Target bronchus determination in giant emphysematous bullae: A case report

Rationale: Giant emphysematous bullae (GEB) in chronic obstructive pulmonary disease cause severe respiratory compromise. While surgical resection is standard, bronchoscopic volume reduction is crucial for surgically ineligible patients. Accurate target bronchus identification remains challenging with conventional imaging. Patient concerns: A 67-year-old male with chronic obstructive pulmonary disease and right lung GEB presented with severe dyspnea (modified Medical Research Council score 4), hypercapnia (partial pressure of carbon dioxide: 45 mm Hg), and markedly limited exercise tolerance (6-minute walk distance: 62 m). He required home noninvasive ventilation and was deemed unfit for surgery due to critically impaired lung function (Forced expiratory volume in 1 second: 0.36 L, 12.2% predicted). Diagnoses: Preoperative high-resolution computed tomography (CT) and 3D reconstruction localized the target bronchus to the right middle lobe. However, percutaneous aspiration and drug injection via drainage tube revealed misalignment, prompting reidentification of the target bronchus in the posterior segment of the right upper lobe. Interventions: CT-guided percutaneous GEB volume reduction was performed, involving air extraction and intrabullous injection of erythromycin lactobionate. Subsequent selective bronchial occlusion of the posterior right upper lobe segment via bronchoscopic autologous blood and thrombin injection was conducted. Continuous negative-pressure drainage was maintained post-procedure. Outcomes: Follow-up CT at 6 months confirmed complete GEB closure. Dyspnea improved significantly (modified Medical Research Council score 3), exercise capacity increased (6-minute walk distance: 220 m), and ventilator use was discontinued. No complications or recurrence were observed during follow-up. Lessons: Percutaneous aspiration and drug injection refine target bronchus identification when imaging yields ambiguous results, enhancing precision for subsequent bronchoscopic interventions. This strategy minimizes reliance on endobronchial valves, reducing costs and procedural complexity. Larger studies are needed to validate long-term efficacy, but this approach offers a promising minimally invasive alternative for high-risk patients.