A 38-year-old man is admitted with progressive shoness of breath and cough. He denies any fever, chills, or purulent sputum production. He wants to be evaluated to determine the reasons for his symptoms. On exam, he is afebrile and has decreased breath sounds with hyperresonant upper lung field more obvious on the right. ABGs on RA: pH 7.35; PCO2 38 mm Hg; PO2 78 mm Hg. Spirometry: FVC 1.72 (70% of predicted); FEV1 1.34 L (60% of predicted); FEV1/FVC% 76%; TLC 4.1 L (100% of predicted); TLC by helium dilution method 3.4 (71%); DLCO 70% of predicted. There is no bronchodilator response. Chest radiographs are shown below.What is the next management option?
These x-rays show a large area of hyperlucency with no lung markings in the right upper and middle zone bounded by a very distinct margin. The area below the margin shows increased density and compression. There is attenuation of vascular markings and increased lucency in the left upper zone also. This is consistent with a large bulla in the right upper lobe and a smaller bulla in the left upper lobe. The CXR shows a large bulla, which accounts for the symptoms of this patient. Discrepancy in total lung capacity as assessed by the helium dilution and body plethysmography methods suggests significant gas trapping in the bulla and can be used to estimate the volume of the bulla. Bullae become symptomatic as they enlarge, and the goal of surgical therapy is to excise them to enable the surrounding tissue to reexpand. CT scan is helpful to determine the size, extent, and number of bullae present. It also helps in evaluating the anatomy of the remaining lung and its potential for effective reexpansion. PFTs may show a restrictive pattern if the bulla does not communicate with the airways. If there is no diffuse, widespread emphysema and profound hypoxemia or hypercarbia is not present, surgical resection of the bulla is likely to improve the symptoms. Placement of a chest tube in this case would conve an intrapulmonary closed airspace into a bronchopleural cutaneous fistula and is therefore not an appropriate option.
Place a chest tube urgently
Increase bronchodilator dosage and frequency
Sta chest physical therapy
Perform CT scan of chest
Respiratory system