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Images in thorax
Extrathoracic proof of intrathoracic trouble
  1. C Dickhoff1,
  2. K J Hartemink1,2,
  3. D J Slebos3,
  4. P Symersky4,
  5. A Vonk-Noordegraaf5
  1. 1Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
  2. 2Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
  3. 3Department of Pulmonology, University Medical Center Groningen, Groningen, The Netherlands
  4. 4Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands
  5. 5Department of Pulmonology, VU University Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Dr C Dickhoff, Department of Surgery, VU University Medical Center, 7F-005, postbox 7057, Amsterdam 1007 MB, The Netherlands; c.dickhoff{at},

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A 67-year-old man was referred to our hospital for bullectomy. Chest CT scan showed exhaustive bilateral bullous emphysema with a giant bulla in the right lung (figure 1). Cardiopulmonary exercise testing revealed a maximum exercise tolerance of 30 Watts and a progressive dynamic hyperinflation with an inspiratory capacity of less than 50 mL during maximal exercise. During thoracotomy, manipulation of the airway made the patient cough and a giant bulla rapidly expanded with extension outside the right hemithorax (figure 2). This bulla was resected successfully and quality of life significantly improved with an increase in maximum exercise tolerance to 50 Watts, without signs of dynamic hyperinflation during cardiopulmonary exercise testing.

Figure 1

CT scan showing bilateral emphysema with a giant bulla in the right hemithorax.

Figure 2

Extrathoracic expanded giant bulla of the right hemithorax during anterior thoracotomy.

Dynamic hyperinflation in patients with severe chronic obstructive pulmonary disease with accompanying bullous disease can be very invalidating and significantly reduce quality of life. For this group, bullectomy is safe and may offer clinical and functional improvement in respiratory and cardiovascular function.1 ,2



  • Correction notice This article has been corrected since it was published Online First. The author affiliations have been updated.

  • Contributors CD, PS and AVN conceived the idea for the manuscript. CD, KJH wrote the manuscript, CD and PS made and selected photographs, DJS and AVN critically revised the manuscript.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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