvement has beenmaintained so far for all but two patients over amedian follow up period of 1 6 years. In both patientsdeterioration was attributable to formation of furtherbullae. Percutaneous drainage was performed again inboth cases, under local anaesthesia, with additionalsymptomatic improvement.

Discussion

The presence of bullous disease in association withgeneralised emphysema is well recognised andpresumably represents what Sir John Floyer wasdescribing as the "cystic alterations in the lungs inbroken winded horses" in A Treatise ofthe Asthma in1717.9 In this work Floyer suggested invasive treat-ment for the condition.

The cure of the broken wind cannot easily beprojected any other way but by a paracentesis in thethorax, for if the external air be admitted, it will

*Mann-Whitney test; tWilcoxon rank sum test.

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Intracavity drainagefor bullous, emphysematous lung disease: experience with the Brompton techniquecompress the flatulent tumour and through the samehole a styptic and carminative hydromel be injected,to restore by its stypticity the tone of the membranes,and discuss by its aromatic acrimony the windy spiritsor air retained in the lungs.

The surgical treatment of such bullae was notpopularised until the early to middle part of thiscentury. Such surgery has typically been "bullec-tomy": formal resection of lung incorporating thebullae, the resection ranging in magnitude from asmall wedge of pulmonary tissue to one or occasion-ally more lobes. Occasionally a bulla presents itself asa discrete "cyst" on a narrow based pedicle, allowingsimple ligation and removal without the excision ofany underlying pulmonary tissue. This usually occurswithout associated emphysema. The mortalityassociated with surgery has ranged from 2% to26%.' 6'3 '1'7 Death is usually due to progressivepostoperative respiratory failure, precipitated bypulmonary infection in patients with poor lungfunction. Their condition is aggravated by theoccurrence of a persistent air leak and the attendantimmobilisation after pulmonary resection, to whichthese patients are particularly prone because of theirunderlying emphysema. For this reason some authorshave advocated the use of Teflon pledgeted sutures forsuch tissue.'8

Patients presenting with bullae usually havemoderate or severe respiratory impairment, as in ourown series, with a low FEV, and other evidence ofairflow obstruction. Such patients cannot usuallytolerate any further reduction in their respiratoryperformance, however brief. The best results fromsurgery, in terms both of mortality and of symptoms,have been when bullae have been removed ordecompressed without resection of lung tissue oralternatively when the resection encompasses an entirelobe.3478 3

The assessment of patients for surgery has proveddifficult. Earlier reports noted that the best resultswere in those patients in whom the bulla exceeded onethird of the volume of the affected hemithorax andwhose respiratory function was not complicated bygeneralised emphysema.7141516 Wesley'" advocatedpreoperative indium perfusion scanning to identifypatients with large, discrete, perfusion defects as a signof larger, discrete bullae. Other techniques have beenadvocated. Logan (personal communication) foundbronchography of value in assessing the distributionof emphysema within a lobe and the compression ofadjacent lung tissue. Most surgeons have relied onposteroanterior and lateral chest radiographs, choos-ing to operate only on patients with radiographicevidence of parenchymal "compression" adjacent tothe bulla. Latterly, in our own series, we employedcomputed tomography and this allowed visualisation

of intrathoracic bullous disease far superior to thatafforded by conventional radiology. It will distinguishlarge discrete bullae from more generalisedemphysema, where bullous surgery is ofteninappropriate and unrewarding.Many observers have had difficulty in equating the

subjective improvement reported by patients aftersurgery for bullous disease with improvement in theresults of conventional lung function tests.'0"' 141617Some sceptics argue that this indicates the placeboeffiect of surgery in this condition. The alternativesuggestion, that we cannot easily define and measurethe cause of dyspnoea in these patients, may be morerealistic. In our own series subjective improvementcorrelated well with improved spirometric results andreduction in total lung capacity and residual volume.The absence of any improvement in arterial blood gastensions and carbon monoxide transfer factor wouldargue against the relief of lung compression as thecause of the subjective improvement. The reduction inlung volumes would cause a reduction in the work ofbreathing and this, combined with a reduction in thesensation of discomfort, possibly from chest wallstretch receptors as a result of the reduction in chronichyperinflation of the chest, may play an importantpart in the symptomatic improvement reported bythese patients.

Monaldi's technique of closed intubation drainage,initially used for the treatment of post-tuberculousand subsequently other localised pyogenic abscesscavities, has been advocated by others for the treat-ment ofbullous disease.67 It was initially described as atwo stage procedure. The first stage was to obtain apleurodesis with the extrapleural insertion ofan iodinesoaked pack,67 which was subsequently removed, thewound being allowed to heal before the second stage ofcatheter insertion and suction drainage of the bulla.We have combined these two stages to allow asatisfactory pleurodesis and drainage of the bulla to becarried out at the same time. The technique has thegreat appeal of requiring a very limited surgicalapproach and avoids resection of underlying lungtissue, which is important for these patients withlimited respiratory reserve. The use of computedtomography has greatly facilitated the selection ofpatients, allowing exclusion of those with generalisedemphysema accompanying their bullous disease, inwhom surgery produces poor results. It has alsoallowed better preoperative planning of the surgicalapproach by localising underlying compressedpulmonary tissue. This enables the surgical incision tobe positioned to allow the base of the bulla and theintracavity drain to lie adjacent to the chest wall afterdecompression. The technique was valuable in treat-ing the two patients who presented after their initialsurgery with further bulla formation. The pleurodesis

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obtained at the initial operation allowed intubationand drainage of the new bullae percutaneously underlocal anaesthesia, without risk of pneumothorax.We have attempted to push this technique to the

limit and now recognise that, although highly suitablefor patients with poor respiratory function, two of thethree patients who died had respiratory function(FEV, 220 and 350 ml) that was too poor to allow evenminimally invasive surgery. The percentage im-provement in lung function provided by this techniquewould have left these patients still housebound andbedridden. We now accept a preoperative FEV, of500 ml as a minimum prerequisite for surgery. Thismay seem somewhat arbitrary; but we believe that thislevel oflung function offers safe surgery, and the orderof improvement to be expected by this technique willprovide an important improvement in the quality oflife of such patients.

References

I Hugh Jones P, Ritchie BC, Dollery CT. Surgical treat-ment ofemphysema Br MedJ 1966-i: 1133-8.

2 Monaldi V. Tentativi di aspirazione endocavitaria nellecaverne tuberculari del polmone. Lotta Contro laTuberculosi 1938;9:910-1.

3 Monaldi V. Endocavitary aspiration in the treatment oflung abscess. Dis Chest 1956;29:193-201.

4 Head JR. Intracavity (Monaldi) suction. J Thorac Surg1946;15:153-61.

5 Monaldi V. Endocavitary aspiration: its practicalapplication. Tubercle 1946;28:223-8.

6 MacArthur AM, Fountain SW. Intracavity suction and

Venn, Williams, Goldstrawdrainage in the treatment of emphysematous bullae.Thorax 1977;32:668-72.

7 Head JR, Avery EA. Intracavitary suction (Monaldi)in the treatment of emphysematous bullae and blebs.J Thorac Cardiovasc Surg 1948;18:761-76.

8 Head JM, Head LR, Hudson TR, Head JR. The surgicaltreatment of emphysematous blebs and localisedvesicular and bullous emphysema. J Thorac CardiovascSurg 1960;40:443-60.

9 Floyer JA. A treatise ofthe asthma. 2nd ed. London: 1717.10 Wesley JR, Macleod WM, Mullard KS. Evaluation and

surgery of bullous emphysema. J Thorac CardiovascSurg 1972;63:945-55.

11 Knudson RJ, Gaensler EA. Surgery for emphysema. AnnThorac Surg 1965;21:332-62.

12 Sung DT, Spencer Payne W, Black LF. Surgicalmanagement of giant bullae associated withobstructive airway disease. Surg Clin North Am1973;53:913-20.

13 Potgieter PD, Benatar SR, Hewitson RP, Ferguson AD.Surgical treatment of bullous lung disease. Thorax1981;36:885-90.

14 Rogers RM, DuBois AB, Blakemore WS. Effect ofremoval of bullae on airway conductance and conduc-tance volume ratios. J Clin Invest 1968;47:2569-79.

15 Pearson MG, Ogilvie C. Surgical treatment ofemphysematous bullae: late outcome. Thorax1983;38: 134-7.

16 Fitzgerald MX, Keelan PJ, Cugell DW, Gaensler EA.Long term results of surgery for bullous emphysema.J Thorac Cardiovasc Surg 1974;68:566-87.

17 Pride NB, Hugh-Jones P, O'Brien EN, Smith LA.Changes in lung function following the surgical treat-ment of bullous emphysema. Q J Med 1970;39:49-69.

18 Parmar JM, Hubbard WG, Matthews HR. Teflon strippneumostasis for excision of giant emphysematousbullae. Thorax 1987;42:144-8.

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