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Giant bullae are space-occupying lesions that compress the surrounding lung parenchyma, impairing lung function. Bullae arise from emphysematous areas of destroyed lung tissue. Hence, they differ from blebs, which are localized collections of air between visceral pleural layers without underlying parenchymal disease.1 Giant bullae can be classified as three types based on morphology: Type I bullae have a narrow neck and are superficial, type II are superficial as well but have a broad neck, and type III are both broad and deep.2 Giant bullae usually require surgical resection (Fig. 104-1). A wide range of procedures from open excision, plication, and drainage to video-assisted bullectomy and anatomic lung resection can be applied.3 Developments in anesthesia and surgery enable us to operate on patients with very limited pulmonary function; however, a subgroup of patients carries a significant risk of prolonged air leak and respiratory complications following open resection. For these patients, a minimally invasive operation known as the Monaldi procedure can be performed. Named after the surgeon who developed the technique, the Monaldi procedure was used in the mid- and late 20th century to drain apically located tuberculous cavities and lung abscesses. Eventually, it was used for treating giant bullae.4

Figure 104-1

A giant bulla in the right upper zone of the chest. This bulla originated from the middle lobe and extended to the pulmonary hilum. It was treated with middle lobectomy.


Most of the patients with giant bullae are heavy smokers of middle and advanced age with a prolonged history of medical treatment. Common symptoms include dyspnea and chest pain. Giant bullae occupy a significant portion of the intrathoracic space causing compression of adjacent healthy lung tissue. As a result, the physiologic dead space increases, and the presence of the bulla aggravates dyspnea in patients with already limited lung function.

Secondary pneumothorax and hemoptysis are often the initial presenting complications. When the bulla is infected, additional complications including fever, cough, and increased sputum production accompany the clinical picture. Evaluation usually begins with a chest x-ray. A concave contour at the base of the bulla distinguishes it from pneumothorax (see Fig. 104-1). If the bulla is infected, an air–fluid level will be observed. A chest CT scan can usually delineate the extent of the bulla and the degree of compression on surrounding lung tissues. Generalized heterogeneous emphysema, areas of scarring secondary to previous infections, and interstitial fibrosis are also common among these patients (Fig. 104-2).

Figure 104-2

A patient with a giant right upper lobe bulla, generalized emphysema, and interstitial fibrosis of the lung. His pulmonary function was severely limited with an FEV1 of 0.90 L (29%) and FVC of 1.84 L (48%). The patient would constitute an ideal candidate for a Monaldi procedure.

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