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Spontaneous Pneumothorax Caused by Pulmonary Blebs and Bullae in 12 Dogs

Spontaneous pneumothorax caused by pulmonary blebs and bullae was diagnosed in 12 dogs based on history, clinical examination, thoracic radiographs, surgical findings, and histopathological examination of resected pulmonary lesions. Radiographic evidence of blebs or bullae was seen in only one dog. None of the dogs responded to conservative treatment with thoracocentesis or thoracostomy tube drainage. A median sternotomy approach was used to explore the thorax in all dogs. Pulmonary blebs and bullae were resected with partial or complete lung lobectomy. Ten of the dogs had more than one lesion, and seven of the dogs had bilateral lesions. The cranial lung lobes were most commonly affected. Histopathology results of the blebs and bullae were consistent in all dogs and resembled lesions found in humans with primary spontaneous pneumothorax. None of the dogs developed recurrence of pneumothorax. Median follow-up time was 19 months. The outcome following resection of the pulmonary blebs and bullae was excellent. J Am Anim Hosp Assoc 2003;39:435–445.
Victoria J. Lipscomb, MA, VetMB, MRCVS, CertSAS, Diplomate ECVS Robert J. Hardie, DVM, Diplomate ACVS, Diplomate ECVS Richard R. Dubielzig, DVM, Diplomate ACVP

Introduction Spontaneous pneumothorax occurs when air or gas enters the pleural
space in the absence of a traumatic or iatrogenic cause.1-4 The most common source of air is the lung parenchyma; however, other sources include the trachea, bronchi, and esophagus or gas-forming organisms within the pleural cavity.1 Spontaneous pneumothorax can be further classified as either primary or secondary based on the history, clinical signs, and whether an underlying cause can be determined from diagnostic tests, such as thoracic radiographs, thoracic computed tomography (CT), or thoracoscopy.4-7 Reported causes of spontaneous pneumothorax in dogs include bacterial pneumonia, pulmonary abscesses, dirofilariasis, pulmonary neoplasia, bullous emphysema, and pulmonary blebs and bullae.8 Based on previous reports, the most common cause of spontaneous pneumothorax is pulmonary blebs or bullae.2,3,7,9 Pulmonary blebs are accumulations of air within the layers of the visceral pleura, most commonly located at the lung apices [Figure 1].6 They form when air escapes from within the lung parenchyma and travels to the surface of the lung and becomes trapped between the layers of the visceral pleura.6 Grossly, blebs appear as small “bubbles” or “blisterlike” lesions on the surface of the lung that range in size up to several centimeters in diameter. In contrast, pulmonary bullae are air-filled spaces within the lung parenchyma that result from the destruction, dilatation, and confluence of adjacent alveoli.6 Bullae can vary in size, with some being small (involving only a few alveoli) and others being very large (involving a majority of the lung).10 Bullae are confined by the connective tissue septa within the lung and the internal layer of the visceral pleura. Bullae have been classified into three types based on the size and connection with surrounding lung tissue [Figure 1].6 Type 1 bullae are thin, with empty interiors and a small, narrow connection to the pulmonary parenchyma. They are usually found at the apices of the lung and have outer walls that may or may not be lined by mesothelial cells on the
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From the Department of Small Animal Medicine and Surgery (Lipscomb), Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, Hertfordshire, AL9 7TA England and the Departments of Surgical Sciences (Hardie) and Pathobiological Sciences (Dubielzig), School of Veterinary Medicine, University of Wisconsin, 2015 Linden Drive, Madison, Wisconsin 53706. Address all correspondence to Dr. Hardie. JOURNAL of the American Animal Hospital Association

Type 3 bullae can be very large and may contain emphysematous lung tissue that extends deep into the pulmonary parenchyma. type 1 bulla (B). 39 Figure 1—Line drawings illustrating the apex of the lung (shaded box in top drawing) and a pulmonary bleb (A). .436 JOURNAL of the American Animal Hospital Association September/October 2003. Type 2 bullae arise from the subpleural parenchyma and are connected to the rest of pulmonary parenchyma by a neck of emphysematous lung. external surface. C. and type 3 bulla (D). type 2 bulla (C). and the outer walls are formed by intact pleura lined by mesothelial cells. and D. The interior of the bullae is filled with emphysematous lung tissue. Vol. Note the accumulation of air between the layers of the visceral pleura in the pulmonary bleb and the different connections to the underlying pulmonary parenchyma in B.

lesion description. history. Materials and Methods Case Material The records of dogs diagnosed with spontaneous pneumothorax caused by pulmonary blebs and bullae at the Royal Veterinary College. CBC. histopathological findings.c or both were given as required for analgesia. physical examination findings. If the source of leakage was not readily identified. and intramuscular morphine. Eight dogs were purebreds. depression. clinical signs. and histopathological interpretation have resulted in conflicting information about pulmonary bleb and bulla lesions. prior treatment. and the median weight was 25 kg (range. the location and extent of the pulmonary lesions were not always reported. Histopathological examination was performed by the same pathologist (Dubielzig). 9. Complete blood count and serum biochemical profile results were within reference Surgical Technique A median sternotomy was performed on all dogs. The duration and outcome of initial treatment with thoracocentesis or thoracostomy tube drainage were recorded.2. or bullous emphysema.5 to 12 years). between May 1991 and September 2000 were reviewed. The signalment. Staple lines were checked for leakage by filling the thorax with warm. the terms bleb. and one dog was treated with thoracostomy tube drainage prior to referral. In addition. The sternotomy incisions were monitored. and complications were recorded. Vol. Finally. Also. the thorax was filled with warm. increased respiratory effort. and serum biochemical profile were performed on all dogs. staplinga the bronchus. Results Signalment and History Twelve dogs were identified with spontaneous pneumothorax caused by pulmonary blebs or bullae [Table 1]. or diffuse. differences in lesion terminology. There were seven males and five females. If the dog was no longer alive. postoperative complications. sterile saline and inflating the lungs. multifocal. was excluded from the study. and four were mixed-breed dogs. 39 Pulmonary Blebs and Bullae 437 Several reports have described the clinical findings from dogs with spontaneous pneumothorax due to pulmonary blebs. Initial Management Physical examination.b intrapleural bupivacaine. and longterm outcome of 12 dogs with spontaneous pneumothorax caused by focal pulmonary blebs and bullae.September/October 2003. and long-term outcome were recorded. Spontaneous pneumothorax was diagnosed if evidence of trauma was excluded based on history. Radiography. and thoracic radiographs. and resecting the lung distal to the staples. The thoracostomy tubes were aspirated as necessary. Any dog with a history of trauma or underlying pulmonary disease. radiographic findings. sterile saline and leaks were located during ventilation. Eight dogs were treated with thoracocentesis. differing interpretations of the histopathological findings has resulted in uncertainty as to whether pulmonary blebs and bullae should be considered primary lesions or lesions that develop secondary to some other underlying cause. and bullous emphysema have been used interchangeably in some reports. anorexia. such as neoplasia or pneumonia. however. 3. the cause of death and time since the surgery were recorded. and the lungs were inspected for lesions. Serial lateral and dorsoventral radiographs of the thorax were made after thoracic drainage. and the thorax was closed with stainless steel wire placed around the sternebrae in a cruciate pattern.9 In particular. bullae. Physical Examination. Postoperative Management The dogs were monitored after surgery.9 to 42 kg). complete blood count (CBC) and serum biochemical profile findings. The description and location of the resected lesions were recorded. embedded in paraffin. All dogs were either large breed or had deep-chested conformation. Long-Term Follow-up Follow-up information was obtained by clinical examination or by telephone conversation with the owner. Auscultation of the thorax revealed decreased lung sounds on one or both sides. sectioned. Complete lung lobectomies were performed by double ligating the pulmonary vasculature. surgical treatment. lesions were removed by partial or complete lung lobectomy. and exercise intolerance. All visible . making it difficult to determine the specific lesion being described.7. A thoracostomy tube was placed. Other clinical signs included lethargy. postoperative complications. surgical technique. coughing. and respiratory distress. The median age was 7. University of London. Pneumothorax was treated initially with intermittent thoracocentesis or placement of a thoracostomy tube. and Initial Management Physical examination revealed varying degrees of tachycardia. and the time of removal was recorded. making it unclear as to whether lesions were focal.5 years (range. radiographic findings. the findings of this study are compared to those described for humans with primary spontaneous pneumothorax due to pulmonary blebs and bullae. Details of exercise tolerance and respiratory effort were recorded. Partial lung lobectomies were performed by stapling the lung parenchyma using an automatic stapling devicea and resecting the lesion distal to the staple line. tachypnea. The purpose of this study is to describe the clinical signs.3. histopathological findings. Eleven of 12 dogs had a history of intermittent or progressive dyspnea that was acute in onset for some dogs. bulla. initial management. and stained with hematoxylin and eosin. Histopathological Examination The resected lung tissue was preserved in 10% formalin.

managed by daily thoracocentesis for 7 days Thoracocentesis for 24 hrs Bilateral pneumothorax. M standard poodle Acute-onset dyspnea and coughing. Partial right cranial and complete left cranial lung lobectomy Bilateral lesions. 39 (continued on next page) . 31. no recurrence of clinical signs 3 7-yr. 9. MN mixed-breed wolfhound Acute-onset dyspnea. 35. suture removal delayed Died of gastroenteritis after 24 mos. and Long-Term Outcome in 12 Dogs With Spontaneous Pneumothorax Case No. no recurrence of clinical signs September/October 2003. bulla in left caudal lung lobe Recurrent pneumothorax after surgery due to leakage from a staple line. managed by thoracocentesis Thoracostomy tube for 48 hrs Bilateral pneumothorax Bilateral lesions. No recurrence of clinical signs at that time JOURNAL of the American Animal Hospital Association 2 7. F mixed-breed dog Dyspnea and exercise intolerance for 6 weeks. 15-kg. Vol.438 Table 1 Signalment. Partial right middle and complete left cranial lung lobectomy Bilateral lesions. Complete left cranial lung lobectomy Edema around incision. Complete left cranial lung lobectomy None None Lost to follow-up after 2-mos reexamination. continued leakage.5-kg. no recurrence of clinical signs 4 6-yr. Partial right cranial. Surgery Complications Signalment* History Initial Management Radiographic Findings Long-Term Outcome 1 7-yr. History.75-yr. emergency sternotomy Bilateral pneumothorax Thoracostomy tube for 6 days Left pneumothorax and pneumomediastinum Lost to follow-up immediately after surgery 5 9. treated by restapling the lung None Died acutely after 36 mos (cause of death unknown). Surgery. Complications. Initial Management. managed by thoracocentesis Thoracostomy tube for 48 hrs Left pneumothorax Died of hepatic disease after 36 mos. M mixed-breed dog Dyspnea for 3 weeks.9-kg. Radiographic Findings.4-kg. FS Old English sheepdog Intermittent dyspnea for 9 days. partial left caudal. 42-kg.5-yr. managed by thoracostomy tube for 10 days Thoracostomy tube with continuous suction applied for several hours. managed by thoracocentesis and emergency referral Unilateral lesions. and complete accessory lung lobectomy Unilateral lesions.

Partial right and left cranial lung lobectomy None Alive at 6 mos. partial right cranial. Complications. M Laborador retriever Thoracostomy tube for 4 days Bilateral pneumothorax Acute-onset dyspnea. no recurrence of clinical signs 8 8.4-kg. Partial right cranial lung lobectomy Unilateral lesion. cervical/thoracic subcutaneous emphysema Bilateral pneumothorax Right pneumothorax Dyspnea and anorexia for 5 days Seroma around incision. FS German shepherd dog Dyspnea and exercise intolerance for 18 days. Partial left cranial. Surgery.5-yr.6-kg. 12-kg. resolved over 2 weeks Bilateral lesions. FS German shepherd dog Thoracostomy tube for 3 days Left pneumothorax.5-kg. managed by thoracocentesis Thoracostomy tube for 5 days Alive at 16 mos. and Long-Term Outcome in 12 Dogs With Spontaneous Pneumothorax September/October 2003. History.Table 1 (cont’d) Signalment. FS=female spayed. MN rough-coated collie Poor oxygen saturation during routine anesthesia Pulmonary Blebs and Bullae 12 12-yr. Vol. F=female 439 .5-yr.5-yr. M whippet Dyspnea for 3 weeks. None Partial right and left cranial lung lobectomy Alive at 22 mos. MN=male neutered. 39 Case No.6-yr. Radiographic Findings. no recurrence of clinical signs Alive at 40 mos. Complete right cranial and partial left cranial lung lobectomy None Died of splenic hemangiosarcoma after 6 mos. Complete right cranial lung lobectomy Bilateral lesions. 38-kg. 16. 22. M mixed-breed dog Acute-onset dyspnea over 1 day Bilateral pneumothorax Bilateral lesions. 37. managed by thoracocentesis Thoracostomy tube for 24 hrs Bilateral pneumothorax Unilateral lesions. 14-kg. F Old English sheepdog Thoracocentesis for 3 days Thoracostomy tube for 2 days Dyspnea for 3 weeks. no recurrence of signs * M=male. managed by thoracocentesis for 5 days Died of neoplasia on digit after 8 mos. Initial Management. Partial right cranial lung lobectomy None Thoracostomy tube for 24 hrs Bilateral pneumothorax Bilateral lesions. resolved over 10 days 9 3. no recurrence of clinical signs 10 3. Surgery Complications Signalment* History Initial Management Radiographic Findings Long-term Outcome 6 6. resolved with bandaging and antibiotics Seroma around incision. no recurrence of clinical signs 7 10-yr. 28. managed by thoracocentesis Edema with serosanguineous discharge from incision. no recurrence of clinical signs Alive at 10 mos. and partial right middle lung lobectomy Unilateral lesion. pneumomediastinum.7-kg. no recurrence of clinical signs 11 9.6-yr.

focal. and black foreign particulate matter. Five dogs (case nos. In two dogs (case nos. and an emergency median sternotomy was performed the day of admission. 3. the incision was bandaged and antibiotic therapy was continued for 2 weeks before resolution. 8. A Surgical Findings Bleb and bulla lesions appeared as thin. Focal bleb lesions were identified in two dogs (case nos. Two dogs had pneumomediastinum. translucent. mild to moderate perivascular lymphoplasmacytic inflammation. B Figures 2A. 9). 5. smooth-muscle hypertrophy surrounding the respiratory ducts. . one or both cranial lung lobes had lesions. 2B—Intraoperative photographs of pulmonary bullae on the apical margin of the right and left cranial lung lobes from case no. None of the other dogs had pulmonary lesions identified on radiographs. placement of a thoracostomy tube and the use of continuous suction could not control the pneumothorax. In all of the dogs. 12. 11. The accessory lung lobe and left caudal lung lobe (bulla identified on radiographs) were also affected in case no. Histopathological Findings Histopathological examination was performed on representative samples of resected lung tissue from all dogs except case nos. There were no recurrences of pneumothorax due to pulmonary blebs or bullae in the immediate postoperative period. The focal changes surrounding the bleb and bulla lesions included dilated alveoli and peripheral emphysema. 6. 10) [Figure 3]. In dogs with multiple lesions. For case no. disruption of the superficial portion of the lesion during preservation made it difficult to accurately determine whether the lesion was a bleb or bulla. 10) had bullae that resembled the type 2 classification. although the surrounding changes were similar to those found in the other bleb and bulla lesions.440 JOURNAL of the American Animal Hospital Association September/October 2003. 5. No underlying cause for the lesions was identified in any dog. The foreign particulate material present in the lungs was most likely carbon from inhaled smoke or other pollutants in the environment. Radiographs of the thorax revealed bilateral pneumothorax in eight dogs and unilateral pneumothorax in four dogs [Table 1]. A second surgery was performed to restaple the lung. Ten of the 12 dogs had more than one lesion. 9). Thoracostomy tubes were removed between 1 and 6 days after surgery. the bleb and bulla lesions had a similar appearance. 6. A 2-cm bulla was identified in the left caudal lung lobe on dorsoventral radiographs in case no. In the fourth dog (case no. and it was not possible to distinguish the differences between the lesions on gross inspection. and multiple bullae were identified in one dog (case no. focal bulla lesions were identified in six dogs (case nos. 4. chronic collapse of adjacent parenchyma. and the pneumothorax resolved. 5. and the right middle lung lobe was also affected in case nos. 3. Postoperative Management and Complications Pneumothorax occurred in the immediate postoperative period in case no. 39 ranges. 3 due to leakage from the staple line of a partial lung lobectomy. 1. and surgery was performed the following day. “bubble-like” lesions on the apical margins of the affected lung lobes in all dogs. A seroma developed at the sternotomy incision in four dogs. and two dogs (case nos. Vol. In some dogs. 1 and 9. although smooth-muscle hypertrophy was suggestive of a chronic change. 3. varying in size up to several centimeters in diameter [Figure 2]. 3 and 7 [Table 2]. thoracocentesis was performed as necessary. and seven of 12 had bilateral lesions [Table 1]. Histopathological findings of the pulmonary lesions were similar in all dogs. 1. and one dog had subcutaneous emphysema over the cervical and thoracic areas. 2). For case no. In three of the dogs. which is often seen in the lungs of normal dogs. not all were leaking at the time of surgery. thoracostomy tubes were in place for 1 to 5 days prior to surgery. Initial treatment consisted of thoracostomy tube drainage for 10 of the dogs and thoracocentesis for two dogs. Pneumothorax persisted in all of the dogs despite conservative treatment with either thoracocentesis or thoracostomy tube drainage. The rest of the lungs appeared grossly normal. the seroma resolved without any treatment. 2. 10-12) [Figure 4]. For the other 10 dogs. 12) had bullae that most closely resembled the type 1 classification.

respiratory signs may develop rapidly and be very obvious. In addition. and gross and histopathological characteristics is essential for making the diagnosis and providing appropriate treatment. 200×). Other diagnostic tests.7 Due to their relatively small size and location on the margins of the lungs. 8. with no recurrence of pneumothorax 6. The bulla was located in the left caudal lung lobe. pulmonary blebs or bullae are found most often in healthy. largebreed or deep-chested dogs that have no previous history of respiratory problems or lung disease. however. The use of thoracic computed tomography (CT) or thoracoscopy for the diagnosis of pulmonary blebs and bullae has not been reported in a series of dogs. tachypnea. Nevertheless. depression. or dirofilariasis.9 Understanding the typical clinical signs. their use warrants investigation and may prove more accurate than radiographs for identifying small pulmonary lesions. 3) was a bulla identified on radiographs. 8. There is muscular hypertrophy around respiratory ducts and a moderate amount of particulate foreign material around the bronchioles (Hematoxylin and eosin stain. 1. The most common clinical signs include lethargy. however. Definitive diagnosis of pulmonary blebs and bullae can be difficult since the lesions are not usually apparent on thoracic radiographs. although they may identify other concurrent problems. increased respiratory effort. anorexia.2. Initial treatment should focus on stabilizing the dog with strict rest. Long-term Outcome Long-term information was available from 10 of the dogs [Table 1]. oxygen supplementation.7. radiographic findings or lack thereof.2. however. serial thoracic radiographs should be taken to identify other potential causes of pneumothorax such as pulmonary neoplasia. Air has accumulated between the layers of the visceral pleura. signs of pneumothorax had not been reported previously. Five dogs were still alive at the time of writing. or thoracic radiographs. and in only one dog (case no. and 40 months after surgery. There is marked pleural thickening but note the lack of an epithelial lining. Figure 4—Photomicrograph of a pulmonary bulla from case no. The median follow-up time for the 10 dogs with long-term information was 19 months (range. Thoracocentesis should be performed as often as necessary to maintain adequate respiration. 22. Pneumothorax Figure 3—Photomicrograph of a pulmonary bleb from case no. 16. all of the dogs had various degrees of unilateral or bilateral pneumothorax.8 In this study. 3) collapsed and died suddenly 36 months after surgery. There is peripheral emphysematous change and muscular hypertrophy around the respiratory ducts (Hematoxylin and eosin stain.7. Four dogs died from unrelated problems. 6 to 40 months). middle-aged. The cause of death was unknown. There is marked peripheral emphysematous change and focal atelectasis. and thoracic drainage.2. initial clinical signs may be very nonspecific and respiratory signs may not develop until the pneumothorax progresses over days. most blebs and bullae are not usually seen unless they become very large or develop thickened walls. Note the connection between the bulla and the underlying lung parenchyma and the presence of an epithelial lining. exercise intolerance. 39 Pulmonary Blebs and Bullae 441 Discussion Diagnosis and treatment of spontaneous pneumothorax caused by pulmonary blebs and bullae in dogs can be particularly challenging since the source of air leakage is not usually evident from the history. Information was not available for two dogs 1 week and 2 months after surgery. clinical examination.3. and various degrees of respiratory distress. .3. at surgery. with no recurrence of pneumothorax 6. For dogs with more rapid accumulation of air. 24. additional bullae were discovered on other lung lobes. coughing. Based on the results of this study. a thoracostomy tube should be placed to allow more frequent drainage of the thorax or the use of continuous suction.September/October 2003. understanding how bleb and bulla lesions in dogs compare to those found in humans is necessary so that diagnostic and treatment strategies developed for humans can be applied appropriately to dogs. For some dogs. and 36 months after surgery. are not usually helpful for determining the cause of pneumothorax. whereas for other dogs.9 Conservative treatment with thoracocentesis or thoracostomy tube drainage was not effective in resolving the pneumothorax in any of the dogs in this study. One dog (case no. Vol. response to conservative and surgical treatment. and there is no indication of a connection between the air-filled space and the pulmonary parenchyma. 20×). abscesses. such as a CBC and serum biochemical profile. 10.

7 No histopathology obtained. Extensive peripheral emphysematous change. Extensive peripheral emphysematous change. 9 Extensive peripheral emphysematous change. Moderate particulate foreign material surrounding bronchioles. Extensive central atelectasis and prominent smooth muscle hypertrophy around airways. Peripheral emphysematous change. Superficial portion of bulla or bleb not included in section. Moderate particulate foreign material surrounding bronchioles. 2 Bullae (type 1). Prominent muscular hypertrophy around airways and central atelectasis. Extensive atelectasis and moderate muscular hypertrophy around airways. . Moderate muscular hypertrophy around airways and extensive central atelectasis. Extensive peripheral emphysematous change. Extensive peripheral emphysematous change. Marked pleural capsule fibrosis and intermittent interstitial fibrosis. Moderate particulate foreign material surrounding bronchioles. 4 Mild peripheral emphysematous change. Marked peripheral emphysematous change. Multifocal areas of extensive atelectasis. September/October 2003. Moderate particulate foreign material surrounding bronchioles. Increased perivascular lymphoplasmacytic inflammation with inspissated mucous secretions in some bronchi. Increased particulate foreign material surrounding bronchioles. Marked central atelectasis and minimal muscular hypertrophy around airways. Moderate particulate foreign material surrounding bronchioles. 10 Bulla (type 2) and bleb. Vol. blood-filled vascular anomaly of unknown significance. Slight amount of particulate foreign material surrounding bronchioles. Minimal perivascular lymphocytic inflammation. Minimal perivascular lymphocytic inflammation. Marked central atelectasis and prominent muscular hypertrophy around airways. Prominent atelectasis and muscular hypertrophy around airways. Marked atelectasis. Moderate particulate foreign material surrounding bronchioles. Moderate peribronchiolar lymphoplasmacytic inflammatory infiltrate and inspissated mucinous secretion seen in some airways. Moderate peripheral emphysematous change. 39 12 Bulla (type 1) with low cuboidal epithelial lining and multifocal smooth muscle indicating continuity with respiratory ducts. Pleural thickening. Histopathological Findings From Various Representative Lesions Submitted for Examination 1 Bulla (type 1). 11 Bulla (type 1) with low cuboidal epithelial lining and multifocal smooth muscle indicating continuity with respiratory ducts. Superficial portion of bulla or bleb not included in section. JOURNAL of the American Animal Hospital Association 5 Bulla (type 2) with low cuboidal epithelial lining and multifocal smooth muscle indicating continuity with respiratory ducts. 8 Bleb dissecting within the pleural capsule. Small amount of particulate foreign material surrounding bronchioles. Abundant particulate foreign material. 3 No histopathology obtained. Small number of peripheral lung foci with lymphocytic infiltrate and interstitial fibrosis.442 Table 2 Histopathological Findings in 12 Dogs With Pulmonary Blebs or Bullae Case No. Dilated. Marked peripheral emphysematous change. 6 Bulla (type 1) with low cuboidal epithelial lining and multifocal smooth muscle indicating continuity with respiratory ducts. Extensive atelectasis and mild muscular hypertrophy around airways.

however. these treatments have had limited success in creating pleural adhesions.15. Definitive treatment for dogs involves resecting the pulmonary blebs and bullae with a partial or complete lung lobectomy. however. and location of the lesions on each lobe will determine the amount of lung tissue that needs to be removed. it may be related to differences in the thrombolytic and fibrinolytic systems that ultimately lead to adhesion formation and the sealing of bleb or bulla lesions.15 More recently. Blebs and type 1 and 2 bullae may look very similar depending upon their size and location. The precise reason for the leakage was not determined. For dogs with lesions involving multiple lobes.14. with minimal morbidity and recurrence rates ranging between 16% and 52%. 3) experienced leakage of air from a staple line after partial lobectomy.15 In cases where thoracic CT has been performed.4.12 For humans that do not respond to conservative treatment.13 Results of surgical treatment were considered excellent for the dogs in this study. the cause of death was not determined.18 In contrast to dogs. who have no previous history of lung disease. so each lobe should be thoroughly examined.14.4. Similar results were also found in two previous studies where pneumothorax persisted or recurred in eight of 11 (73%) and seven of eight (88%) dogs with confirmed or presumed blebs and bullae after treatment with thoracocentesis or thoracostomy tube drainage.14. conventional surgical treatment is performed by resecting pulmonary blebs and bullae through a thoracotomy incision. video-assisted thoracoscopic techniques has been described for resection of pulmonary lesions. In humans. and the availability of appropriate surgical expertise and postoperative care. prolonged conservative treatment may eventually resolve the pneumothorax. however.15. other treatments that preserve lung capacity such as mechanical or chemical pleurodesis may be of benefit. thoracic drainage with thoracocentesis or. A median sternotomy approach is recommended so that the entire thorax can be explored. Unfortunately. involving strict rest and.14.6. sudden death without prior respiratory signs would not be typical for recurrent pneumothorax due to pulmonary blebs or bullae. and dyspnea. however. the ability to rule out underlying lung disease. if necessary. the average recurrence rate for pneumothorax after conventional surgical treatment is 1. and in most cases it is not possible to distinguish the difference between the lesions on gross inspection. Bleb and bulla lesions typically appear as focal. For dogs in which surgical treatment is not an option. it may not be possible to completely resect all of the lesions without significantly reducing lung capacity.15.15. although it was most likely due to staples failing to engage tissue properly. For these dogs. less commonly.11 Other treatments such as mechanical and chemical pleurodesis have been described in dogs in both experimental studies and in a small number of clinical cases. but complication rates and surgical times are reduced. necropsies were not performed on any of the dogs.18.14. tachypnea. although they may be located anywhere within the lung. and their use for the treatment of pneumothorax due to blebs and bullae has not been reported. 3) that collapsed and died suddenly 36 months after surgery. a thoracostomy tube. mechanical pleurodesis. despite 1 to 5 days of conservative treatment. because it is faster and results in fewer complications compared to conventional suturing techniques.15 It occurs most commonly in young men. and surgical treatment should be pursued once other obvious causes of pneumothorax have been ruled out. However.2. translucent. one dog (case no. spontaneous pneumothorax due to pulmonary blebs and bullae is typically classified as primary spontaneous pneumothorax. 39 Pulmonary Blebs and Bullae 443 persisted in all of the dogs. and partial pleurectomy. the rate of air accumulation.19 The reason for the improved results with conservative treatment in humans compared to dogs is not known. and their use for the specific treatment of pneumothorax due to blebs and bullae requires further investigation. although rarely bulla lesions may be detected. None of the dogs developed signs of recurrent pneumothorax due to blebs or bullae in the follow-up period. between 20 and 40 years of age. number. conservative treatment should not be considered a reliable means of treating pneumothorax caused by pulmonary blebs and bullae in dogs. Vol. The use of an automatic stapling device is recommended for partial lung lobectomy.12.4.7 Based on these results.September/October 2003. “bubble-like” lesions on the apices of the lungs.17 Treatment for humans with primary spontaneous pneumothorax caused by blebs or bullae is typically conservative. blebs or bullae have been identified on the margins of the lungs and have been described as emphysema-like changes.11 In this study. For the one dog (case no.15.16 Clinical signs include chest pain.15 Other forms of treatment that have been described for bleb and bulla lesions include chemical pleurodesis. the decision regarding how long to pursue conservative treatment should be based on the severity of clinical signs.18 The bulla lesions from the dogs in this study most closely resembled the type 1 and type 2 bullae described in Figure . thoracic radiographs in humans usually do not reveal any underlying pulmonary disease as a cause of the pneumothorax.5%. the pneumothorax in humans is typically unilateral and does not usually progress or result in immediate respiratory compromise. the use of minimally invasive.20 The average recurrence rate for video-assisted thoracoscopy techniques is slightly higher (4%).6 The size.14.15.14 As is often the case with dogs. although some patients may be asymptomatic or only mildly affected. Ultimately.16 In contrast to dogs. Lesions may be present on multiple lung lobes. so the condition of the lungs at the time of death was not known. conservative treatment in humans is generally successful. with recurrence rates ranging from 8% to 25%.18 In humans. these treatments have had limited success in creating pleural adhesions in experimental studies.14. this possibility must be balanced against the extended hospitalization time and potential complications associated with repeated thoracocentesis or thoracostomy tube drainage.

chronic inflammation. . Analysis of bronchoalveolar lavage samples from affected and unaffected lobes may help determine if inflammation of the distal airways is present that may potentially contribute to a partial obstruction and the “check-valve” effect. Prospective examination of the histopathology of multiple areas of grossly normal and abnormal lung is necessary to further define the origin and distribution of the lesions. however.24 Increases in transpulmonary pressure resulting from changes in atmospheric pressure have also been implicated as a potential cause for formation and rupture of pulmonary bleb and bulla lesions. smaller diameter airways.18 However. creating a focal imbalance between elastase and alpha-1 antitrypsin. bronchiolar wall fibrosis. bronchial lesions.25 Cigarette smoking has been determined to be a significant risk factor for developing pulmonary bleb and bulla lesions in humans. the histopathological similarities between species may suggest a similar pathogenesis. fibrosis. has been suggested by a study that examined the interior and exterior surfaces of type 1 to 3 bullae using scanning electron microscopy. and varying degrees of inflammation. In humans. increased foreign particulate matter. Previous veterinary reports have suggested that there are marked differences between the histopathological findings from bleb and bulla lesions in dogs compared to those found in humans with primary spontaneous pneumothorax. without actual rupture.29 In addition to the many theories regarding the formation of bleb and bulla lesions. Conclusion Pulmonary blebs and bullae are the most common cause of spontaneous pneumothorax in dogs.2. and accessory airways.27 Bronchoalveolar lavage in humans with primary spontaneous pneumothorax has shown a close relationship between the total cell count. bleb and bulla lesions from humans with primary spontaneous pneumothorax exhibit consistent focal changes. however.22 Further investigation into the anatomical. Vol. and the histopathological findings from these dogs clearly illustrate the similarities with bleb and bulla lesions observed in humans with primary spontaneous pneumothorax.28 Another theory suggests that there may be anatomical differences in the lower airways that predispose humans who have never smoked to spontaneous pneumothorax.22 It is generally accepted that rupture of a bleb or bulla lesion is the cause of pneumothorax. muscular hypertrophy of the respiratory ducts. the actual source of pneumothorax and the mechanism of leakage from the bleb and bulla lesions are also debatable. with the remainder of the lungs appearing macroscopically normal. and vascular changes. the fact that no obvious cause for the lesions was identified in these sections supports the idea that focal blebs and bullae represent a distinct or “primary” disease in dogs and that they are not the result of some other disease process. clinical examination. the potential for leakage of air through the wall of a bulla.26 Smoking also increases the number of macrophages and neutrophils in the distal airways.444 JOURNAL of the American Animal Hospital Association September/October 2003.9 These findings were not substantiated in the authors’ study. increased particulate foreign material. A significant number of bilateral airway anomalies. and epidemiological aspects of spontaneous pneumothorax in dogs is needed. In addition. This results in increased elastase-induced degradation of elastic fibers and progressive destruction of pulmonary parenchyma. have been identified with bronchoscopy in humans having spontaneous pneumothorax. and eventual bulla formation. Also. 39 1.4 Influx of inflammatory cells has also been associated with bronchiolitis. it does suggest a chronic change and indicates that the lesions may exist for some time before clinical signs develop.7. including abnormal airway branching. especially macrophages. Similarly.9 These comments were based on the idea that bleb and bulla lesions in humans had no associated pathological changes and that the pathological changes associated with the bleb and bulla lesions in dogs represented significant underlying disease such as diffuse emphysema. due to its effect on degradative enzymes in the alveoli and increased inflammation in the lower airways.21-23 The pathogenesis of pulmonary bleb and bulla lesions in both dogs and humans is not completely understood.16 One study revealed a 22-fold increase in relative risk for developing pneumothorax in male smokers and a nine-fold increase in relative risk in female smokers. Affected dogs are typically healthy.22 A marked absence of mesothelial cells on the external surface of type 1 bullae was found. and destruction of pulmonary parenchyma leading to the formation of emphysematous-like changes.16 Alpha-1 antitrypsin may be inactivated by smoking.6 Histopathological examination revealed a consistent pattern of focal abnormalities. This influx of inflammatory cells may create a partial obstruction that acts as a “checkvalve” leading to increased pressures in the distal air spaces. Analysis of degradative enzymes present in the lung parenchyma may help determine if an imbalance exists that may be responsible for progressive weakening of the alveolar wall and bulla formation. atelectasis. hyperinflation of alveoli. epidemiological evaluation of potential risk factors such as “second-hand” smoke in the environment or chest heightto-width ratios may help identify dogs at risk for developing spontaneous pneumothorax. and the extent of emphysematous-like changes seen on CT.2. as has been suggested in humans. atelectasis. or thoracic radiographs. inflammatory. one theory suggests that increased distensile forces generated at the apices of the lungs in tall individuals are responsible for bleb and bulla formation.4. including emphysema. The lesions should be suspected in any dog with spontaneous pneumothorax when no other obvious source of air leakage can be identified from the history. middle-aged.7. including subpleural emphysema.21-23 It is not clear whether the muscular hypertrophy found surrounding the respiratory ducts in the dogs was the cause or result of bleb and bullae formation. supporting the theory that air may diffuse between mesothelial cells and that integrity of the mesothelial cell layer may play an important role in the pathogenesis of spontaneous pneumothorax. biochemical.

Vol. the long-term outcome appears to be excellent after surgical resection of pulmonary lesions. Ciriaco P. Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax. 23. Tanaka S. Am Rev Resp Dis 1991. 12.10:826-832. 10. Polu JM. Valentine A. Lindquist C. Puerto DA. . Postmus PE. McKean HE.P. Heffner JE. Postmus PE. 2nd ed. Drobatz K. Bronchiolar inflammation and fibrosis associated with smoking: a morphologic cross-sectional population analysis.28:322-332. 26. Chest 1987. Slatter MR. Spontaneous pneumothorax in dogs.55:372-376. Shamji F. 18. Vallyathan V. Ir Med J 1987. Am Rev Resp Dis 1989. DeGiamocco T. Scotland b Numorph. Current aspects of spontaneous pneumothorax.B.186:971-974. Isobe J. Bense L. Lesur O. Classification of cystic and bullous lung disease.26:409-417. with no previous history of lung disease. Weaver SO. Chest 1990. Bullous emphysema and recurrent pneumothorax in the dog. West JB. Kramek BA.77:771-777.18:57-62. Kings Langley. Bleb and bulla lesions are not usually evident on thoracic radiographs. Smoking and the increased risk of contracting spontaneous pneumothorax. Histopathological findings are similar to those found in humans with primary spontaneous pneumothorax. Chest 1980. 17. 15. Slough. Multiple lesions are common and are usually located on the apices of the cranial lung lobes. Wykes PM. Withrow SJ. N Engl J Med 2000. J Applied Phys 1975. Edinburgh. Schramel FMNH. Holtsinger RH.220:1670-1674.149:A1022. Am Rev Resp Dis 1992. England c Marcaine.. a Proximate Linear Cutter. Spontaneous pneumothorax in young subjects. however. Effect of shape and size of lung and chest wall on stresses in the lung. Suzuki H. Pathogenesis of spontaneous pneumothorax. Berridge BR. J Am Vet Med Assoc 1985. 29. Florence 1977:296-306. Winan LG. 24. Sadikot RT.29:195-210. Fossum TW. Inoue R. Sassoon CSH. 28. Surgical treatment of the spontaneous pneumothoraces and its pathological findings. McQuillen EN. Bense L. Vanderschueren RGJRA. A median sternotomy approach is recommended to allow thorough examination of all the lungs. 15. Lung resection using surgical staples in dogs and cats. Inc. 21. 19. Yoshioka MM. Eur J Surg 1995. Beale BS. New York: McGraw-Hill. 17. Minihan A. Comp Cont Ed Pract Vet 1996. Thorax 1997. Surgical and nonsurgical management of and selected risk factors for spontaneous pneumothorax in dogs: 64 cases (1986-1999). Greene T. Craighead JE. Hatakenaka R.143:144-149.146:513-516. Gwynne JF. Murphy DM. The role of atmospheric pressure variation in the development of spontaneous pneumothoraces. Gallagher L. Thorax 1971.161:227-230. 30-mm stapler. Delorme N.52:805-809.18:53-62. Smeak D. Comp Cont Ed Pract Vet 1988. Caywood DD. Pathogenesis of blebs and bullae of patients with spontaneous pneumothorax: an ultrastructural and immunohistochemical study. J Am Anim Hosp Assoc 1982.5:701-716. Use pleurodesis in treating selected pleural diseases. 14.98:341-347. Ann Thor Surg 1993. 1995:107-113. Tanaka F. Ricci C. Taki T. Matthews FL. Eur Resp J 1997. Scott GC.I.39:9-17. Surgical treatment involves partial or complete lung lobectomy. Vet Surg 1987. Kuwabara M. Jerram RM. Philadelphia: Lea & Febiger. Evans Medical Ltd. Nagase C. Lena A. 39 Pulmonary Blebs and Bullae 445 large breeds or have deep-chested conformation. 16. A pathogenic factor in spontaneous pneumothorax. England References 11. Yamanaka N. with special reference to the ultrastructure of emphysematous bullae. Arnold AG. Venuta F. Birchard SJ. Secondary spontaneous pneumothorax. 14. 16. Management of spontaneous pneumothorax in twelve dogs. Spontaneous pneumothorax: aetiology. Clinical signs include various degrees of respiratory distress that may progress over several hours to days. Inflammation as a cause of spontaneous pneumothorax and emphysematous-like changes: results of bronchoalveolar lavage. Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax. Bernadac P.139:659-662. 13. Sahn SA.80:306-311. Curr Opin Pulmon Med 1995. 12. Ohata M.342:868-874. Vawter DL. 19. Spontaneous pneumothorax in the dog: a retrospective analysis of 21 cases. The aetiology and treatment of spontaneous pneumothorax. 22.1:331-338. Berkshire. 11. Meyer CJLM. Fishman AP. Brockman DJ.. Bellah JR. Haraguchi S. Chest Surg Clin North Am 1995. Recurrence of primary spontaneous pneumothorax. Eklund G. Am J Resp Crit Care Med 1994. Wiman LG. a clinical and pathological study. Meadows K. Ikeda S.92:1009-1012. management and complications. the use of CT or possibly diagnostic thoracoscopy may be more helpful for detecting small pulmonary lesions.September/October 2003. Mauterer J. O’Brien TD. Pulmonary diseases and disorders.16:238-240. 27. The efficacy of mechanical abrasion and talc slurry as methods of pleurodesis in normal dogs. Odont D. Bullous disease of the lung. O’Neill S. 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